GAMES/GRTC Winter Meeting
Washington Update:
Complex Rehab Technology
February 4, 2014
Cara Bachenheimer
Senior Vice President, Government Relations
Invacare Corporation
Today’s Topics
 Health Care in DC this year
 Observations On CRT
 Medicare Separate Benefit Category
 Other Medicare Issues
 Medicaid Activities
 Educational Tools
 Questions and Discussion
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Health Care in DC
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SGR/Doc fix/Physician payment reform bill
SFC: Sen. Baucus leaving, Sen. Wyden likely moving in
Ways and Means mark up Dec 12, 2013
Now:
Senate Finance Committee December 12, 2013 mark-up
 Sen. Charles Schumer (D-NY) submitted CRT bill (S. 948) to
Physician Payment Reform bill amendment list
 Later withdrawn
 Why is this significant?
3
Keys To The Future of CRT
 Increase CRT “awareness”…..what is it?
 Establish needed coverage, coding, standards, and
payment changes with payers
 Enhance/develop data on clinical evidence and
outcomes
 Build on advocacy involvement of consumers and
clinicians
 Increase available financial support and other
resources for advocacy and research
4
Positive CRT Factors
 Policy makers at federal, state, and private levels
are more aware of CRT
 All CRT stakeholders are more engaged and that is
building
 Exemption from Medicare Competitive Bidding
 Noble mission..…improving the quality of life for
people with disabilities
 DC terminology: White Hat issue!
 We’ve had some wins!
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Past CRT Wins
 Power WC Competitive Bid exemption
 Power WC purchase option retention
 Classifying K0005 and E1161 as CRT
 Competitive Bid exclusions of K0005 and E1161
 Washington State CRT recognition
 Variety of Medicaid resolutions
6
National CRT Week
 First time event held last year - the week
of August 19th to 23rd , 2013
 Campaign took CRT message to
Congress when they were home for
August Recess
 Good participation for first year from
CRT stakeholders…generated 11 cosponsors
 Will be expanded and held annually
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Message To Congress
 CRT is critical to the health and independence of
people with complex disabilities
 CRT is specialized and individually configured like
Orthotics/Prosthetics (custom braces/artificial
limbs)
 These products and services are different than
standard DME and need segregation
 Broad DME policies and codes do not address
needs of people with disabilities
 H.R. 942 and S. 948 must be passed to provide
needed distinction and solutions
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Describing CRT
 Medically necessary and individually configured
 Manual and power wheelchair systems
 NOT what is seen on TV!
 Specialized seating and positioning systems
 Other adaptive items (standers, gait trainers)
 Requires evaluation, configuring, fitting, adjustment,
training, or programming
 Provided through an interdisciplinary clinical and
technology team (physician, therapist, ATP)
 Designed to meet the individual's specific and unique
medical, physical, and functional needs
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Congress Has Said CRT Is Different
 Congress gave a partial exemption from
Competitive Bidding in 2008 (but that
only protected CRT power wheelchairs)
 Congress maintained purchase option for
complex rehab power wheelchairs in 2010
 Recognition needs to be expanded
through the establishment of a Separate
Benefit Category for CRT
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SBC Federal Bills
 The “Ensuring Access to Quality Complex
Rehabilitation Technology Act of 2013”
 Creates separate Medicare DMEPOS benefit category
for CRT and improves safeguards and access
 House bill H.R. 942 introduced in March 2013 by
Representatives Joe Crowley (D-NY) and Jim
Sensenbrenner (R-WI)
 Senate bill S. 948 introduced in May 2013 by Senators
Chuck Schumer (D-NY) and Thad Cochran (R-MS)
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Key Provisions of Legislation
 Creates separate category for CRT within the Medicare
DMEPOS benefit (similar to O&P)
 Recognizes specific HCPCS codes as CRT and allows
creation of new CRT codes as needed
 Eliminates the in-the-home restriction for CRT and adds
functional considerations
