MSATC Wheeled Mobility 080509

8/14/2019 MSATC Wheeled Mobility 080509

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AT FOR P OINT A TO B

WHEELED MOBILITYAS A TOOL

TOWARD INDEPENDENCE Midnight Sun

Assistive Technology Conference

August 5, 2009

Presented by

Lisa E. Maurer MS, PT, ATP

with

Jerry Godden, CRTS, ATPWayne Gould, CRTS, ATP


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__________________________________________________________________

INTRODUCTIONS __________________________________________________________________

THE S PEAKERS

Lisa Maurer MS, PT, ATP is the Program Coordinator at The Wheelchair and Seating Clinic at Providence. A physical therapist for 19 years, and a Certified Assistive Technology Practitioner since 1997, she has extensive experience in multi-disciplinary Assistive Technology services,specializing in seating and mobility.

Jerry Godden, ATP is a Rehabilitation Technology Supplier with Geneva Woods Home Medical Supply in Anchorage. An advocate for people with disability s since 1990, and a Certified Assistive Technology Practitioner since 2004, he 13 years of experience in custom rehab equipment.

Wayne Gould, CRTS, ATP is a Rehabilitation Technology Supplier and Rehab Manager at Frontier Medical in Anchorage. He been working with people with disabilities for 20 years, and has 10 years of experience in custom rehab equipment.


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_________________________________________________________________

OBJECTIVES __________________________________________________________________

Participants will understand the role of mobility products as assistive technology.

Participants will demonstrate knowledge of the referral process for obtaining recommendations forwheeled mobility products.

Participants will have an understanding of the evaluation process, funding coverage criteria, anddocumentation requirements for mobility products.

Participants will have an understanding of the various types of wheelchairs currently available.


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_________________________________________________________________ HISTORY

__________________________________________________________________

WHEELCHAIRS AS ASSISTIVE TECHNOLOGY ?

Excerpts from CMS s Decision Memorandum for Mobility Assistive Equipment (CAG-00274N), May 5,2005:The use of assistive technology to aid ambulation goes back into prehistoric times when the simplest crutchesand canes to compensate for functional disabilities were fashioned from sticks. Since then, the evolution ofmobility assistance equipment has become increasingly more technological - from King Phillip II of Spain s rollingchair with foot rests in 1595 to the paraplegic watchmaker Stephen Farfler s self propelled chair which he built forhimself in 1655 at the age of 22 to the specialized power wheelchairs of today.

For many beneficiaries, a device of some sort is compensation for (a) mobility deficit.


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_________________________________________________________________

DEFINITIONS __________________________________________________________________

Wikipedia: Assistive technology (AT) is a generic term that includes assistive, adaptive, and rehabilitative devices for people with disabilities and includes the process used in selecting, locating, and using themAT promotes greater independence by enabling people to perform tasks that they were formerly unable to accomplish, or had great difficulty accomplishing, by providing enhancements to or changed methods of interacting with the technology needed to accomplish such tasks.

Durable Medical Equipment (DME): an assistive technology product

Seating products that assist people to sit comfortably and safely (seating systems, cushions,therapeutic seats)

Standing products to support people with disabilities in the standing position whilemaintaining/improving their health (standing frame, standing wheelchair, active stander).

Walking products to aid people with disabilities who are able to walk or stand with assistance (canes,

crutches, walkers, gait trainers). Advanced technology walking products to aid people with disabilities, such as paraplegia or cerebral

palsy, who would not at all able to walk or stand exoskeletons). Wheeled mobility products that enable people with reduced mobility to move freely indoors and

outdoors (wheelchairs/scooters) Robot-aided rehabilitation is a sensory-motor rehabilitation technique based on the use of robots and

mechatronic devices


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CENTERS FOR MEDICARE AND MEDICAID S ERVICES

CHANGING DEFINITIONS

Excerpts from CMS s Decision Memorandum for Mobility Assistive Equipment (CAG-00274N), May 5,2005:

Recent allegations of wheelchair fraud and abuse have focused considerable public interest on the provision of wheelchairs under the Medicare benefit. The agency has responded with a multifaceted plan to ensure the appropriate prescription of wheelchairs to beneficiaries who need them.

Mobility Assistive Equipment (MAE): described by CMS as:(equipment which is) reasonable and necessary for beneficiaries who have a personal mobility deficit sufficient to impair their participation in mobility-related activities of daily living such as toileting, feeding,dressing, grooming, and bathing in customary locations in the home.

