Mobility Management – MAY/JUNE 2024

UNDERSTANDING HCPCS CODE DEFINITIONS

AND DISTINCTIONS

Seat Elevation Update: Funding, Codes, Next Steps

Physics 101

Iwas an English major (writing concentration) in college, and I’ve never taken a physics class.

I have, however, learned a lot about physics from covering the Complex Rehab Technology (CRT) industry.

Because while seating and wheeled mobility is assistive technology, it’s also all about movement, balance, energy, and how they relate to each other. I’ve learned that the number of pounds (or kilograms) matters, but so does the way that the weight is distributed. (Spoiler alert: Asymmetrically distributed weight completely changes the equation.)

I’ve learned about center of gravity, determining it and using it to your advantage. I’ve learned how everyday environments — ramps, curb cuts, grass, gravel, broken pavement — can alter a wheelchair’s center of gravity and upset its stability.

So while I am still no physics expert, I know that when a client in a power wheelchair activates seat elevation, a lot happens. Yes, the seating system rises, making it safer and easier for the client to, for example, stir the pot of spaghetti sauce simmering on a stove top.

But I also know that the client, by rising 10 inches or so above the power base, has changed the seating’s dynamics. That body weight that was previously right on top of the power base is now literally up in the air.

I also know that an elevated client does not sit completely still. This isn’t like elevating Mr. Lincoln inside the Lincoln Memorial. Elevated wheelchair riders move. They lean to the side to reach for a spoon. They lean forward to peer into the pot while they stir the pasta sauce. They turn toward the sink to grab a kitchen towel.

And seating engineers need to be ready for those real-world scenarios. They need to design and build chairs that remain stable not just when the seating is 10 inches in the air, but also while the chair is driving over cobblestones, asphalt, gravel.

In our seat elevation update story (page 12), industry experts explain why they believe seat elevation isn’t just a power chair accessory, but an actual seating system even more complex than power tilt.

Industry advocates also discuss how the Centers for Medicare & Medicaid Services (CMS) decision to issue just one HCPCS code and one allowable (based on standard weight capacities) could cause access issues for bariatric seating clients.

It’s a reminder that even with coverage from payers, access can still be threatened if allowables aren’t adequate. And that today’s allowables for CRT support manufacturers’ research and development of the next generation of assistive technology to improve mobility and independence.

I hope ongoing funding and coding talks are fruitful and client centered. And that a CMS decision on power standing is on the way. m

Laurie Watanabe, Editor in Chief lwatanabe@wtwhmedia.com @CRTeditor

May/June 2024

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Power wheelchair HCPCS codes, power options and finding the best fit for clients

By Laurie Watanabe

The Group 2 and Group 3 Healthcare Common Procedure Coding System (HCPCS) power wheelchair codes sound straightforward — as shown in the sidebar.

Group 2 power wheelchairs are not Complex Rehab Technology (CRT) wheelchairs; Group 3 power chairs are CRT power chairs.

“Single power option” means one; “multiple power option” means more than one.

But as is so often the case with CRT, even something that sounds simple can quickly become much more complicated.

HCPCS codes are for power bases

Correctly understanding the K0835, K0841, K0856, and K0861 codes starts with understanding their formal definitions. While the codes do include the words power wheelchair, the single power option and multiple power option portions of the code actually refer just to the power wheelchair base, said Josh Haynes, director of research and development for Merits USA, a power wheelchair manufacturer based in Fort Myers, Florida.

Take, for example, the K0835 code: “Power wheelchair, Group 2 standard, single power option, sling/solid seat back, patient weight

capacity up to and including 300 lbs.”

“All those codes refer to the power base itself,” Haynes explained. So, a K0835 is “a power base that’s in Group 2 that is capable of powering one power function. A single power is able to one power function.”

Here’s where it gets more complicated: “Single power” doesn’t mean the power chair can only operate one powered seating component or system.

Single power vs. multiple power

Jim Stephenson is senior market access manager, Permobil Americas, Lebanon, Tennessee. When addressing single and multiple power, Stephenson used the example of seat elevation, currently a buzzedabout seating function given the recent Centers for Medicare & Medicaid Services (CMS) decision to provide Medicare funding for it.

“Even before seat elevation came into the equation, people were confused about what single and multiple power are,” Stephenson acknowledged. “Because people think, ‘That’s a power function, so that’s a power option. I should count it.’”

