The latest HCPCS Coding Cycle included coverage and funding determinations for a number of durable medical equipment (DME) items.
Announced at the start of March, the final coding, benefit category and payment determinations followed a November 2023 meeting between industry representatives and the Centers for Medicare & Medicaid Services. The March document “presents a summary of each HCPCS Level II code application and CMS’s coding decision for each application processed in CMS’s Second Biannual 2023 Non-Drug and Non-Biological Items and Services HCPCS Level II code application review cycle,” CMS said.
While the most talked-about product category this time around was power seat elevation for Complex Rehab and consumer power chairs, the coding cycle included decisions on a number of other products.
Here are three DME items/issues submitted to CMS for Medicare coding and funding consideration this time around, and the agency’s final determinations.
VOCSN VC and VOCSN VC Pro Ventilators, React Health/Ventec Life Systems: CMS noted that the applicant described these devices as products that “combine ventilation and cough stimulation into one integrated device. VOCSN VC may be used for invasive and non-invasive applications.” CMS established a new HCPCS code, E0468, defined as “Home ventilator, dual-function respiratory device, also performs additional function of cough stimulation, includes all accessories, components and supplies for all functions.”
Ankle foot orthosis (L1971): CMS reported that Restorative Medical, headquartered in Bradenburg, Kentucky, requested a revision to the L1971 code (Ankle foot orthosis, plastic or other material with ankle joint, prefabricated, includes fitting and adjustment) to include coverage “for individuals who do not ambulate.” The Restorative Medical request said, in part, “Many neurologically involved patients need this orthosis and cannot ambulate. Patients with neurological conditions that have diagnosis of inversion or eversion require ankle foot orthoses that are coded using HCPCS Level II code L1971 to bring their foot into a neutral position.”
CMS concluded, “The description of L1971 does not distinguish between patients who do or do not ambulate. As such, CMS has not identified a program operating need for Medicare or other payers to revise existing HCPCS Level II code L1971.”
Sully Walker, Sully Walker LLC: The company requested a HCPCS code “to identify a powered walking aid,” CMS said, noting that the application said the Sully Walker uses electronic power by providing forward motion that’s controlled via a thumb throttle.
CMS established a new HCPCS code (E0152), defined as “Walker, battery powered, wheeled, folding, adjustable or fixed height.” The agency added that following public comments, it decided “that the Sully Walker is best described as a single device, rather than as a walker plus a separate code describing the powered feature. We believe the Sully Walker is a new category of walkers that provides power assist and is different than other manual walkers, therefore creating the need to establish a separate code for this new type of walker. The Sully Walker is not a power assist accessory that can be added on to any walker.”
When it comes to funding the item as DME, however, CMS noted the Sully walker “is appropriate for use outside of the home when extra power may be needed to ambulate uphill, across rugged terrain (a grassy field, a cobblestone street, etc.), and over longer distances. Since the capabilities of the Sully Walker relate to use of the walker outside the home, it does not appear that the walker serves a medical purpose for use in the home.”
CMS declined to categorize the Sully Walker as DME and added, “There is no Medicare payment for the new HCPCS Level II code E0152.” The agency did encourage the presentation of any data “that supports the manufacturer’s medical claims of alleviating leg stress, hip pain, spinal misalignment along with arms, shoulder and neck discomfort. We welcome evidence (such as case studies) demonstrating the medical benefit of the Sully Walker specifically when used in the home.”