Seeing a child propel a wheelchair for the first time as she gains both independence and mobility is extremely gratifying. But increasingly it is becoming more and more difficult to accomplish this goal. Funding sources have already limited the number of equipment options and have now created a reimbursement coding system that often prolongs and complicates the process.

As Medi-Cal (California’s Medicaid) and most insurance companies have become more compliant with HIPAA, several new codes have been implemented. They include but are not limited to mobility bases, seating systems, and their components. The implementation of codes, some would argue, is long overdue. Using miscellaneous coding is ripe for abuse with no way for the state to control costs. On the other hand, some codes are confusing and misunderstood, while many allowables are too low for adequate reimbursement.
For manufacturers to be more HIPAA compliant, they have changed their wheelchair designs and order forms. For the new wheelchairs to be approved by SADMERC (Statistical Analysis Durable Medical Equipment Regional Carrier), they have to be somewhat different from their predecessors. They cannot simply change the pricing to make it more profitable to suppliers.

Medi-Cal has stated that we must use pricing effective August 2003. We cannot use pricing after that date unless it is a new product or design. Their fear was that the manufacturers would just raise prices to help suppliers offset the mandatory discounts, ranging from 10% to 20% off retail.

The new order forms are broken down to reflect existing codes rather than various components included in the base price. Even though the justifiable components are an up charge, the new structure is still less expensive to the funding source.

Coding Examples
Now that those pediatric mobility bases are coded, with established allowables, it is more important than ever that rehabilitation technology suppliers (RTSs) pay closer attention to the allowable and acquisition costs. This is not to suggest that the cost of the product dictates which product the client gets, but it has to be a consideration.

If you consider a folding tilt-in-space wheelchair that may retail for $2,750, the new coded allowable is $1,928.95, a 30% discount off retail. The newer designs (some identified as SE) are more closely priced to the allowable. The new retail price is $2,250.

Certain options now have codes. Pneumatic tires, for example, are billed using code K0067. Angle ad-justable footplates that may be needed when ankle foot orthoses are used would be billed using K0040. Flat-free inserts use K0064.

Billing for the wheelchair and for the justifiable options separately still saves insurance companies money over their previous acquisition cost, and suppliers can still make a reasonable gross profit. It is important for various reasons to get the order right the first time. From a business standpoint, it is important because when we need to repair the wheelchair or even grow it, the reimbursement rates for some replacement parts are below our costs. For example, I may provide a child a wheelchair with 90-degree hangers. When the child outgrows that hanger and I need to replace it with a 70-degree one, our reimbursement using K0044 is $16.37. I can’t even buy it for that.

Stroller bases or pediatric tilt-in-space mobility systems can be ordered from one manufacturer with a seating system, and a similar stroller from another manufacturer is ordered as a base with the seating system separate. The first manufacturer’s stroller is coded E1232 with seating—an allowable of $2,138.41. The second manufacturer is coded as E1234 with an allowable of $1,928.95. The seating is coded as E1013 with a reimbursement of $837.93.

It seems obvious to order the latter since reimbursement is over $2,700. However, the manufacturer’s list price for the base is under $1,600. Is it ethical to submit the E1234 at the manufacturer’s list price or the coded amount? You could argue to submit at the full allowable since that is what SADMERC has classified. The extra profit would offset losses taken on other codes. We have taken the position that if the retail price is lower than the allowable, then that is what we submit.

Two New Codes
There are two new codes for seating systems. In California, when billing Medi-Cal, we are using E1012 for a planar seat and back with a connecting hinge and fixed mounting hardware. For insurance companies using HCPCS codes, they would be E2291+ E2292. E1013 is for contoured seating, and this would include an antithrust seat and/or contoured foam back. This also includes fixed hardware. HCPCS codes are E2293 + E2294 alternative mounting hardware. A knob release with an adjustable plate is justifiable and billed as K0108 when needed for positioning.

If you used the adjustable hardware for the seat, you could angle the seat up for hip flexion. You could also use the adjustable hardware on the back to close the seat to back angle. Some wheelchairs have adjustable angle backs, so if you needed to open the seat to back angle, you could do that with the back canes and possibly use the fixed hardware. The adjustable knob-release hardware would provide an increased adjustment range and would be my preference. You may also need the knob-release hardware to remove the seating system and fold the chair for transport.