But that isn’t always the case.

ATP Series Crunching the Numbers

K0835

Power wheelchair, Group 2

Standard, Single Power Option, sling/solid seat/back, patient weight capacity up to and including 300 lbs.

K0841

Power wheelchair, Group 2

Standard, Multiple Power Option, sling/solid seat/back, patient weight capacity up to and including 300 lbs.

K0856

Power wheelchair, Group 3

Standard, Single Power Option, sling/solid seat/back, patient weight capacity up to and including 300 lbs.

K0861

Power wheelchair, Group 3

Standard, Multiple Power Option, sling/solid seat/back, patient weight capacity up to and including 300 lbs.

“If you have tilt or recline [on the power chair], it’s single power,” Stephenson said. “If you have tilt and recline, it’s multiple power. Those are the only things that matter in this equation. Elevation doesn’t change that [equation] because [funding sources are] considering it to be similar to power elevating legrests, which historically don’t count towards multiple power options.”

When counting seating functions as options, Haynes thinks of it this way: “When we take a look at Group 2 and a single power function, if we break it down to its absolute must-haves, you would take a look at what power function has the greatest impact clinically for the end user. And that would be tilt.

“So combine that with the rest of your basic equipment package: legs, arms, non-coded backrest and a headrest that supports you when you’re in full tilt. That’s your starting point. From there, you can — if need be on a single power base — add different accessories, like seat elevation, power elevating legrest. And that’s how you build out your full seating around a single power base.”

The Electronics Question

The next step, Haynes continued, would come if the seating team determines there’s a need for recline as well as tilt.

“In that case, recline becomes your other necessary power function,” he said. “So currently, the way that the industry does it is if you need recline, you generally need and will qualify for Group 3, if you need to pair tilt and recline.”

Also potentially complicating matters is the question of power chair electronics. “The thing that makes it confusing is that those things [such as seat elevation] do count towards whether you have a singleor- multiple-operate-the-functions-throughthe-joystick code,” Stephenson said. “So if you have tilt, seat elevate and power legs, that’s a single power option chair. But to operate those through the drive control, you need a multi-function control kit.”

Knowing that seat elevation is being frequently discussed these days, Stephenson added, “With seat elevation, nothing changes. It’s business as usual. It’s just that seat elevation doesn’t count in that [single/ multiple power] part of things, but it does count when it comes to the electronics.”

Group 3 PWC Requirements

Moving on to distinguishing Group 2 from Group 3 power chairs, Haynes pointed out that a neurological diagnosis is required for a patient to qualify for a Group 3 power wheelchair.

“You need to have had a stroke or MS [multiple sclerosis] or something along those lines,” he said.

But here’s where it gets complicated again: Patients without neurologically based

diagnoses can still have complex seating and positioning needs. Common examples include patients with diabetes who experience neuropathy and/or amputations, but don’t qualify, diagnosis wise, for that Group 3 power chair.

“That’s a classic example of somebody who would need Group 3 with powered seating,” Stephenson said. “Other people who fall into that gap are those with rheumatoid arthritis, or amputees.”

Think, for example, of a wheelchair rider who’s a high-level, double above-the-knee amputee — and how the lack of lower extremities can impact the rider’s stability.

Even without that neurological diagnosis, Stephenson said, some wheelchair riders “really should be in Group 3 because they present with complex needs, although their diagnoses don’t qualify them for a complex base.”

The need for pressure relief also persists, even for wheelchair users whose diagnoses don’t qualify them for Group 3 chairs.

“That’s one of the driving factors, too, depending upon strength level, if you can’t offload to do a pressure relief, if you have maybe some desensitization due to diabetes or some neuropathy,” Haynes said. “All of that is absolutely key and why you would need both tilt and power legs to be able to position yourself correctly, without the neurological diagnosis.”

Powered Seating: It’s Complicated

There are also clients who do have the neurological diagnoses to qualify for a Group 3 chair, but only need a single power option. Consider someone with cerebral palsy — a diagnosis that would qualify for a Group 3 chair. “You may have someone who has cerebral palsy who doesn’t necessarily need the recline function,” Haynes said. “They’re more suited to a properly fitted tilt product, so that would put them into a K0856, which is the single-power Group 3. Your standard function — tilt — is your main function, and then the accessories — say, power legs, elevate — those get added on.