 Expands clinical evaluation for CRT mobility
 Increases supplier standards regarding credentialed
staff and repair capabilities
 Fully exempts CRT from competitive bidding
 Bill text and other info at www.access2crt.org
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Support So Far
 House Bill - H.R. 942
 85 co-sponsors
28 Republicans; 57 Democrats
Georgia:
Rep. Hank Johnson (D)
Rep. John Barrow (D)
Rep John Lewis (D)
Rep Tom Price (R)
 Senate Bill - S. 948
 5 Democrats; 2 Republicans
 See list by state at www.access2crt.org
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“Cost” of Legislation
 NCART hired DC actuarial firm (Dobson &
DaVanzo) to estimate the cost
 Congressional estimates are typically made
based on a 10 year projection
 “Cost” of the bill is estimated at $5 Million a
year ($56 Million over 10 years)
 Does not include the impact of “savings” from
improved access to CRT
 Congressional Budget Office (CBO) does
“official” scoring
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Legislative Road Map
1) Need additional Senate and House cosponsors, especially key committee
members
2) Key committee staff
3) Congressional Budget Office score
4) Ultimate goal: get bills attached to larger
Medicare-related legislation and passed
in both chambers
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Dedicated SBC Website
 SBC Headquarters at www.access2crt.org
 “Sign-up for Updates”
 “Contacting Congress”
 “Sponsor Scorecard”
 “Advocacy Tools”
- Call To Action
- Legislation Info Pack
- Intro to CRT Video
- Legislation Text
- Supporting Organizations
- CRT Facts & Figures
- SBC Proposal (detailed)
- Other helpful documents
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CRT Legislation Information Pack
 Key documents all in one PDF file for emailing
and printing
-- Pictorial Cover
-- Reps. Crowley and Sensenbrenner letter
-- Summary of Bill
-- Sens. Schumer and Cochran announcement
-- SBC Position Paper
-- Complex Rehab vs Standard Mobility pictorial
-- List of supporting consumer/clinician groups
 Download at www.access2crt.org
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Call To Action!
 Grassroots is critical!
 All CRT stakeholders need to take action:
Step 1- Go to www.access2crt.org
Step 2- Email your Members of Congress
Step 3- Follow up until your Members sign on
Step 4- Spread the word (using the one page
Call To Action) and get other CRT supporters
engaged in our efforts
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CRT Items & Comp Bidding
 CRT power wheelchairs (Group 3 and above)
are legislatively exempt
 H.R. 1717 would expand Medicare CRT
definition
 CRT manual wheelchairs (E1161, K0005,
K0009) were excluded from Round 2 by CMS
based on stakeholder advocacy
 Exemption/exclusion includes accessories
and options supplied for these bases
 Suppliers must use modifiers when billing to
get “traditional” fee schedule amounts- MLN
Matters Bulletin 8181
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WC Repairs & Comp Bidding
 Round 2 rules need further written clarification Technically, certain repairs can be done by either
contract or non-contract suppliers
 “Repair” vs. “Replacement” – some replacements
can only be done by contract supplier
 See CMS Fact Sheet (Google “ICN 905283 March
2013”)
 CB items must be billed on assignment basis and
supplier gets paid Single Payment Amount
 Labor and non-CB items can be billed non-assigned
 Active discussions underway with CMS
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CMS Reclassifies 78 codes to Capped Rental
 Issued in CMS Final ESRD Payment Rule November 22, 2013
 Items currently paid for on-purchase basis
 CMS claims they don’t meet original intent of “purchase”
items, that they are $100 or less
 If the accessory is furnished with complex rehab
equipment (K0835-K0864), the accessory will also have
first month purchase option
 50 of the 78 codes are wheelchair related
 Legislative pressure on CMS to address
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CMS Reclassifies 78 codes to Capped Rental
 Effective Dates Vary – Whether Item is in Round 1 and/or
Round 2:
 April 1, 2014: for items furnished in all areas of the country,
if the item is not included in either Round of national
competitive bidding – E1161 Adult Tilt-in-Space chair!
