The HME industry rightfully greeted the release of 49 new power wheelchair codes with relief. Getting CMS to admit that the coding for mobility products was inadequate has taken the better part of 10 years. However, the coding is just one leg of the three-legged Medicare stool of coding, coverage, and payment. All three legs must stand together for beneficiaries to have adequate access to mobility devices.

As much as the industry fought for new codes and new national coverage to clarify claims processing, CMS has at least two additional if not different objectives. CMS wants to create policies to reduce fraud and abuse, and CMS wants very specific codes for implementing competitive bidding in 2007.

At press time, all stakeholders were eagerly awaiting the final National Coverage Determination (NCD) for mobility assistance equipment. Along with the final NCD will be CMS’ Decision Memorandum and CMS’ explanation of its thought process behind the final NCD.

The more specific these documents are the better, because specifics mean that the DMERCs will be more likely to interpret the national NCD consistently. If the NCD is vague, it could be more challenging to document a consumer’s need for a motorized wheelchair or power operated vehicle (POV or scooter). The DMERCs will also issue local medical policy, marrying the 49 new codes to local policy. And, importantly, CMS and the DMERCs must issue specific documentation guidance to minimize subjective interpretations of whether coverage is met.

For the sake of argument, let’s say that CMS is able to finalize a good NCD. Further, let’s assume that the industry and the agency can reach acceptable common ground on the NCD, the local coverage policy, and the payment policies. Hold off on the celebration because the assignment that the industry accepted is not yet completed.

The mission was to repair an obviously broken and outdated system. That meant making it possible for providers to outfit consumers with the most appropriate technology that meets their needs. Briefly defined, that means the mobility products they need to live and function in the least restrictive, most appropriate environment possible. CMS has taken the position that this is accomplished if the products provided “enable the consumer to perform the activities of daily living within the four walls of their home.”

As long as this stipulation is on the books, providers will never be able to get consumers what they need to live out the promises of the Americans with Disabilities Act; the Ticket-to-work/Work Incentives Improvement Act; or President Bush’s New Freedom Initiative.

CMS will tell you that it will take a literal Act of Congress to change this provision. Congress says CMS can do this with its existing rule-making authority. Ironically, CMS knows that Congress does not intend for any rule to restrict a person’s movements to the “four walls of their home.” It said so when debating legislation (the David Jayne Act) removing the “homebound restriction” to retain eligibility for home health services under Medicaid. The bill never passed because, lo and behold, CMS found that it does have the power to make such regulatory changes.

Unless the “four walls” coverage restriction is totally removed from all references in the payment policies and coverage guidelines for mobility products, providers are going to continue to have claims rejected based on subjective interpretations.

This is not simply an issue of making life easier for providers and manufacturers. It is the right thing to do. As long as the “in the home” clause exists, people with disabilities will remain second class citizens.

Those three words—in the home—tell consumers that their government does not think that their ability to be part of a community is important. They tell them that America does not care if they have the opportunity to interact with their family and neighbors.

The industry has worked hard to get where it is today. Yet, as important as the new codes, payment policies, and coverage guidelines are to the business of providing appropriate rehabilitation and assistive technology, the job is not done. The industry should not walk away from the table until and unless CMS completes the mission and removes the “in the home” restriction. If CMS continues to resist, join hands with consumers and storm Capitol Hill, the White House, and the courts and let them know that they have a fight on their hands.

Cara C. Bachenheimer, JD, is vice president of government relations for Invacare Corp, Elyria, Ohio. David T. Williams is a consultant for political and legislative strategy.