“You may have someone who doesn’t need a cantilever arm — one that flips back for a tilt. They’d be fine without that because they transfer differently. Maybe they do a stand-pivot transfer.”

Haynes added that powered seating can also impact other components chosen for the system.

“When you go up to multiple power, you need arms that adjust their angle along with the recline, so that that whole transition angle is correct,” he explained. “That’s all part of that component, too. It’s not just the power function, but it’s how it’s all connected, and that’s another level of seating and positioning that’s required for the multiple power function.”

As for Group 2 multiple power option wheelchairs — basically, Group 2 chairs with both tilt and recline — Stephenson said, “We don’t have anybody that’s [manufacturing] that product in that category right now in the entire industry. That space doesn’t have

any products that are available based on what we can see on PDAC [Pricing, Data Analysis and Coding].

“That’s part of the challenge, as well: You have insurance companies who are trying to push people down from Group 3 into Group 2, not taking into account that there are no products in that equivalent category group. Plus you’re taking away some of the potential add-ons for somebody in the chair. You have a lot more flexibility with a Group 3 chair as far as add-ons, whereas Group 2 is basically standard mobility with complex seating on it.”

Leaving no client behind

Which is to say that while there’s room for seating teams to build more robust seating and positioning into less robust Group 2 power chairs, there remain critical differences between Group 2 and Group 3 devices.

After 18 Years, Is It Time to Rethink Power Chair Codes?

In 2006, Twitter (now X) was launched. Pluto was demoted from planet to dwarf planet. Sony launched PlayStation 3. The terms crowdfunding, crowdsourcing and bucket list were born.

And HCPCS power wheelchair “K” codes — by definition, temporary as opposed to permanent “E” codes — were implemented.

“They went into effect November 15th of 2006,” said Jim Stephenson, senior market access manager, Permobil Americas. A veteran policy expert deeply involved in the coding discussions at the time, Stephenson added, “These codes are going be 18 years old this year. I will never forget that project.”

What’s changed in nearly two decades In the 18 years since power chair K codes went into effect, technology has evolved: Examples include smart technology, sensor technology and robotics. Wheeled mobility professionals’ understanding of seating has evolved as well, with new knowledge, for instance, on deep tissue injuries and the ways that pressure injuries — previously known as pressure ulcers — can form. Treatments now exist for amyotrophic lateral sclerosis (ALS) and spinal muscular atrophy.

Is it time for power wheelchair codes to evolve as well?

address it and what that would look like.”

One current problem area is the language concerning power chair electronics, he added. “As manufacturers, once you have three actuators on a chair, you have to have an expandable controller. An expandable controller is the only thing that has strong-enough processing power to be able to accommodate all the different communications and functionality on the chair. A non-expandable controller can only control up to two actuators. So if you’re not going to pay for an expandable controller, what are these folks who have three actuators on their chair supposed to do?”

“Honestly, we should probably be on some sort of a cadence to where we review codes every 10 years or something like that, so we don’t let it get to 18 years,” Stephenson said. “We’re living in the past so heavily that we can’t take care of people the way we need to take care of them.”

Ideally, Stephenson added, codes would be regularly reviewed to make sure they’re still serving the purposes for which they were intended. “In a perfect world, we would go back and review these code sets at some sort of cadence to say, ‘Hey, is this working for us? Is this still taking care of the needs of the people we’re here to serve?’” Stephenson said. “And if not, then maybe we need to

At least one prominent funding source, Stephenson explained, believes “that they only need that extra processing power if they’re operating their seat functions through their drive control. But that’s just not true. No manufacturer builds a three-function chair without an expandable controller. But because of the way the [funding] language is written, [payers] take advantage of it.”

Keeping up with ever-changing times

Stephenson noted that he’s not suggesting a complete overhaul of the codes. “It doesn’t need to be a full revamp. Just massage it a little bit.”

As an example, he pointed out the Group 2 multiple power category, which Stephenson said doesn’t include models currently offered by power chair manufacturers. “If [that code] doesn’t need to be there anymore, let’s get rid of it,” Stephenson suggested. “All it’s doing is creating a problem. It’s something that doesn’t exist.”

