Important Reimbursement Changes to Consider When Choosing Your Next Wheelchair Cushion

Every wheelchair cushion has a finite lifespan and eventually, every brand, make and model of cushion will wear beyond its usability. When this happens the cushion no longer supports and protects your skin the way it was designed — putting you at risk of a pressure sore.  This is why it is vital to replace your cushion before it fails. Two important questions I’m frequently asked and have written about in the past are, “How often should I replace my cushion?” and “How often will insurance pay for a new cushion?” The answers to these two questions are linked. It is a good idea to replace your cushion as often as your insurance will pay for it. This way you are best protected with a cushion that’s performing optimally, plus you can keep your old cushion for back-up use.

The answer to “How often will insurance pay for a new cushion?” is a moving target, and in my opinion has moved in the wrong direction in the two years since I last wrote about it. In my September 2011 blog post, “How Often Should You Replace Your Cushion?,” Dave McCausland, senior VP of planning & government affairs for The ROHO Group explained that CMS (Centers for Medicare and Medicaid Services — the federal agency that decides how often Medicare will pay for a new cushion) said that in the past it was generally accepted that Medicare would pay for a new cushion approximately every three years, and Medicaid and private insurance tend to follow Medicare’s lead. To reinforce this position, back in 2004 when Medicare established the current policy for coverage and reimbursement of medical seat cushions, they stated that they did not anticipate that cushions could last the five years necessary to be classified as “durable medical equipment” (DME).  This was the justification that they gave regarding why a beneficiary must have, and qualify for, a wheelchair in order to get a seat cushion. They stated that since a cushion was not expected to last five years it had to be considered as an accessory to a piece of DME in order to be eligible for coverage and reimbursement. In this case the piece of DME that cushions were associated with was a wheelchair. However, recently it appears that Medicare is changing its position. I learned from Mr. McCausland that in recent correspondence and communication Medicare has indicated that they will require five years to pass before they will pay for the replacement of a cushion! Why they are making this change is anyone’s guess…

Another important change, as of May 1st, is that CMS has enhanced the definition of an adjustable skin protection cushion vs. non-adjustable cushion under HCPCS codes (Healthcare Common Procedure Coding System numbers — the codes used by Medicare for medical goods and services). The old definition was very subjective and vague. Under the new CMS definition, only cushions that contain a fluid medium (air, gas, liquid or gel) and that can be altered by addition or removal of the fluid (as in adding or removing air from a ROHO cushion) will be considered adjustable. The adjustable cushion definition also covers cushions in which the adjustment is done by adding or removing packets of fluid medium (such as adding or removing a gel pack under a gel cushion). Cushions that are custom fit and/or custom molded are in a different HCPCS category than adjustable cushions.

Cushions that are custom fit and/or custom molded are in a different HCPCS category than adjustable cushions.

An important part of the enhanced CMS definition of adjustable cushions is that the adjustment must be able to be accomplished by the wheelchair user or their caregiver with the items supplied when the cushion is delivered, and the adjustable cushion must be able to address changes in skin protecting/seating issues such as weight gain, weight loss, or muscle tone changes. CMS wants to ensure that when they pay for an adjustable cushion, it will protect a wheelchair users skin not just today, but months and years down the road.

CMS’ coverage criteria for wheelchair users to qualify for an adjustable cushion are the same as it is for a non-adjustable cushion. With the time to get a cushion reimbursed getting longer and longer, it seems only logical to get an adjustable cushion rather than non-adjustable. Five years between cushions is a long time, and seating needs are dynamic, not static.

In my personal experience with spinal cord injury (SCI) – I’m a T10 complete para – as well as the experiences of friends with SCI, by not having the “guywire” support of trunk muscles it seems more often than not our seating requirements change and shift a bit here, a bit there. An adjustable cushion addresses these changes; changes such as sitting more on one ischium. This is something that is easily caught during a mirror skin check and can be quickly addressed with an adjustable cushion. For instance, if I notice a bit of pinkness on an ischium during my evening mirror skin check, I will hop into my chair and push the green knob on the ISOFLO Memory Control® of my ROHO QUADTRO SELECT® HIGH PROFILE® Cushion, then put weight on the ischium with the pinkness to let some air out of that chamber.  When I push the ISOFLO’s red knob to lock the cushion in place, the cushion is now adjusted to put less pressure on that ischium.

An important caveat: Anytime the cushion you are using shows signs it isn’t doing an effective job of protecting your skin, for example you notice your skin remaining red after a day of sitting (another reason it is vital to do skin checks with a mirror each evening and morning), please see your doctor right away and get a seating evaluation, (SeeIs It Time To Replace Your Cushion?”)!

Be aware that the process of getting in for a seating evaluation and seeing if you can get approval of funding for a cushion that meets your changed skin protection needs may take months – months where a serious pressure ulcer could develop. Whereas with an adjustable cushion you can quickly adjust the cushion to adapt to the change, and the skin issue should vanish.

As always, when it comes to ordering a new cushion, it is vital to make sure the exact make, model, and size cushion are on all therapists’ and physicians’ prescriptions.

Last but not least, knowing that CMS reimburses a new cushion only every five years, it is important to make sure you get a quality cushion that will go the distance.  For a good look at an example of the stringent quality control, testing and tracking that a quality cushion manufacturer employs, as well as warrantee, repair and replacement policies, read “Why there is such a big price difference in medical products that look so similar?”

The article addresses important questions to ask when you are looking at a new cushion. When getting a new cushion that will be protecting your butt for five years it is important to do your research!

Questions you should ask include:

  • Is the cushion manufactured entirely at the manufacturer’s plant?
  • What kind of quality control does each individual cushion go through before it is shipped?
  • What is the return policy?
  • How is the manufacturer’s customer service?
  • Does the manufacturer maintain quality control over every aspect of its cushions onsite?
  • How long is the warranty?
  • Is the manufacturer continually improving the product?
  • Does the manufacturer include research papers about its product on its website?

Bottom line, as reimbursement time between cushions gets longer it becomes even more important to educate yourself about the cushion you choose. By taking the time to do your homework, and choosing a quality adjustable cushion that will last and address your needs, you are taking control of your health.

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Bob VogelBob Vogel, 51, is a freelance writer for the ROHO Community blog. He is a dedicated dad, adventure athlete and journalist. Bob is in his 26th year as a T10 complete para. For the past two decades he has written for New Mobility magazine and is now their Senior Correspondent. He often seeks insight and perspective from his 10-year-old daughter, Sarah, and Schatzie, his 9-year-old German Shepherd service dog. The views and opinions expressed in this blog post are those of Bob Vogel and do not necessarily reflect the views of The ROHO Group. You can contact Bob Vogel by email at online.relations@therohogroup.com.

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