Includes devices such as: canes crutches mobile geriatric chairs motorized wheelchairs

quad-canes rolling chairs safety rollers walkers manual wheelchairs power operated wheelchairs specially sized wheelchairs power operated vehicles


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_________________________________________________________________

SERVICE DELIVERY MODEL __________________________________________________________________

THE GOOD OLD DAYS

THE HERE AND NOW

The demand in health care today is to do everything we used to do with the same amount of money or less,

and with the same staff or less.

- Mark Schmeler, OTR/L, ATP 1999.


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_________________________________________________________________

INFORMATION GATHERING __________________________________________________________________

REFERRAL AND INTAKE

Wheelchair and Seating Clinic Referral Form (see Appendix)Key Information:

Client contact info

Client Date of Birth Diagnoses Funding sources Physician contact info

Reason for Referral: Why is evaluation being requested? What type of wheelchair or equipment being used?

In what condition is the current equipment? Current skin breakdown?

Physician Order

Payor Authorization (VA, TriWest)


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P RE -SCREENING

Clinical review

Enough information to schedule?Request for additional information/reports if needed

Therapist reports School Private

Medical reportsRehabilitation Technology Supplier information

Past equipment Documentation on past attempts at obtaining equipment


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Determination of servicesSeating/Mobility Evaluation

Clients typically have one or more of the following impairments: Impaired mobility function Impaired postural control or alignment Inappropriate wheelchair or seating system Discomfort with prolonged sitting Endurance limitations affecting mobility and/or functional abilities Current skin breakdown History of compromised skin integrity

Severe deformities Need for customized seating intervention Chronic or severe pain related to positioning/prolonged sitting Severe spasticity or postural instability which compromises safety and/or mobility

function Medical issues necessitate Physical Medicine examination prior to evaluation of

positioning and mobility needs.

General Therapy Evaluation/TreatmentPT Evaluation is a component of the Wheelchair and Seating Evaluation.General PT or OT evaluation may be useful to determine need for further services


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Determination of services (contd)Other Assistive Technology Services

Augmentative communicationEnvironmental controlComputer accessHome or worksite modificationJob accommodationVision or hearing aidsVehicle modificationDriving Evaluation

Comprehensive Assistive Technology Evaluation

Client has needs spanning all areas of assistive technology, or his/her needs are verycomplex, requiring the involvement of specialists in several disciplines.


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Determination of team membersFamily and caregivers are a givenRole of therapists

Physical Therapist Evaluates physical performance and mobility function, balance, coordination, and

posture Brings knowledge of anatomy, palpation of bony landmarks, lower

extremity/pelvic/trunk range of motion/flexibility Division of labor: wheelchairs and accessories

Occupational Therapist Evaluates functional, perceptual, and cognitive performance; sensorimotor

impairments; and posture Brings knowledge of anatomy, upper extremity/hand range of motion/flexibility, fine

motor function, access, and environmental accessibility Division of labor: cushions and backs

Assistive Technology Practitioner Clinician has RESNA required clinical experience and credentials, and has passed

the RESNA national certification examination.


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Determination of team members (contd)Role of supplier

Works with the evaluation team to recommend technology options, procures theequipment through funding source, delivers and fits equipment, trains client/family inuse, maintains and repairs equipment

Rehabilitation Technology Supplier NRRTS definition

A SPECIALIST WHO PROVIDES ENABLING TECHNOLOGY IN THE AREAS OF WHEELEDMOBILITY, SEATING AND ALTERNATIVE POSITIONING , AMBULATION ASSISTANCE , ENVIRONMENTAL CONTROL , AUGMENTED COMMUNICATION , AND/OR ACTIVITIES OFDAILY LIVING . EMPLOYED BY A COMPANY THAT SELLS DURABLE MEDICAL EQUIPMENT AND OFFERSCONSUMERS PRODUCT CHOICES , ALONG WITH PRICING AND FUNDING INFORMATION . MEETS BASIC STANDARDS OF ACCEPTABLE PRACTICE IN THE PROVISION OFEQUIPMENT , INCLUDING : ORDERING , ASSEMBLING , ADJUSTING , DELIVERING , ANDPROVIDING ON -GOING SUPPORT AND SERVICE

Credentialing CRTS: C ERTIFIED REHABILITATION TECHNOLOGY S UPPLIER

Has met NARTS certification requirements for rehabilitation technologysuppliers

ATP: A SSISTIVE TECHNOLOGY P RACTITIONER Has RESNA required clinical experience and credentials, and has passedthe RESNA national certification examination for assistive technologypractitioners.