Revisiting the codes could also open the door to, for example, examining the question of actuators or looking again at the potential benefits of funding Group 4 power chairs.

“That’s all the types of stuff,” Stephenson said, “that we would want to explore.” m

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“That’s one of the gaps in our industry right now,” Stephenson said. “There’s a certain population of people that just kind of fall into no man’s land. They end up getting stuck with [equipment] that helps them, but doesn’t meet all their needs because it’s not capable of meeting all their needs.

“How many Group 2 chairs do you see that people can drive with a sip and puff? How many Group 2 chairs do you see people rolling around in with a head array? Granted, the population that typically qualifies for Group 2 doesn’t generally need that type of equipment [such as alternative driving controls]. But to be a true complex chair, you have to be able to accommodate those things.”

Stephenson described a “blurred line” between clients who need basic mobility devices — perhaps because of congestive heart

failure, osteoporosis, and other conditions that reduce strength and stamina — and clients who truly have more complex needs.

“Once you start getting into needs that require special seating and special electronics and so forth, that’s not geared towards Group 2,” he said. “Those chairs were not originally designed or intended to be those type of [devices].”

One final question: The industry still awaits a CMS decision on potential Medicare coverage for power standing. Should CMS decide to fund it, would standing likely be considered a system along the lines of tilt or recline? Or would it be considered an add-on, such as seat elevation is?

“We don’t know yet,” Stephenson said. “But you need tilt and recline to do standing, so it’s always going to be a multiple power option chair.” m

Evolving Perspectives on Power Chairs and Seating

A perennial challenge for seating teams is configuring or building a seating and wheeled mobility system that will meet the client’s needs today and also anticipate future needs.

While significant changes to a client’s condition can result in a funding source agreeing to cover a new system before the end of a wheelchair’s reasonable, useful lifetime — generally, five years — procuring the equipment can be a laborious, drawn-out process.

Part of the seating team’s task, then, is to consider what the client’s future will be like, including disease progression, aging, and new goals, environments and activities.

That includes considering what’s down the road: Even if a non-expandable single-power setup is fine for now, will it be fine going forward?

‘Future proofing’ seating and mobility

Josh Haynes, director of research and development for Merits USA, refers to this as “future proofing” a system.

“Everybody progresses at a different rate, depending upon diagnoses and age,” Haynes said. “Where you’re starting out and where you’ll be within five years can vary quite a bit.”

Building in flexibility — in the form of choosing a system that can accommodate more robust or additional positioning in the future — is key, he added.

“Maybe you don’t need power legs now, but you develop edema at some point and you need that function,” he said. “We build it in so you can go ahead and add it in later on if you need to. Or if you’re not qualified for a Group 3, we make it so that you can add in those extra power functions, up to three now on a single-power base, because that patient needs extra positioning care.”

Global differences in seating strategies

In fact, single-power option power bases are preferred by some seating clinicians, Haynes added.

“Different countries view the functions of recline differently,” he explained. “In our surveys for Europe and the U.K. [United Kingdom], they tend towards tilt more often, as opposed to a combination of tilt and recline. We were kind of surprised at that because here in the U.S., that [tilt and recline] combination is used so frequently.

“If somebody can meet the justification for recline, U.S. therapists have no problem going in that direction. But in Europe and Australia, they tend toward more just tilt as a single solution.” m

Where Seat Elevation Goes from Here

CMS’s allowable creates access concerns among advocates

By Laurie Watanabe

April 1 was the first day of Medicare coverage for Complex Rehab Technology (CRT) power seat elevation under the new E2298 code, with its allowable of $2000.34.

While CRT stakeholders continue to laud the decision by the Centers for Medicare & Medicaid Services (CMS) to provide Medicare coverage — an effort decades in the making — the new fee schedule amount is raising questions about beneficiary access to the technology.

Access is also a concern because of the CMS decision to issue a single, standard-weight HCPCS code, without a bariatric counterpart.

Julie Piriano, PT, ATP/SMS, NCART’s new senior director of payer relations and regulatory affairs, was the primary presenter during the November 2023 second biannual HCPCS Coding Cycle public meeting. Brad Peterson, Amylior’s VP of sales, U.S., was an additional speaker at that meeting.

Mobility Management also spoke to NCART Executive Director Wayne Grau, and Dan Fedor, director, reimbursement and education, U.S. Rehab, to get their reactions to the new seat elevation policies.

