Understanding the options for patients, and coverage available for power mobility.

by Sharon Frant Brooks, MA, OTR/L, ATP/SMS, CRTS

wheelchari climbs_curbThere are a lot of articles and discussions in many forums that deal with “sexy” topics that get everyone’s high tech juices flowing, such as alternative switching systems, multiple output options, and Bluetooth or InfraRed options. But, as an occupational therapist and an ATP (Assistive Technology Specialist)/SMS (Seating and Mobility Specialist) who travels as a consultant to facilities and home health services, working with therapists “in the trenches,” the sad reality is, this is not what they seem to be clamoring to know more about.

What I am asked consistently to share information about—or make the focus of in-services—is more pedestrian. “I know my patient needs power mobility from my clinical observations and assessments, but what are they covered for under their … (fill in the blank—Medicare, Medicaid, insurance)?” In addition, items such as positioning modalities that include tilt, recline, seat elevation, and elevating leg support systems are often of concern for the patients served by these clinicians. Add cushion, back, head supports, lower limb devices, and positioning pads and straps, and that addresses the concerns of more than 90% of therapists I work with, and their clients. Although there is considerable interest and cachet in topics such as alternative switches and controls, the issue that impacts most therapists and users remains: “What can this person get, and how do I help them get it?”

WORKING THE NUMBERS

As I always explain to both clinicians and equipment end users, there are groups and codes for all equipment and codes for all medical conditions. It is important to understand the implications of these numbers to get the most positive and predictable outcome for the recipients of the equipment. While not advising a “cookie cutter” approach to match equipment codes with eligible diagnostic codes, the current environment of Competitive Bidding Areas is bringing that closer to reality without our doing it. To assure that those receiving power mobility devices (PMDs) obtain the most clinically advisable system, we, as therapists and assistive technology professionals, need to educate ourselves about how to best employ our skills and knowledge of disability, therapeutic tools, and positioning/mobility devices to meet today’s challenges in addressing the needs of end users of these devices.

Because what is being set as the Medicare standard is fast becoming the accepted standard for many other third-party payors, that is the system that is the focus of this article. As in all of health care, there is an alphabet soup of jargon vital to the Medicare system of documenting need and appropriateness of power mobility devices. To know your regional standards, it is important to know what your Local Coverage Determination (LCD) area is. To determine that, go to the Centers for Medicare and Medicaid Services (CMS) website at http://www.cms.gov. While there is not significant variation between coverage areas, it is important to reference the specific language of a local area’s stated standards. The LCD defines those areas not clearly defined in the National Coverage Determination (NCD).

The CMS defines whether an individual is even eligible for PMD as follows:

Indications and Limitations of Coverage and/or Medical Necessity
For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this local coverage determination, the criteria for “reasonable and necessary,” based on Social Security Act §1862(a)(1)(A) provisions, are defined by the following indications and limitations of coverage and/or medical necessity….The term power mobility device (PMD) includes power operated vehicles (POVs*) and power wheelchairs (PWCs).1

*Please note that the term Power Operated Vehicle is the accepted terminology for what we typically call a “scooter.”

UNDERSTANDING COVERAGE

How is one to understand from this very limited statement of indications of need, who and what are covered by Medicare for power mobility? Aside from the obvious, that the end user is entitled under coverage determination for Medicare services at all, how is a therapist to further document the stated need for power assistance in mobility? The Contractor information page on LCD coverage further goes on to distinguish who is eligible for any sort of power assist in mobility as follows:

“All of the following basic criteria must be met for a power mobility device or a push-rim activated power assist device to be covered. The patient must have a mobility limitation that significantly impairs his/her ability to participate in one or more mobility related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. These limitations must prevent the patient from accomplishing an MRADL entirely, place the patient at a heightened risk of injury or death secondary to the attempts to perform an MRADL, or prevent the patient from completing the MRADL within a reasonable time frame. All lower technologies must be ruled out, including the use of an appropriately fitted cane or walker. In addition, it must be well documented that the patient does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to perform MRADLs during a routine day.”

There must be well-documented limitations of the upper limbs in the areas of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities that are relevant to the assessment of upper extremity function. An “optimally-configured manual wheelchair” is one with an appropriate wheelbase, proper device weight, corrective seating options, and other appropriate nonpowered accessories.1

Therapy documentation is key here for a person to be eligible for power assistance of any sort in their mobility. A MRADL limitation must clearly state in measurable terms why an appropriate nonpowered device would not be adequate to achieve independence. The measures that should be listed can include range of motion, manual muscle testing, balance testing, endurance testing, and clinical observations. It is significant to have an opportunity to afford the individual a functional trial with a PMD comparable to the device and features that are anticipated for that end user, preferably performed with a therapist who is involved with that individual’s care. Therapy documentation on that trial can go a long way to providing the measurable and observed benefits for power mobility for the end user. This documentation must be available upon request to the equipment provider.