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Determination of team members (contd)Durable Medical Equipment Dealer/Supplier/Vendor

Essentially performs the same functions as the RTS, but is not certified, and notbound to the standards of the CRTS Scope of practice and level of experience varies greatly Choose wisely based upon reputation, credentials, demonstrated knowledge, and

past experience.


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Rehabilitation Technology Supplier Selection Criteria Client is first priority

Responsive to clientsTimely

Available in emergency situations Willingness to be a team player

Responsive to therapists and other team membersTimelyAvailable as necessary

Relationships with a variety of manufacturers Wide range of technologies and services Availability of equipment for trials prior to procurement High value placed on informing and educating clients Knowledge of service provision

ProcurementCoverage criteriaRequired documentationPayor specific processes and proceduresHandling of denials and appeals

Repair and servicingWarranty servicing and repairWillingness to consider servicing equipment provided by other dealers

Qualified and competent staff Trained regarding specific technologiesAttendance of manufacturers technical schools

Regular continuing education/equipment inservicesAttendance of trade showsRTS Certification

Membership in NRRTS, NAMES, RESNA Adherence to NRRTS and NAMES Standards of Practice Joint Commission accreditation Receptive to new ideas and techniques


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Other team members

Physician (MD)

Determines diagnoses and prognosis, writes orders for the evaluation, certifies medicalnecessity of equipment by signing required documentation Physiatrist and Orthopaedic Surgeons are often more involved in the evaluation process,

and are often team members in some settings

SpeechLanguage Pathologist Evaluates cognitive and language abilities, and oral motor function (speech, swallowing,

drooling) Typically involved if seating/positioning affects swallowing, communication, or

augmentative communication use, or if cognitive factors have a significant affect on

mobility function Division of labor: mounting of AAC device, access of AAC device, integration of AAC

device with wheelchair where appropriate.

School Therapists, Teachers May provide valuable information relating to positioning and mobility function within the

educational setting; may identify accessibility and transportation concerns/requirements. Equipment may affect current treatment, treatment plan, and goals.

Private Therapists Client may be receiving general therapy services elsewhere, but therapists may not be

able to complete seating/mobility evaluation. Incorporate their input, and preventduplication of services or conflict of therapeutic goals. Many payors will not cover bothservices, but in some case will recognize the role of PT and OT in seating/mobility as aseparate specialized service.


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Other team members (cont d)

Rehabilitation Engineer

Modifies equipment to meet the client

s specific needs, designs and fabricates customizedequipment when commercially available products are inappropriate.

Nurse Caregiver Specialist in wound management (enterostomal nurse)

Orthotist/Prosthetist Typically involved when seating intervention consists of an actual orthosis or prothesis

(i.e. polypropylene TLSO, bilateral hip disarticulation or hemipelvectomy prosthesis)

Case ManagerPayorEmployerOther Support Systems


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VERIFICATION OF BENEFITS

PT/OT coverageIf currently receiving general therapy services by another provider, ensure coverage forPT/OT for seating/mobility as a specialized service (vs. duplication of services)

Coverage for extended evaluation/extended evaluation ratesMay request information on content of evaluation, length of time required

Requirement for use of specific RTS/DealerSome payors have participating RTS/Dealers that they will use exclusively

Some state agencies may require several bids before processing through one RTS/Dealer;some RTS/Dealers may not wish to be involved if they will not get the sale.


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VERIFICATION OF BENEFITS (CONT D)

Coverage of durable medical equipmentRTS/Dealer will handle funding issues, but therapists must have general knowledge toplan for the evaluation, select equipment, and complete documentation.Funding source should not determine the equipment evaluated or drive the selectionprocess, but must be taken into consideration.Payor for equipment may be different from payor for servicesCovered items

Allowables, caps

Percentages

Amount of client responsibility may limit options

Some clients may not wish to be evaluated if they are responsible for a large portionof the cost.Medical necessity vs. educational, vocational or other restriction on environment

Appropriate for use in home environment

Use outside of payorcovered environment (i.e. school, workplace)


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S CHEDULING

Location

Notification of team membersClient/familyTherapistsRTS/Dealer

Transportation to appointment

Coordination of equipmentSpecific cushions, backs, wheelchairs needed

REQUEST FOR CURRENT P HYSICIAN ORDERS

Physical Therapy Evaluation for Seating/Mobility


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_________________________________________________________________ THE EVALUATION

__________________________________________________________________

REVIEW OF INFORMATION

Pertinent demographic informationDiagnoses

Primary Primary diagnosis relating to present concerns (e.g. cerebral palsy with spastic

quadriplegia and scoliosis) Secondary

Additional pertinent diagnoses Functional or treatment diagnoses

Hemiplegia, etc. Abnormal posture Abnormal involuntary movement Gait abnormality

Specific dates of onset

PrognosisProgressContraindications/precautions affecting equipment use

Uncontrolled seizures Orthostatic hypotension Open skin areas


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Pertinent demographic information (contd)Pertinent medical/surgical history