Will lack of a bariatric code impede access?

CRT stakeholders had requested two HCPCS seat elevation codes: the first for standard weight capacities (up to and including 300 lbs.) and the second for heavy-duty weight capacities from 301 through 450 lbs. CMS instead issued a single code.

“Our research did not show a significant price difference between power seat elevation systems based on weight class for complex rehabilitative power wheelchairs,” the agency said in its final decision in March. “Instead, the price differences based on weight class exist between the base CRT power wheelchairs themselves. Thus, we do not believe there is a programmatic need for two new HCPCS Level II codes, and only one code for CRT wheelchair power seat elevation systems is being established.”

Asked about the differences between standard and bariatric seat elevation systems, Piriano said, “Power seat elevation systems designed for the bariatric population (greater than 300 lbs.) require more materials in their construction, as well as increased strength

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of those materials to ensure the stability of the chair and the safety of the user. This is especially true for CRT power seat elevation of at least 10 inches, that can elevate and descend while driving, drives in the elevated position, and is compatible with other power seat functions.”

As a possible explanation of why CMS nevertheless believes there is no significant distinction between standard and heavy-duty seat elevation systems, Piriano added, “To minimize the disparity associated with this patient population, manufacturers typically did not pass along the cost differential to the provider and ultimately the consumer for power seat elevation, as it was often an ‘out of pocket’ expense. As a result, CMS did not see a significant cost difference.”

“We are currently dealing with a population that is getting larger and heavier, yet we still only have one set of codes for systems such as tilt and recline, and now power seat elevation that covers all weight capacities,” Peterson said. “It should be common sense that a power tilt for someone that weighs 150 lbs. is much different than one that safely moves someone weighing 500 lbs. The same can be said for power seat elevation.”

With his long history of working for CRT seating manufacturers, Peterson is very aware of the engineering and design considerations that go into these systems.

“There are differences in manufacturing cost and components, and the lack of power seating codes specific to the unique needs of our bariatric population precludes many manufacturers from designing and building systems that support larger patient weights and, more importantly, the asymmetrical shapes of these larger clients,” he noted. “Retail prices may be similar, but those don’t necessarily reflect costs and lower margins

associated with more heavy-duty systems.

“Increasing retail and associated provider costs, especially for something that was previously not covered like power seat elevation, will only serve to reduce access to people that need the technology,” Peterson added. “Again, not speaking for others, but I know there are many out there, both providers and manufacturers, that take a lower margin to provide this important technology. Pegging one allowable for all weights will only continue this practice, and more will go without.”

He said the ITEM Coalition — a consumer organization that has been among the leading advocates for Medicare seat elevation coverage — shares the industry’s concern about seat elevation for bariatric clients.

“We’re very concerned about access for those individuals weighing over 300 lbs.,” Grau explained. “Whether they are going to be able to get this equipment remains to be seen, but it’s going to be very tough for the suppliers to be able to provide that — so that’s why we felt two codes made a lot of sense.

“Unfortunately, CMS disagreed.”

From a physics perspective, elevating the seat 10 inches or higher significantly raises the lever arm of the system. As a result, manufacturers have designed mechanical and electrical safety measures into the chair

— Julie Piriano

Grau pointed out that a significant number of Medicare patients would qualify for heavy-duty equipment.

“You need to remember that 21% of Medicare beneficiaries would have the diagnosis of obesity and would benefit from that second code, the higher [weightcapacity] one,” he said. “This is a population that continues to grow.”

Grau also noted the additional safety challenges manufacturers face when designing higher weight-capacity systems.

“When you’re up 10 inches and you weigh 120 lbs., the balance is a lot different than when you’re up 10 inches and you’re 450 lbs. So there are enough additional safety requirements, additional testing and so forth that we felt justified asking for a second code.”

You need to remember that 21% of Medicare beneficiaries would have the diagnosis of obesity and would benefit from that second code, the higher [weight-capacity] one

— Wayne Grau

Gap filling to set the allowable CRT stakeholders asked CMS to define power seat elevation for CRT power chairs as a seating system, similar to the way tilt is defined as a seating system. But when setting the funding amount for the new E2298 code, CMS said it could not find an item in its existing fee schedule that was comparable to seat elevation. The agency therefore decided “the gap-fill approach is the most appropriate method for making a payment decision.”

