Maximize reimbursements for wheelchair cushions by presenting an accurate and thorough justification letter.

Competitive bidding is coming, faster than you think and whether you want it or not. Are you ready? I’ve spent a few days this year testifying before the Centers for Medicare and Medicaid Services (CMS) in Baltimore, and the Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC), in Columbia, SC. Lots of intelligent people (mostly members of the National Coalition for Assistive and Rehab Technology) worked together to match codes for durable medical equipment (DME) with technology and patient needs. To get ready for competitive bidding, we have to define items and put them in categories. This was the last coding cycle to be in place as this process begins to implement competitive bidding. Eventually, most categories will have a price tag associated with it.

To get reimbursed for wheelchair cushions, you’ll need to know their categories and criteria. In the past, physical therapists left the details up to the supplier. Now, those days are gone. We need to medically justify every item (that is, write the letters) and make sure that patients’ needs match the technology we are requesting. Reimbursement will continue to get tougher and tighter as more and more cuts are made.

The process of assigning a code for a cushion (or any DME item) is very long and complicated. Anyone can ask CMS for new Healthcare Common Procedure Coding System (HCPCS) codes. You begin by filing a petition in April. Then you get the preliminary findings and have a chance to appeal at an open public meeting. These meetings are held in late June. You wait until the following November and get a statement as to the final decision. If you are lucky, you get a code and a definition that you may or may not understand—you may also get a denial that you may or may not understand. If you get denied, it is usually because CMS feels that your item already fits nicely in an existing code or that the State Medicare/Medicaid have not expressed any need for a new code. The hearings are open, and the folks at CMS and SADMERC are really trying to address the Health Insurance Portability and Accountability Act guidelines for electronic filing and they are also helping to meet the reality of huge cuts to Medicare and Medicaid.

Letter of Medical Necessity

Let’s get to the details. There are now four general categories of wheelchair cushions:

• general use cushion;

• skin-protection cushion;

• positioning cushion; and

• skin-protection and positioning cushion.

To meet reimbursement criteria, your letter of medical necessity has to show, through diagnosis codes, that your patient is at risk and requires additional skin protection and/or positioning. Table 1 (page 36) outlines which cushions go with which diagnosis codes.

The key to getting maximum reimbursement is two-fold. The first step is knowing how to write an appropriate letter of medical necessity, and the second is knowing when to use the miscellaneous code.

In the letter, describe the relationship between the cushion’s features and the anticipated functional outcome for the client. Also, describe what the client will be able to do as a result of having this particular cushion. You must link each description of the cushion with the specific diagnoses codes (or code).

It is important that the cushion being requested is truly medically necessary. This might sound obvious, but the letter writer (and/or signer) would be abusing the funding system or third-party payor if they requested a cushion that the client wanted but did not actually need. Funders mostly care about what happens in the home, not at work or in the community. A feature that helps the caregivers or helps the client care for their children probably won’t work, either.

A letter of medical necessity also helps third-party payors realize why it might be better to spend a little more money for a certain feature of a cushion now to avoid a more costly expense later.

Letter Elements Example of Letter

Client  and physician name and all their contact information: Include date of birth, diagnoses codes, and insurance numbers of the patient.

Introduction: Sean is a 5-year-old boy with a diagnosis of cerebral palsy, spastic tetraplegia (aka quadriplegia). He has decreased trunk control and balance, and requires maximum support to sit on a flat surface. He is unable to maintain an upright position independently; is nonambulatory; has decreased upper-extremity strength and poor endurance; and requires a power wheelchair in the home, community, and school environments. A power wheelchair will provide independent mobility in all environments for a full day of activity. Below is a report on his medical and functional status, along with recommendations for his medical equipment.

Current Medical/Physical Status

Cardio-respiratory status: Decreased cardiac output and respiratory capacity, as reflected in his multiple bouts of pneumonia.

Strength and endurance: Poor endurance; and poor strength in his trunk, neck, and upper and lower extremities.

Tone/movement: The client presents with spasticity in the trunk, and in the lower and upper extremities.

Orthopedic conditions: Moderate right hip subluxation, 20° scoliosis, flexible kyphosis, and windswept deformity (pelvic obliquity).

Range of motion: Within functional limits for passive range except bilateral knee contractures (-15° bilaterally) and ankle plantarflexion contractures (-10° bilaterally).

Cognition: Scores at the 3-year-old level.

Visual and perceptual deficits: Limited depth perception and some difficulty with spatial awareness.

Bowel and bladder status: Wears diaper at school and at nighttime, but has no accidents and uses the toilet when at home.

Swallowing status: Cannot tolerate thin liquid or chunky textures.

Sitting Posture

Balance: Absent dynamic movement and poor static sitting with hands propped.

Pelvic posture: Posterior tilt, yet a flexible pelvis with right-sided elevation and rotation.

Spinal alignment: Flexible with scoliosis and kyphosis.

Head position: Forward and flexed, can hold head in midline and upright for 30-45 seconds.

Lower extremity: Requires full support.

Skin Integrity

Client is susceptible to decubitus ulcers. He is a high-risk candidate due to decreased mobility and sensation. He also is not independent with his pressure relief due to decreased upper-extremity strength and poor memory.

Sensation: Impaired due to cerebral palsy.

Present/past history of ulcer: None, but redness occurs when he has been in the chair all day and persists for more than 15 minutes when he is removed.

Location: None

Functional Status

Transfers: Maximum assistance using a stand pivot and one person to assist.

Ability to perform pressure relief: Maximum assistance is needed.

Wheelchair Propulsion

In home: Dependent in manual wheelchair. Independent in a power wheelchair.

Outside environment: Dependent in a manual wheelchair. Independent in a power wheelchair.

Ambulatory Status

Household ambulator: This client will not be an independent ambulator.

Distance ambulating: N/A

Home environment accessibility: Modifications required for exit and entrance into the home with the power wheelchair. His bathroom is also not accessible.

Hours spent in wheelchair: All day, as he is dependent on a wheelchair for mobility.

Equipment Recommendations

Name your choice, and now justify each and every component.

1) A power wheelchair is required for independence with mobility needs, both in his home and in the community. This client has decreased trunk control, and cerebral palsy with very limited upper-extremity function. He has poor balance in a nonsupported surface, which requires external support to maintain his posture. He is able to use a head array.

2) Angle-adjustable foot plates. This client has decreased ankle range of motion, and he cannot tolerate a standard footrest angle. An adjustable foot plate can be adjusted to his current range of tolerance and be changed if he gains range of motion.

3) A pressure-relieving cushion with postural control is required due to decreased sensation of the lower extremities and a pelvic obliquity. The cushion will provide appropriate weight distribution to reduce high-pressure areas. The gel properties will decrease shearing and help maintain a neutral pelvic position through the contoured base.

For More Information

Coding

www.cms.hhs.gov/providers/pufdownload/anhcpcdl.asp

www.cms.hhs.gov/medicare/hcpcs

http://www.wheelchairnet.org/WCN_Prodserv/Funding/ funding.html

Assessment tool

http://www.seniors.gov.ab.ca/aadl/faq/manual/pdf/55%20Assessment%20Tool%20Wheelchair%20Cushion.pdf#search=assessment%20and%20wheelchair%20and %20cushion

Sample Letters

http://www.ridedesigns.com/CustomFunding.pdf

Ginny Paleg, MPT, is a pediatric physical therapist in Silver Spring, Md, and is a member of the APTA Pediatric Section Government Affairs Subcommittee on Equipment Reimbursement. She teaches continuing-education programs and can be reached at ginny@paleg.com.