Seat elevation systems: Stakeholders help CMS shape next steps

WASHINGTON – With Medicare coverage secured for seat elevation systems, stakeholders are working their way through steps 2 and 3 of the process: coding and pricing. 

Manufacturers, led by NCART, submitted code applications to CMS by a July 3 deadline, following about two years of work, including gathering detailed and comprehensive information from each manufacturer. 

“The main goal is to clearly differentiate the standard power seat elevation technology from the complex power seat elevation technology,” said Seth Johnson, vice president of government affairs for Pride Mobility Products. “There is broad agreement on that.” 

CMS in May posted a final benefit category determination and national coverage decision approving seat elevation systems for power wheelchairs. Stakeholders expect the DME MACs to publish draft local coverage determinations, which will include more guidance on coding, later this year, Johnson says. 

NCART is also in the process of collecting data from providers on which payers have covered seat elevation systems in the past and what they’ve paid for the technology. The organization will “scrub” that data and provide it to CMS, per a request from Joel Kaiser, the director of the Division of DMEPOS Policy for the Technology, Coding and Pricing Group at the Center for Medicare, says Wayne Grau, executive director of NCART. 

“We need as many data points as we can get – we don’t want to go in there with 10 or 15; we need thousands of these things – to show them where the majority of the pricing is coming in,” he said. 

It’s pivotal that CMS get the pricing right – “we’ve heard ranges of $1,300 up to $7,200,” Grau says. 

“It’s great to get coverage and coding, but if the pricing comes back and it’s too low, no one is going to get (seat elevation systems),” Grau said, “and we all know how valuable this product is.” 

Because coverage went into effect immediately in May but there is no coding or pricing, providers are living in a world of “interim billing” for seating elevation systems, says Dan Fedor, director of coding and reimbursement for U.S. Rehab. Right now, they must use code E2300 for K0835-K0864, K0890-91 complex wheelchairs, he says. 

“The interim fee schedule will be based on gap filling,” he said. “So, a percentage of the average MSRP on the market will probably be where it lands. We did hear from the MACs that it will be based on each individual claim. So, as you submit a claim with MSRP, there will be an average and that will be the allowable and may vary per state. More to come on that.”