 July 1, 2016: for items furnished in all areas of the country, if
the item is included in a Round 2 bid area and not in a
Round 1 Re-compete and for items included in Round 1 Recompete but furnished in an area other than one of the 9
Round 1 Re-compete areas, and
 January 1, 2017: for items included in a Round 1 Re-compete
and furnished in one of the 9 Round 1 Re-compete areas
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The 78 codes
HCPCS Brief Description
A4639
Infrared heat system replacement pad.
A7025
Replace chest compress vest
E0117
Underarm spring assist crutch
E0140
Walker with trunk support
E0144
Enclosed walker with rear seat
E0149
Heavy duty wheeled walker
E0197
Air pressure pad for mattress
E0198
Water pressure pad for mattress
E0300
Enclosed pediatric crib hospital grade
E0457
Chest shell
E0620
Capillary blood skin piercing device laser
E0656
Segmental pneumatic trunk
E0657
Segmental pneumatic chest
E0740
Incontinence treatment system
E0760
Osteogenesis ultrasound stimulator
E0762
Trans elec jt stim dev system
E0764
Functional neuromuscular stimulation
E0849
Cervical pneumatic traction equipment
E0855
Cervical traction equipment
Included
in NCB
Round 2
Included in
NCB 1
Recompete
x
x
x
x
x
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Item billable as “purchase”
when provided with
Complex Rehab power
wheelchair
The 78 codes
HCPCS Brief Description
Included
in NCB
Round 2
Included in
NCB 1
Recompete
x
x
E0856
Cervical collar w air bladder
E0955
Cushioned headrest
E0984
Add power tiller
E0985
Wheelchair seat lift mechanism
E0986
E1002
Manual wheelchair push-rim power
assist
Power seat tilt
E1003
Power seat recline
E1004
Power seat recline mechanism
E1005
Power seat recline power
E1006
Power seat combo w/o shear
E1007
Power seat combo w/shear
E1008
Power seat combo power shear
E1010
Add power leg elevation
E1014
Reclining back add ped w/c
E1020
Residual limb support system
x
E1028
Wheelchair manual swingaway
x
E1029
Wheelchair vent tray fixed
E1030
Wheelchair vent tray gimbaled
E1161
Manual adult wheelchair w tilt in space
Item billable as “purchase”
when provided with
Complex Rehab power
wheelchair
x
x
X
X
X
X
X
X
X
X
x
x
X
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The 78 codes
HCPCS
Brief Description
E1232
E1233
Folding pediatric wheelchair tilt-inspace.
Rig pediatric wc tilt in space w/o seat.
E1234
Fld pediatric wc tilt in space w/o seat.
E1235
Rigid pediatric wheelchair adjustable.
E1236
Folding pediatric wc adjustable.
E1237
Rigid ped wc adjustable w/o seat.
E1238
Fld ped wc adjstable w/o seat.
E1700
Jaw motion rehab system.
E2227
Gear reduction drive wheel.
E2228
Mwc acc, wheelchair brake.
E2310
Electro connect btw control
E2311
Electro connect btw 2 system
E2312
Mini-prop remote joystick
E2313
PWC harness, expand control
E2321
Hand interface joystick
E2322
Mult mech switches
E2325
Sip and puff interface
E2326
Breath tube kit
E2327
Head control interface mechanism
Included
in NCB
Round 2
Included in
NCB 1
Recompete
Item billable as “purchase”
when provided with
Complex Rehab power
wheelchair
x
X
X
X
X
X
X
X
X
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The 78 codes
HCPCS
Brief Description
Included
in NCB
Round 2
Included in
NCB 1
Recompete
E2328
Head/extremity control interface.
E2329
Head control interface nonproportional
E2330
Head control proximity switch
E2351
Electronic SGD interface
E2368
Pwr wc drivewheel motor replace
x
E2369
Pwr wc drivewheel gear box replace
x
E2370
Pwr wc dr wh motor/gear comb
x
x
x
x
E2373
Hand/chin ctrl spec joystick
E2374
Hand/chin ctrl std joystick
E2375
Non-expandable controller
E2376
Expandable controller, replace
E2377
Expandable controller, initial
E2378
Pw actuator replacement
E2500
SGD digitized pre-rec <=8min.