The major seating manufacturers have submitted their products to SADMERC for classification. They have changed their order forms and have added codes to the applicable products. You can view what has currently been classified at www.palmettogba.com. Check this often because products are added frequently.

Molded Seating
There are several manufacturers of molded seating. Most use a seating simulator, which has a seat and back filled with beads. The air is removed from the bags, forming a perfect shape around the body. Molded seating is typically for clients with structural deformities, scoliosis, or lordosis, or where you cannot get good contact with planar seating.

Other types of molded seating include foam in place. This system has a wood base and a cover with a zipper. A bag is inserted in the cover to which chemicals are poured, and the chemical reaction forms a shape for the seat or back.

The code for a molded back is E0666, with a “by-report” allowable. This code includes mount hardware. The reimbursement will depend on the total dollar amount billed for the claim. The molded seat is E0658 with the same reimbursement. When providing molded seat systems on a new wheelchair, most funding sources will not pay for labor. You cannot collect for the time it takes to set up the molding machine, mold the client, and install it on the wheelchair. So it is important to keep your costs to a minimum. As a result, we have gone away from the system that requires a plaster cast and instead are using the digital method. This system has reduced the time it normally takes to complete a mold. With the digital system, I can usually complete a mold in about an hour and a half. There is virtually no cleanup, the digital image is transferred to your laptop, and the image is then e-mailed to the manufacturer. This saves time and money by not having to ship the cast for fabrication. And since it is on your computer, changes can be made if needed without having to remold.

Planning for Growth
When evaluating for seating, plan on providing for future growth. It is easy to get a three-inch growth tail. The extra seat depth that is tucked underneath the back will have the obvious benefit of replacing the seat later rather than sooner. The Medi-Cal code for a solid seat insert is E0992 with an allowable of $77.14. The retail price from the manufacturer is about $140 to $150.

Other seating components such as an abductor and headrest will have two codes. The one for the abductor pad is E0957, and E1028 is for the swing-away hardware. The headrest will be E0955 for the pad and E1028 for the mounting hardware, swing away, or detachable.

Coding for trunk supports is a little more confusing. Medi-Cal uses E1025 for fixed hardware and flat pad, while the HCPCS code is E0956. Use E1026 for swing-away bracket and tracks. E1027 is for swing-away hardware, summer/winter brackets, and tracks.

Appropriate Mobility Base
Always consider growth when pondering wheelchair bases. Depending on the client’s diagnosis, the ability to expand the seat depth may be more important than frame width. This is not to say that you cannot get both seat depth and width on the wheelchair frame. There are wheelchair frames that have several holes that allow you to move the back canes rearward as the child grows. This feature, with the growth tail on the seat insert, will get you extended usage. This service life span will depend on the child’s growth. Occasionally, I see a child, 10 to 12 years old, in a rigid ultra-light wheelchair. Although I understand why it is being prescribed, it is difficult to justify to the funding source. There is no growth in the frame, so as the child outgrows the chair, a new frame is required.

Another feature on the same base has a tab where the crossbars mount. This tab has one or two holes that allow you to grow the frame width by relocating the crossbars. Again, this will give you more usage out of the chair.

Frame components have to be replaced to grow in length. To grow in width, the crossbars need to be replaced. Some manufacturers will provide a one-time crossbar assembly at no charge. Other manufacturers charge for the crossbar on the assumption that the supplier can bill for the growth kit. It is my opinion that if you can get the growth for free and built into the chair, then that is the ethical thing to do.

Ultimately, it is our responsibility to provide the seating and mobility system that will provide the most growth potential while fulfilling the client’s needs. When new codes arrive in January 2006, we must make sure that billing frustration does not interfere with helping children.

Mark Grillo, CRTS, works at ATG-Wheelchair Center, Sacramento, Calif, and has more than 20 years experience in the field of seating and positioning. Grillo can be reached via email: m.grillo@atgwci.com.