In view of reductions to the Medicare fee schedule, rehab providers revaluate coding procedures.

The recent reductions to the Medicare fee schedule have pushed the complex rehab provider’s margins to a razor-thin level. To counteract these cuts, extreme efficiency is needed. So, it is essential that providers ensure that they are receiving the maximum reimbursement on the products that they are supplying. In order to secure proper funding, providers must possess a strong understanding of appropriate coding procedure. A good framework for this knowledge is insight into how codes are determined and what can be done to make them more practical.

Base Codes

Power wheelchair base codes expanded from just four codes in 2006 to include nearly 60 codes that more appropriately reflect the technology and distinguishing characteristics of today’s power bases. A group of industry experts along with Medicare and its contractors developed the new code set to be applicable for both the existing marketplace and the foreseeable future. The Pricing and Data Analysis Contractor (PDAC) is responsible for the coding of power wheelchair bases. Manufacturers develop a base and submit the product along with its required testing data to the PDAC, which in turn assigns it to a particular code. This list is published on the PDAC Web site, so that each base can be specifically referenced and tied to its proper code.

Options and Accessory Codes

Option and accessory coding is a bit more complicated. While the coding of a power wheelchair base is required by policy, not all accessories are required to go through the same process. Some accessories such as backs and cushions are required to be officially coded by the PDAC prior to being recognized and eligible for payment by Medicare. The responsibility of ensuring that the product receives approval from the PDAC lies with the manufacturer.

There are several paths that can be taken in order to determine the appropriate code to use for accessories with no official code verification. Manufacturers can submit an application for parts to the PDAC for an official coding. This, in many cases, can provide additional certainty and clarification. This is especially true for items, like a pair of elevating legrests, where it’s fairly obvious how an accessory should be coded.

Miscellaneous items with less obvious coding provide more of a challenge. The current list of codes, despite being more complete than in the past, does contain several gaps. Submission of a miscellaneous part for an official coding depends on several factors, including utilization of an item and the historical processing of that item by payor sources. If a claim to a payor for a part results in inconsistent processing, the manufacturer can formally submit the product to the PDAC for verification. The verification can then be used in any disputes with payors.

Another step that can be taken for any item that doesn’t fit into an established description would be to request that the Centers for Medicare and Medicaid Services (CMS) establish a new Healthcare Common Procedure Coding System (HCPCS) code. CMS has a formal process in place for an initial application for a code. This generally takes place at the beginning of a calendar year when CMS’ Alpha Numeric Workgroup will review pertinent information about an item to determine if there are grounds to develop a new code. If there are, the workgroup will schedule a series of public hearings. Pending the outcome of these hearings, assignment of a code would be followed by the integration of the code into any relevant medical policy or the development of a new policy.

Opportunity For Change

Pride has sought to help providers resolve situations where an item has been underfunded or improperly coded. The process described above is open to a degree of subjectivity, which makes it possible for reasonable coding changes to be made for items that receive incorrect codes or that have fees established that do not reflect real world pricing. When an existing code is underpaid or the policy is applied in a prohibitive manner, there are steps that can be taken to try to resolve the situation. An example of this process can be illustrated by the handling of code E2399. When the code for an expandable controller (E2377) was first developed, CMS instructed providers to also bill using a miscellaneous electronics code for the cables, electronics, and joystick used with an expandable controller (E2399). A code was then developed for the harness used with an expandable controller (E2313) at which time providers were instructed to no longer use the miscellaneous code. The problem with this instruction was that while the miscellaneous code encompassed the electronics and joystick, E2313 only covered the electronics. In an effort to have the joystick recognized as an integral part of the expandable controller, an application was sent to CMS to establish a code for the joystick used with the expandable controller. The process to establish a new HCPCS code takes a full year, and there is no guarantee of approval. However, it is a necessary step to ensure appropriate coding, coverage, and payment for the components beneficiaries require for their unique situations.

From a manufacturer’s standpoint, there are several things that can be done to support providers. As discussed, first make sure that any products that are required to be submitted for coding follow this process. If it’s not required, but would help ensure proper coverage or payment, get it formally coded as well. When there is a problem with an existing code or fee, follow the steps to try to rectify the problem. Manufacturers proactively working to address coding issues are yet another way to help offset the impact of the recent 9.5% payment reduction and add more clarity and certainty to the process.

Seth Johnson is vice president, government affairs, Pride Mobility Products Corp, Exeter, Pa. He is also vice-chairman of AAHomecare Rehab and Assistive Technology Council. He can be reached at (800) 800-8586, or .

Paul Komishock is general manager, government affairs, Pride Mobility Products Corp. He can be reached at (800) 800-8586 or .