Monthly Archives: September 2017

Complex Rehab Technology and Manual Wheelchair Accessories:Help HR 3730 Get Passed

By – Kay Koch, OTR/L,ATP, RESNA Fellow

Complex Rehab Technology (CRT) includes specialized wheelchairs, seating systems, and other adaptive equipment such as standing devices and gait trainers.  These individually configured products are used by people with high level disabilities such as ALS, cerebral palsy, multiple sclerosis, muscular dystrophy, spinal cord injury, and traumatic brain injury to meet their unique medical needs, reduce their medical complications and costs, and maximize their function, mobility and independence.

Currently, Congress is considering legislation that would protect access to Complex Rehab Technology.  This will replace the previously introduced broader bill, H.R. 1361, written to prohibit CMS from using Competitive Bid pricing for accessories used with either CRT power or CRT manual wheelchairs.

The CRT “power” wheelchair accessories issue was resolved in late June 2017 when CMS announced a policy clarification stating it would not use Competitive Bid pricing for accessories used with Group 3 CRT power wheelchairs. We thank CMS and Congress for that needed action.

Unfortunately, the clarification did not extend to accessories used with CRT “manual” wheelchairs so this follow up legislation is needed. Passage of this new bill would address and fix the current disparity that prevents people who use a CRT manual wheelchair from having the same access to CRT accessories as those using a CRT power wheelchair.

H.R. 3730 is the newest bill introduced to stop CMS’ inappropriate application of Medicare Competitive Bid pricing to CRT ( Complex Rehab Technology) manual wheelchair accessories, which are critical wheelchair components. This legislation was introduced September 8, 2017 by Representatives Lee Zeldin (R-NY) and John Larson (D-CT) to stop CMS from using Competitive Bid pricing for accessories used with CRT manual wheelchairs.  They were joined in this bipartisan action by 41 original cosponsors (19 Republicans and 22 Democrats) and includes excellent representation from the key Congressional Committees.

This bill is needed to resolve the lingering issue of CMS applying competitive bid pricing to accessories used with CRT manual wheelchairs.  Unfortunately, the June policy change by CMS solved the problem for CRT power wheelchairs but did not extend that same correction to CRT manual wheelchair accessories.  People with disabilities who use a CRT manual wheelchair should have the same access to critical wheelchair components as those who use a CRT power wheelchair.

Please contact you representative to either ask them for support of this legislation or thank them for their support. If you work with people who use CRT as them to get involved with asking their representative for support of this legislation.  A Senate companion bill is expected to be introduced shortly, but for now, the focus remains on securing House of Representatives cosponsors.

 

The following website links provide information on the legislation, and how to contact your representative.

www.acess2CRT.org

www.ncart.us

Audit Alert: CPAPs and Spinal Orthoses

On August 2, 2017, Performant Recovery, the National DMEPOS RAC, added Spinal Orthoses to their approved issues list. According to their website, Performant Recovery will perform complex reviews of these claims to determine if coverage criteria outlined in the Local Coverage Determination (LCD) for Spinal Orthoses was met. Performant will review medical documentation provided to determine that services were reasonable and necessary.

Codes included in the audit are: L0452, L0480, L0482, L0484, L0486, L0629, L0632, L0634, L0636, L0638, L0640, A9270.

Per the LCD, a spinal orthosis (L0450 – L0651) is covered when it is ordered for one of the following indications:

  1. To reduce pain by restricting mobility of the trunk; or
  2. To facilitate healing following an injury to the spine or related soft tissues; or
  3. To facilitate healing following a surgical procedure on the spine or related soft tissue; or
  4. To otherwise support weak spinal muscles and/or a deformed spine.

If a spinal orthosis is provided and the coverage criteria are not met, the item will be denied as not medically necessary.

 

On September 8, 2017, Performant Recovery announced that they added CPAPs billed without a diagnosis of Obstructive Sleep Apnea (OSA) to their approved issues list. According to their website, Performant Recovery will perform automated reviews of these claims to identify improper payments for claims for a CPAP with the missing diagnosis of OSA.

Codes included in the audit are: E0601

Per the LCD, an E0601 device is covered for the treatment of obstructive sleep apnea (OSA) if criteria A – C are met.

A. The beneficiary has a face-to-face clinical evaluation by the treating practitioner prior to the sleep test to assess the beneficiary for obstructive sleep apnea.

B. The beneficiary has a sleep test (as defined below) that meets either of the following criteria (1 or 2):

  1. The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events; or,
  2. The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of:
    • Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or,
    • Hypertension, ischemic heart disease, or history of stroke.

C. The beneficiary and/or their caregiver has received instruction from the supplier of the device in the proper use and care of the equipment.

If a claim for an E0601 is submitted and all of the criteria above have not been met, it will be denied as not reasonable and necessary.