“I respectfully disagree,” Peterson said. “When you look at the components, structural, mechanical, electrical and ‘all related electronics’ for a tilt-only system compared to an elevate-only system, they are identical — actually, there are more electronics required for elevate than tilt-only in most cases due to the necessity of having reduced drive and full drive lockout in addition to different types of switches.

“Looking at power seat elevation as a simple add-on module completely ignores the associated costs of elevateonly systems that are medically necessary for beneficiaries to perform transfer and reaching activities for daily MRADLs

[mobility-related activities of daily living], although they may not qualify for or require a tilt and/or recline.”

Piriano agreed. “When you look at the physical components of power tilt and power seat elevation, there is a direct comparison between the two systems,” she said. “However, a review of the electrical and mechanical components of every manufacturer’s CRT power seat elevation system clearly shows that it is more complex than a power tilt system to ensure the stability of the chair and the safety of the user. This is especially true for CRT power seat elevation [systems] that do not go into drive lockout at any point in the elevation of the seat to ensure the user can perform or participate in the ADLs [activities of daily living] while driving in an elevated position.

“While CMS rejected the industry’s compelling evidence that power seat elevation is comparable to power tilt and should be reimbursed accordingly, and chose to use ‘gap filling’ methodology to establish the final reimbursement rate, they can also use a third method to determine the rate, which the industry did not have solid information on at the time of the public meeting as claims for power seat elevation systems were just being submitted.”

Piriano explained that CMS “also has the authority to use information derived from the ‘pricing history’ of the product established under the [previous seat elevation code] E2300 and map that to the new E2298 code to ensure continuity of pricing. As an industry, our assertion is that CMS had seven to 10 months of claims data for CRT power seat elevation systems billed on behalf of traditional Medicare beneficiaries, instituted by the DME MACs in every state that could have also been used to establish the final reimbursement rate.”

Does seat elevation only impact the vertical axis?

In contrasting tilt and seat elevation, CMS said in its decision, “While seat tilt must accommodate an expected shift in the center of gravity from front to back, seat elevation only impacts the center of gravity in the vertical axis.”

From an engineering perspective, is that accurate? Or should seat elevation be considered a seating system, just as power tilt is?

“The word ‘only’ is interesting in that sentence,” Peterson said. “During our November 30 meeting, we had Bill Ammer, an independent testing expert, try to explain that loads that raised ‘only’ in the vertical axis actually impact center of gravity and stability more than those that move only in the horizontal due to the fact that most popular, commercially available power tilt systems feature significant center-of-gravity shift. As a system tilts, the entire seat shifts forward to move the consumer’s weight more toward the middle of the base for greater stability and to ‘…accommodate an expected shift in the center of gravity from front to back.’

“When a system elevates (a minimum of 10 inches), there is no such shift or accommodation. Thus the center of gravity is moved upward, vertically. This will reduce both the static and dynamic stability of the system and must be considered in all designs and manufacturing.”

Peterson added that CRT power chairs are made even more complex by the addition of other components and systems.

“Furthermore, add tilt, recline, power legs, asymmetrical patient shapes (of any weight) and vital components such as ventilators

and/or O2 [oxygen], backpacks, etc., and you have a complicated system that must be thoughtfully designed and interfaced for maximum beneficiary safety,” he said. “Hence why the word ‘only’ is quite interesting. I believe it is a drastic understatement and misunderstanding of what CRT power seat elevations systems are really asked to do.”

“The industry continues to maintain that power seat elevation is a power seat function due to the significant testing requirements mandated by the ANSI/RESNA standards to ensure the stability of the chair and the safety of the user,” Piriano said.

“All power tilt systems have a shift in center of gravity as they move to maintain the position of the seating system and the wheelchair user in a relatively consistent position over the base, with the seating system in very close proximity to the base. When the power tilt system reaches a preset position by the manufacturer, the ability to drive the chair in that position is locked out.

“From a physics perspective, elevating the seat 10 inches or higher significantly raises the lever arm of the system. As a result, manufacturers have designed mechanical and electrical safety measures into the chair so that it can not only elevate at least 10 inches and be safe in a ‘static position’ and allow the user to reach for things outside of the chair’s base of support — it can also drive in the elevated position in accordance with the testing requirements for the base.”

