Corporate Compliance

CMS proposes new coverage criteria for wheelchairs, scooters

Compliance Monitor, February 9, 2005

The Centers for Medicare & Medicaid Services (CMS) on February 3 released draft coverage criteria for power wheelchairs and scooters, as well as new codes to ensure proper payment for these devices. A CMS release indicated that the agency is proposing the new criteria and codes in order to improve coverage and protect the program and U.S. taxpayers from fraud and abuse.

"In taking these steps, we move closer to our goals of supporting appropriate prescribing, making accurate payment, and providing clear guidance to physicians and suppliers about power mobility devices," CMS Administrator Mark McClellan, MD, PhD, said in the release. "It also makes it clear that Medicare recognizes the importance of clinically based coverage decisions.

Under the proposed guidance, Medicare would rely on clinical guidance to evaluate whether a beneficiary requires a device to assist with mobility, and if so, what type of device is needed. This is a departure from the agency's previous thinking, which relied on whether a patient was "nonambulatory" or "bed or chair confined."

In addition to the change in coverage criteria, CMS added dozens of new codes--going from five to 49--to be used in billing for mobility devices. According to the release, the new codes will help facilitate getting the right products to patients and improve Medicare's ability to appropriately pay suppliers.

"The technology, range of products, and market for power wheelchairs have changed substantially since the HCPCS codes for power wheelchairs were last revised in 1993," said Herb Kuhn, director of the CMS Center for Medicare Management. He added that until now, Medicare used only one code--K0011--to pay for most power wheelchairs.

CMS plans to publish a final National Coverage Determination (NCD) in March and provide guidance on how to use and document the new criteria. To read the proposed NCD, click here.

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