Once the determination has been made that power mobility is the mobility option of choice, how is it decided what type of device and what features are both necessary and, in many cases, covered by a third-party payor? Power mobility devices have codes that identify the power operating system, weight capacity, and power operation options. Those codes identify not only the systems but power positioning options and weight capacity of the PMD. These codes create a set of demands that increase with the codes applied to the devices to which they are assigned. The coded equipment is, in turn, put together into groups that share the same qualifying criteria. Knowing the qualifying criteria for each group of equipment empowers the clinician to identify an appropriate and covered device, and the seating and positioning modalities and devices that maximize functioning, and to be able to improve the likelihood that that equipment will meet criteria for coverage under Medicare and, therefore, most likely, most other third-party payors.

POWER OPERATED VEHICLES

A power operated vehicle (POV) is the official identifying term for what has come to be called a “scooter.” A POV is covered if all the basic coverage criteria are met, in addition to the following:

a. The patient is able to safely transfer to and from a POV, operate the tiller steering system, and maintain postural stability and position while operating the POV in the home.
b. They must have adequate mental capabilities (eg, cognition, judgment) and physical capabilities (eg, vision) sufficient for safe mobility in the home.
c. The patient’s home must have adequate access between rooms, maneuvering space, and appropriate surfaces for the operation of the POV.
d. The patient’s weight is less than or equal to the weight capacity of the POV that is provided and greater than or equal to 95% of the weight capacity of the next lower weight class POV. In other words, a Heavy Duty POV is covered for a patient weighing 285 to 450 pounds; a Very Heavy Duty POV is covered for a patient weighing 428 to 600 pounds.

There should be sufficient documented evidence that a POV will significantly improve the patient’s ability to participate in MRADLs and the patient will use it in the home. The patient must be willing to use a POV in the home. However, even if a POV will be used inside the home and these criteria are not met, it will be denied as not reasonable and necessary.1

POWER WHEELCHAIRS

Because there is a requirement that the PMD ordered for an end user has applications for in-home usage and is necessary to perform MRADLs, and because scooters often lack turning radius and indoor maneuverability, power wheelchairs are often the PMD of choice.

A power wheelchair is covered if all of the basic coverage criteria are met, but the patient does not meet the coverage criterion of personal mobility or in-home maneuvering space for a POV, but does have the cognitive and/or perceptual skills to operate a power wheelchair, has a home that is more appropriately navigated in a PWC, and also can be determined to be restored to greater independence in MRADLs. If the end user is unable to safely operate the power wheelchair, and has a caregiver who is unable to adequately propel an optimally configured manual wheelchair, but is available, willing, and able to safely operate a power wheelchair, it also may be approved. The weight of the end user must be less than or equal to the weight capacity of the power wheelchair that is provided and greater than or equal to 95% of the weight capacity of the next lower weight class PWC, ie, a Heavy Duty PWC is covered for a patient weighing 285 to 450 pounds rather than placing that individual in a wheelchair with a weight capacity of 300 pounds.

There must be an expressed willingness to use a power wheelchair in the home, something many end users seem reluctant to accept, believing their desired usage to be out of the home and in the community. However, even if a PWC will be used inside the home but the coverage medical and MRADL need is not confirmed, or if a PWC will be used only outside the home, the PWC will be denied as “not reasonable and necessary.”1

PWCs are divided by Medicare into multiple groups defined by power operation capabilities, structural design, and modality options. Once it has been determined based on one’s limitations in MRADLs that a power wheelchair is acceptable, the type of power wheelchair and the features, seating, and operating system must be determined.

A Group 1 PWC or a Group 2 wheelchair is covered if all of the coverage criteria for a PWC are met and the wheelchair is appropriate for the patient’s weight. Specialist documentation is not necessary on the provider or assessment side. The process must be initiated, however, by the end user in collaboration with their physician, and not be the result of salesmanship on the part of providers. Recent court actions have supported this and should serve as a reminder that these units are medical equipment, and not intended to perform in lieu of transportation services.