The industry’s next steps

Grau indicated that industry experts are continuing to talk with CMS representatives to better understand the new allowable and how it was obtained (see sidebar). He noted an 11.5% drop in pricing between the preliminary estimate and the final number of $2000.34.

“So this is why it really is back on us to ask those questions and say. ‘How did you do it? Can you share [your process] with us?” Grau said. “There should be a consistency of pricing when a chair or code is approved and it’s paid for prior to the final ruling or the final fee schedule. Let’s work it out so we can make sure that the people that need this equipment can get it.”

I fear the funding will dissuade future product development and innovation, especially for heavy-duty clients

— Brad Peterson

Peterson also believes today’s funding decisions could impact the types of seating and wheeled mobility that will be available in the future — in effect, discouraging manufacturers from trying to create better seating solutions going forward.

“I fear the funding will dissuade future product development and innovation,” he said, “especially for heavy-duty clients, while completely discouraging anyone from looking at developing CRT power seat elevation for very heavy-duty clients, of which nothing currently exists.” m

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Is Seat Elevation Funding Creating Two Tiers of Access?

Dan Fedor — director, reimbursement and education, U.S. Rehab — crisscrosses the country to educate seating and wheeled mobility providers about Complex Rehab Technology (CRT) policies and funding.

Not surprisingly, Medicare’s new coverage of seat elevation is a popular topic these days.

“We are grateful that it’s covered,” Fedor said. “There’s no doubt about that. People are getting access to it.”

But that doesn’t mean that providers — as well as Fedor — don’t have concerns as seat elevation coverage using the new allowable rolls out.

Less reimbursement than anticipated A lower allowable than expected started with the date of service of April 1, 2024, for code E2298 — “Complex rehabilitative power wheelchair accessory, power seat elevation system, any type.” That new allowable is $2000.34.

That allowable came as a surprise, Fedor said, compared to the reimbursement providers had been receiving prior to the official April 1 date of service.

The final allowable, combined with the lack of a separate code for more costly bariatric seat elevation systems, could inadvertently create a two-tiered model of access. The sheer cost of a more expensive, robust bariatric seat elevation system vs. the $2000.34 allowable could mean that some bariatric clients won’t be able to get seat elevation on their power chairs.

I think it’s logical that when you’re supporting more weight, the system (actuator) would have to be more robust

— Dan Fedor

“I do think that with the fee schedule for E2298 being lower than the proposed allowable by $200 — and being lower than what we were seeing on the interim fee schedule that came out May 16 of last year until April 1 [2024] of about $2800 — that drop in allowable will definitely impact bariatric patients receiving access based on costs and goods,” Fedor said.

“I do see some [risk of lack of access] with the standard [seat elevation], but not as much,” he added. “[A reduction of] $800 [compared to the interim fee schedule] is a big hit. And

it’s $200 less than what they originally proposed in the draft.”

Why heavy-duty seat elevation systems need to be more robust

While acknowledging that he’s not an engineering or manufacturing expert — but adding that he talks to those experts frequently — Fedor said, “I think it’s logical that when you’re supporting more weight, the system (actuator) would have to be more robust.

“There are heavy-duty bases, so [Medicare] pays for that. They pay for a heavy-duty manual chair. They pay for heavy-duty power chairs because they realize they’re different. They cost more, and the rates go up proportionally for those bases. The logic is there.”

But when the funding for bariatric seat elevation is not made available, seating team members, including the providers, can be faced with tough choices to make, Fedor explained, because “We’re not getting reimbursed accordingly.”

As for a final seat elevation allowable for Group 2 power chairs — a decision the Centers for Medicare & Medicaid Services (CMS) postponed — Fedor said, “I think that was good, because we’re not ready to make a move on that until we know more.

“Under the interim fee schedule, it seems to be paying at a fair rate right now,” he noted. “I’m talking with suppliers and manufacturers. I think they’re okay with that for now.”

Fedor also acknowledged the benefit of funding for retrofitting a Group 2 non-CRT power chair with seat elevation while using the K0108 miscellaneous HCPCS code.

Trying to replicate CMS’s math

And Fedor agreed with industry colleagues who have expressed confusion over how CMS arrived at the final $2000.34 seat elevation allowable.

