Mark McClellan CMS Releases Mobility Coverage Criteria CMS recently released new national coverage criteria for mobility assistive equipment (MAE) including power wheelchairs and scooters. The new criteria, which are effective immediately, adopt a function-based determination of medical necessity. This determination looks at the ability of beneficiaries to safely accomplish mobility-related activities of daily living (ADLS) without the use of mobility equipment. The national coverage determination (NCD) addresses the full range of MAE from simple canes and walkers to sophisticated power wheelchairs. “The steps we are taking today are part of our efforts to ensure that seniors who need mobility help will get it promptly, and that we are paying appropriately for MAE,” said CMS Administrator Mark B. McClellan, MD, PhD. “The new functional criteria reflect current medical practice and mean that beneficiaries will have the freedom to live better, more mobile lives, without needing to fit into a rigid ‘bed or chair-confined’ standard.” AAHomecare will continue to press for elimination of the “in-the-home restriction” for coverage of MAE and an expansion of the interpretation of ADLs to include mobility itself. AAHomecare membership anticipates a meeting with CMS to clarify several issues, such as documentation requirements for determination of medical necessity for mobility equipment, and to work toward appropriate implementation. In addition to developing new coverage criteria, CMS has developed new billing codes that will take effect January 1, 2006, to reflect the variety of wheelchairs now on the market. CMS also expects to issue new quality standards for suppliers in 2006.

AARP Study Supports Home Care
The AARP’s new study on livable communities, “Beyond 50.05, A Report to the Nation on Livable Communities,” lists funding of home care as one of its calls to action. The report recommends funding to promote home care and other community-based services to persons of limited means.

The study also reaffirms that the vast majority of people over the age of 50 want to remain in their current residence; 74% of Americans over the age of 50 strongly agree with the statement, “What I’d really like to do is stay in my current residence for as long as possible.” That percentage is 83% for those ages 65 to 74 and 86% for those 75 and older. The data is based on a sample of more than 1,000 surveyed by AARP and Roper in 2004.

OIG Begins Survey of Inhalation Drug Services
A random sample survey sent to providers by the Office of Inspector General (OIG) may result in recommendations that CMS could use in decisions related to the inhalation drug therapy dispensing fee. The survey, sent to providers of inhalation drug therapies, seeks information about services provided in 2003 to Medicare patients in connection with inhalation drugs administered through a nebulizer.

In responding to the survey, it is critical that providers record all services to accurately reflect the extensive costs of dispensing inhalation drugs to Medicare beneficiaries. The survey requires completion of a form for each service provided to patients during 2003. However, the questionnaire does not capture all dispensing fee service categories and therefore requires additional pages to demonstrate the provision of all unlisted services that would fall into the “other” category. For instance, the survey does not capture after-hours or weekend services and excludes billing activities, which omits substantial activities and services that would factor into the costs.

Because the survey requires retrieval of documentation for 2003 services and the OIG requests responses by May 18, 2005, AAHomecare recommends that each provider request that the OIG extend its deadline to June 20 to ensure full compliance with the document and information request. AAHomecare has requested a meeting with the OIG to discuss the survey and convey its concern that the survey may not collect adequate service and cost information.

National Provider Identifier Activities Begin
CMS recently announced availability of a new identifier for use in standard electronic health care transactions. The National Provider Identifier (NPI) will be the single provider identifier, replacing the different provider identifiers currently used for each health plan with which providers do business. According to CMS, all health care providers who transmit health information electronically in connection with any of the HIPAA standard transactions are required by the NPI Final Rule to obtain NPIs. This is true even if providers use business associates such as billing agencies to prepare the transactions.

With national standards and identifiers in place for electronic claims and other transactions, health care providers will be able to submit transactions to any health plan in the United States. According to CMS, many health plans (including Medicare, Medicaid, and private health plans) and all health care clearinghouses must accept and use NPIs in standard transactions by May 23, 2007 (small health plans have until May 23, 2008). After those compliance dates, health care providers will use only NPIs to identify themselves in standard transactions where the NPI is required.

CVS Partners With CMS to Increase Drug Benefit Enrollment
CVS/pharmacy, Woonsocket, RI, has partnered with CMS to help enroll the over 8 million low-income individuals eligible for the government-subsidized Medicare prescription drug benefit that takes effect January 1, 2006. CVS will work with CMS and the Social Security Administration to target low-income seniors and persons with disabilities eligible for this program.