A durable medical equipment provider (DME) with skilled staff should be able to properly measure and provide the correct unit and determine if more basic systems are adequate for the end user’s needs, and if a higher group wheelchair is more appropriate. In addition, the Group 2 wheelchair can be equipped with a captain’s back but with a solid seat pan that will accept a pressure relief or a positioning cushion if appropriate and medically necessary, but a higher end wheelchair is not. Should the end user needs indicate a higher group wheelchair and have the diagnoses to support one, the DME should advise the user of that.

In order for the DME to provide a higher level of wheelchair, they must have a Rehabilitation Engineering Society of North America (RESNA) certified Assistive Technology Practitioner and there must be documentation from a “Licensed Mobility Practitioner” (physical or occupational therapist or a physician with appropriate specialization). A DME that may not have an ATP on its staff may not be inclined to advise the end user of this, as it represents a loss of sale. It is, therefore, generally advisable to use a vendor that has an ATP on board for all PMDs to make sure that no disincentive exists to offer all levels of equipment and seating options.

A Group 2 power wheelchair with single or multiple power options can be provided if medical needs are present, and appropriately credentialed persons are on the assessment team. The user must have a condition that meets the coverage requirements for tilt and/or recline systems—typically, skin integrity, joint contractures, or neuro-motor condition or disease that is chronic, progressive, and irreversible by treatment or surgery, or if the end user uses a ventilator that is mounted on the wheelchair. Power elevating legrests of any sort require that a second power positioning mode be present (tilt or recline), and medical conditions of edema and joint contractures of the lower limbs.

The process requires that the patient has had a specialty evaluation that was performed by a licensed/certified medical, mobility professional, such as a physical or occupational therapist, or by a physician who has specific training and experience in rehabilitation wheelchair evaluations. They must document the medical necessity for the wheelchair and its special features. The PT, OT, or physician may have no financial relationship with the supplier. On the supplier’s end, they must employ a RESNA-certified Assistive Technology Professional who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the patient. All of the eligibility criteria noted must be met or it will be denied as not reasonable and necessary.

A Group 3 PWC with no power options is covered if all of the base coverage criteria for a PWC are met, and in addition, the patient’s mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity. Complete and documented evaluation information must be performed by the licensed/certified medical professional with experience in rehabilitation wheelchair evaluations, and it documents the medical necessity for the wheelchair and its special features. Power options documentation is as noted previously.

Group 4 PWCs have added capabilities that are not needed for use in the home. Therefore, if these wheelchairs are provided, they will be denied as not reasonable and necessary. A Group 5 PWC is a pediatric power wheelchair and requires all of the same criteria be met, but with an understanding that the user will grow in size. Because young children, even normally developing youth, are not typically independent at a young age, the documentation needs to reinforce the developmental skills that developed through movement in space by their nondisabled peers.3

Structurally, no wheelchair with a folding frame can be anything other than a Group 1 wheelchair. This lack of transportability often discourages end users who are in need of, and appropriate for, a PMD, and can be discouraging to individuals who want to be able to take their wheelchair on both medically necessary (eg, to physician offices) and social gatherings no matter the location. While one is not penalized for taking the PWC out of the home, it is not covered unless it is used in the home as the principal method of performance of their MRADLs.

Yet, a PWC simply provides the wheels to move about. Successful performance of MRADLs requires postural supports, pressure relief, positioning correction, and posture that afford safety in seating, breath support, and safe swallowing. The ICD-9 codes that support skin protection and/or positioning aids are very specific and should be referenced to better assure that equipment requests for seating and positioning aids will be covered on either power or custom manual mobility bases.

“Sexy” technologies such as tracking systems, Bluetooth, InfraRed, and multiple input device options expand possibilities for mobility users. However, those charged with documenting, providing, and supporting access to appropriate equipment must be mindful to maintain a priority on getting end users the fundamental power mobility technologies they are eligible for, and that keep them on the move. RM

Sharon Frant Brooks, MA, OTR/L, ATP/SMS, CRTS, is an occupational therapist, as well as an assistive technology practitioner/seating and mobility specialist at Acclaimed Healthcare, Lakewood, NJ. She has a masters degree in Education with a specialization in special education. She is the National and International Paralympic classifier for USA Table Tennis, Paralympic division. For more information, contact RehabEditor@allied360.com.

 

References

1. Local Coverage Determinations for Power Mobility Devices, (L21271), Contractor Information, LCD Information, Document Information.

2. RESNA Position on the Application of Power Wheelchairs for Pediatric Users, chair: Lauren Rosen, PT, MPT, ATP.

3. Adapted from Varilite.com http://varilite.com/pdfs/k_knowledge_reimbursementguide2013.pdf