“How did they determine the interim fee schedule, which was in effect from May 16 through March 31, to come up with an approximate average throughout the country of $2800, and then come up with the national fee schedule draft of $2200, and then land at $2000.34?” he asked. “That’s a big difference. That’s around 30% lower.”

Conversations between CMS and seating industry stakeholders, Fedor added, are continuing as CRT professionals seek additional information and clarity on how the agency arrived at a Medicare reimbursement figure that was significantly lower than what providers were expecting.

Ultimately, the industry’s concern is whether that allowable turns out to be lower than what CRT seat elevation clients need the reimbursement to be to guarantee their consistent access to the technology … and all the function, independence and freedom it can bring. m

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CMS Announces Medicaid Services Final Rule on Access

The Centers for Medicare & Medicaid Services (CMS) has issued a final rule related to Medicaid access.

In an April 24 bulletin, the American Association for Homecare (AAHomecare) discussed the Ensuring Access to Medicaid Services final rule, saying, “One of the biggest changes in this final rule are updates to documentation-related to access to care and service payment rates.

“This rule requires that the Medicaid FFS [fee for service] payment rates are available on a website that is accessible to the general public and must include the last date the payment rates were updated. This will improve transparency in states that have not updated DME [durable medical equipment] fee schedules in several years.”

The AAHomecare announcement added that Medicaid programs will now be obliged to keep their payment information regularly updated.

“The states must ensure that any rate updates based on previously approved state plan amendments must be updated no later than one month after the effective date of the most recent change,” the association noted. “This would require states that follow Medicare rates to update their fee schedules on a quarterly basis. The Payer Relations Council will be reviewing this provision in detail at the next Council meeting and assessing the potential impact to HME [home medical equipment] suppliers.”

An amplified voice for Medicaid beneficiaries

AAHomecare said the new final rule also gives Medicaid beneficiaries and their families more input regarding Medicaid programs.

“The rule also improves and expands the scope of the Medical Care Advisory Committees in the states,” the announcement said. “It requires states to develop a beneficiary advisory council (BAC) comprised of Medicaid beneficiaries and their family members. The Medical Care Advisory Committee will be required to have 25% of their members from the BAC. This will allow for more beneficiary input into the state Medicaid programs, which should help our advocacy efforts.”

“CMS has actively sought to improve access to care and services for the people enrolled in the Medicaid program, but has been limited by outdated regulations that need to be more comprehensive and consistent across all delivery systems and coverage authorities,” the agency said in an April 22 fact sheet about the new final rule.

“The Access rule addresses critical dimensions of access across both Medicaid FFS and managed care delivery systems, including for HCBS [home- and community-based services].

“These improvements seek to increase transparency and accountability, standardize data and monitoring, and create opportunities for states to promote active beneficiary engagement in their Medicaid programs with the goal of improving holistic access to care.” m

Piriano Named NCART’s New Senior Director of Payer Relations & Regulatory Affairs

Complex Rehab Technology (CRT) industry veteran Julie Piriano, PT, ATP/SMS, is the new senior director of payer relations & regulatory affairs for the National Coalition for Assistive & Rehab Technology (NCART).

In a May 6 news announcement, NCART said Piriano will be working “to ensure that all payers and insurers follow policy and cover required equipment and services.”

Piriano, a 40-year industry veteran, most recently served as the VP of clinical education, rehab industry affairs, and was also the compliance officer for Pride Mobility and Quantum Rehab.

During her time in the industry, Piriano has been a national and international speaker and educator while focusing on the topics of seating evaluation, documentation and clinical applications of various forms of CRT equipment.

She is a board member for the Rehabilitation

Engineering and Assistive Technology Society of North America (RESNA), is a member of the Clinician Task Force, and serves on many other industry boards and committees, including Mobility Management’s editorial advisory board.

“NCART and our members are excited to have Julie join in this important new role,” said Wayne Grau, NCART’s executive director, in the announcement. “Her experience working with a variety of stakeholders, including government agencies, regulators, payers and consumers, will strengthen our team and provide leadership on issues that are critical to our members.”

“NCART has been an invaluable resource for the CRT industry, and I look forward to working collaboratively with our members to strengthen their relationships with payers and regulators,” Piriano added in the announcement. Read her seat elevation remarks in the story on page 12. m