Our Report
Our Recommendation on Coverage Policy
Following is an executive summary of the Wheel Mobility Device Coverage Policy Recommendation
submitted September 1, 2004 to the Centers for Medicare and Medicaid Interagency Wheelchair Work Group.
Executive Summary
The Coalition to Modernize Medicare Coverage of Mobility Products (CMMCMP) Clinician Task Force submits to the
CMS Interagency Task Force the following document for consideration during the agency's review of coverage of
mobility products. The goal of the clinician task force is to provide CMS with an objective and consistent
process by which medical necessity may be determined and documented.
The core concepts of this proposal are basic. They rely on a knowledgeable and trained clinician (i.e. a physician,
physical therapist or occupational therapist) to perform a face-to-face evaluation of the patient's functional
abilities and needs. The comprehensiveness of the evaluation (basic, intermediate, or extensive) and the number of
clinical professionals involved depends on the medical complexity and functional needs of the patient. The evaluation
results in the clinical determination of the patient's functional mobility level. The next step involves matching the
patient to the technology by considering additional requirements that will further determine specific equipment
features required (clinical indicators). The functional mobility levels and clinical indicators lead to a
determination of the specific equipment the patient requires (HCPCS Code).
The document is presented in five sections. The first two sections contain new concepts developed by the coalition
including:
- Definitions of key concepts used throughout the document including a proposed definition of Functional Ambulation
- Proposed Coverage and Payment rules which include a Functional Classification System for wheeled mobility device users.
The key measure or standard for determining medical need for wheeled mobility devices is the patient's typical daily
function. Focusing on daily function is consistent with Medicare guidelines for other items of durable medical
equipment, e.g., speech generating devices ("daily communication needs"), and for prosthetic devices, e.g., lower
limb prostheses ("expected, post-rehabilitation, daily function"). For wheeled mobility devices, the standard proposed
here is functional ambulation, measured by the ability to meet the mobility needs arising in the course of typical
daily activities. Please note that while the Functional Classification System developed by the coalition is new, it
is consistent with current clinical practice. The coalition has merely codified a system.
Sections three and four provide background information on the clinical assessment process for persons needing seating
and mobility devices as well as the roles and responsibilities of the professionals involved in the process. The
clinical assessment process outlines the data related to the individual, the environment and the technology. Seven
related topics are assessed:
- the individual's medical history;
- physical abilities and needs;
- functional abilities and needs;
- seating and positioning abilities and needs;
- home accessibility;
- currently used assistive devices; and
- environmental considerations.
Patients will require one of three levels of evaluation (basic, intermediate or extensive), dependent on the
patient's status, in order to establish a clinically appropriate mobility device. While m ost Medicare patients
will fall into one of the first two categories - basic or intermediate, all are described to illustrate appropriate
processes for all potential patients - including those with more advanced needs. Regardless of the level of
evaluation performed, the goal of the evaluation is to provide all the data necessary for the professional(s)
involved to make clinical determinations about the patient's need for a wheeled mobility device and recommendations
and prescriptions for the appropriate mobility device and associated equipment.
The last section of this document, section 5, contains a summary of the activities of the coalition and a listing
of the coalition members. This section provides further information about each of the previously presented
sections.
Intended Next Steps
This proposal, without question, is but a first draft, developed under strict time constraints. Nonetheless, the
participants reached consensus through thoughtful and considerable discussion. The members of this coalition hope
that this proposal creates a foundation for discussion with the CMS interagency task force and seek further
participation in development of new Medicare wheeled mobility device coverage guidelines. By identifying the key
principles, standards, and procedures involved in wheeled mobility device provision, the coalition believes the
end result will be high quality, objective, evidence-based, consistent, professionally sound, appropriate
recommendations for wheeled mobility devices, as well as delivery of equipment by qualified suppliers.
The professionals who developed these documents are interested in CMS feedback. CMS has stated that the development
of new wheeled mobility device guidelines will be a process to continue throughout the summer and fall of 2004.
It is the Coalition's belief that their medical, clinical and rehabilitation technology supplier expertise can
provide unique input to CMS staff and others working on this project. It is the Coalition's desire that CMS will
provide feedback regarding the overall structure of this proposal, as well as its specific elements. Once received,
the Coalition's members will continue to further develop this proposal for CMS consideration.
For example, some key concepts, such as "functional ambulation," and its focus on the individual's mobility needs
arising in the course of typical daily activities, are defined with precision. The Coalition is interested in CMS
staff feedback to ensure there is general accord regarding the standards for wheeled mobility device need.
However, some of the concepts are stated more generally. The Coalition asks for CMS feedback on this proposal and is
willing to assist with any further development that the agency deems appropriate.
The Coalition has not specifically identified training, education or experience pre-requisites for any team member
participating in this process. Upon CMS's request, this is a task the Coalition is willing to pursue. In addition,
upon request, the Coalition is willing to provide recommendations regarding indications for RTS vs. DME supplier
involvement
Finally, the Coalition has not yet addressed necessary reforms to wheeled mobility device coding, an essential
component of the wheeled mobility device coverage policy reform. It is the Coalition's recommendation that coding
proposals must follow the development of coverage rules. The Coalition's members stand ready to assist CMS with
coding as well as assisting the DMERC Medical Directors in the development of the critical underlying medical policies.
However, to be of further assistance and better help CMS in this process, the Coalition will require direction as to
needed information, clarification, supportive evidence, etc., that CMS determines would be beneficial as this
important work continues.
|