E2502
SGD prerec msg >8min <=20min.
E2504
SGD prerec msg >20min <=40min.
E2506
SGD prerec msg > 40 min.
E2508
SGD spelling phys contact
E2510
SGD w multi methods messg/access
K0015
Detach non-adjus hght armrest
x
K0070
Rear whl complete pneum tire
x
K0607
Repl battery for AED
K0730
Ctrl dose inh drug delivery system
Item billable as “purchase”
when provided with
Complex Rehab power
wheelchair
X
X
X
X
X
X
x
X
X
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x
x
CMS PMD PA Demo
 PMD Prior Authorization Demonstration
 3 year demo, began September 2012
 esMD, 10 business days to initial response, 20 for
resubmissions
 7 states (CA, FL, IL, MI, NY, NC, TX)
 DME Providers Support!
 PMD Electronic Clinical Template
 Legislative expansion/acceleration?
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CMS eDoC Initiative
 eDoC: Electronic Determination of Coverage
Workgroup
 Office
of
Information
National
Coordinator
Technology
in
for
and
Health
industry
stakeholders
 Goal: tools to facilitate provider documentation
and communication
 PMD User story – approved October 30, 2013
 Next: Pilot Phase
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Medicaid
 State CRT separate recognition
 NCART National Medicaid Survey
 Movement to managed care plans
 DME Reuse/Refurbish Programs
 Legal advocacy resources available
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State Separate “Recognition”
 Remember, at state level - it’s about separate
“recognition” not a separate “category”
 Can be accomplished in a variety of ways
 Strategy and actions are dependent on STATE
laws and regulations
 Don’t proceed without a plan
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Minimum Recognition Specs
 Supplier Standards-- Increase level of qualifications to provide CRT
-- Require service and repair capabilities
 Coding & Coverage-- Segregate CRT products from standard DME
-- Recognize specialized nature of CRT
-- Base eligibility on medical AND functional needs
 Payment-- Recognize significant services and required supplier
personnel and infrastructure
-- Provide funding to cover product AND service costs
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State Steps
1) Identify specific changes needed (supplier standards,
coverage, coding, payment)
2) Get stakeholder input and support (suppliers,
manufacturers, clinicians, consumers, others)
3) Identify state contacts and potential champions and
have initial discussions
4) Determine pathways (regulatory, legislative)
5) Identify actions and needed resources
6) Develop plan and timetable
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Current State Activity
 Washington legislation- House Bill 144 passed and
effective January 1, 2014
 Other States with active Work Groups -- California
-- Colorado
-- Connecticut
-- Illinois
-- New York
-- North Carolina
-- Oregon
-- Oklahoma
-- Pennsylvania
-- Virginia
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Available State Resources
 Medicare SBC materials
 NCART State Position Paper
 NCART State Outline
 NCART Legislation Templates
 NCART strategic advice and assistance
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CRT Educational Materials
 Everyone needs to be a CRT Advocate
 Education Materials section at www.ncart.us
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Tools For Telling The CRT Story
Separate Benefit Category Information
CRT Facts and Figures
The CRT Company (narrative, workflow, finances)
CRT Delivery Process
Many other helpful documents
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Intro To CRT Video
 Entitled …. “Complex Rehab Technology - Essential for
Health. Essential for Life.”
 Presents CRT from the perspectives of
-- Individuals who use and rely on it
-- Physicians who prescribe it
-- Advocates who protect access
 Invest 10 minutes and get a great overview of CRT -- a
“must see” for any policy maker
 Can be viewed and downloaded at www.ncart.us
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NCART Standing Device Guide
Table of Contents:
1- Introduction
2- Types of Standing Devices
3- The Evaluation and Documentation Process
4- Funding Requests and Decisions
5- The Appeals Process
6- Glossary of Terms
7- NCART Workgroup Contacts
8- Other Resources and Links
9- Standing Device Evaluation Worksheet
See Educational Material section at www.ncart.us
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Questions and Discussion
Cara C. Bachenheimer
cbachenheimer@invacare.com
440-329-6226
Invacare web site: Policy & Funding
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