Past hospitalizationsHistory of skin breakdownRelevant surgeries

Orthopaedic Skin flaps Bone shavings

Pertinent medicationsCurrent or past services

Date last seen by MD

Current therapy and emphasisReferral sourceReason for referralHeight, weight


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Subjective information Client, caregiver, referral source goals

General Expectations What type of equipment does the client want? What does the client want to be able to do? What are the client s priorities? What are the client s expectations of this evaluation?

Functional goalsVocational goalsRecreational/lifestyle/personal goals

Current problems

Level of satisfaction with equipmentLikes/dislikesBroken partsFunctional implications/deficiencies related to current equipmentService history

Pain/discomfortFunctional implicationsRelation to equipment

Past equipment experiencesSuccesses/failuresTolerance/willingness to changePast experience with RTS/Dealer

Recent changes in functionRelated or unrelated to equipment


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Subjective information (contd) Environmental issues

Home environment General accessibility

Levels of homeType of entrance/exitLayoutDimensions of smallest doorways, halls

Does current wheelchair fit through all doorways? Location (i.e. rural, suburban)

Work, school, other environments General accessibility Requirements

Caregiver Role Availability Abilities

Transportation Type of vehicle Method of loading of wheelchair Driver vs. passenger Type of tie-down system


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Subjective information (contd) Psychosocial issues

Lifestyle Passive Active, involved Risk taker

Activity level Daily routine Amount of time up in wheelchair during day Work School Day program Recreation/leisure

MotivationSupport systemCultural influencesFamily dynamics/involvement


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P HYSICAL EXAMINATION Strength/Motor Control

Gross motor control manual muscle testingFine motor controlQuality of movementCoordinationReaction time, ability to initiate or stop movementTone/spasticityReflex activityMovement patterns

Volitional

InvoluntaryFunctional use of extremities

Effect on mobility, posture

Range of Motion/FlexibilityTolerance of corrective forces/pressure Effect on mobility, posture

EnduranceCardiopulmonary

Shortness of breath At rest With activity (i.e. after propelling wheelchair 20 ft.)

Labored breathing At rest With activity

Vital capacity May change with provision of postural support


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Endurance (contd)Muscular

Ability to generate and sustain force

Ability to perform repetitive contractionsTolerance of sustained activity Wheelchair propulsion

General activity tolerance

Sensation

Pressure reliefTechnique

StandingConstant shifting/changing of positionWheelchair pushupsManual tilt/reclinePower tilt/recline

FrequencyEffectiveness


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PainLocationSeverityLength of time presentPossible causesFunctional implications

Balance/Postural ControlHead control

Ability to achieve and maintain midline position

Influence of tone, reflexesTrunk control

Sitting with/without external supportAbility to assume and maintain erect postureInfluences of tone, reflexes

Standing with/without external supportStatic sitting and standing balanceDynamic sitting and standing balanceFunctional implications


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Activities of Daily LivingTransfersFeedingBathingCommunicationDressingHygieneBowel/bladderHousehold/community activitiesAides/caregiversEmployment/educational activities

Assistance providedTime available

Implications of positioning, mobility

VisionAcuityNeglect

Blurred visionForward gazeDepth perceptionField lossesScanningPerceptual deficits


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CognitionAbility to follow directions (simple vs. complex)Attention spanJudgmentDistractibilityUnderstanding of cause/effectNeglectEffect on use of equipment

CommunicationAbility to communicate functionallyEffect of positioning on communication/interactionManagement of secretionsUse of augmentative communication device

Transport/mounting considerationsIntegration considerations


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EVALUATION OF CURRENT EQUIPMENT

Seating System (cushion, back, other supports)Manufacturer, modelAgeDimensionsConditionRepair historyEstimated cost of repairsEstimated remaining life expectancyComfort

Effect on positioning/pressure distributionPressure mappingAcceptability to useAppropriateness


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WheelchairManufacturer, modelAgeDimensionsComponents

Seat and back upholsteryArmrestsLegrestsFootplatesWheels/castersTires

ConditionEstimated cost of repairsEstimated remaining life expectancyComfort

Effect on positioning/pressure distribution Effect on mobility function

Acceptability to userAppropriateness

FitFunctionAccessibility


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S EATING /P OSITIONING ASSESSMENT

Basic Principles

Review of normal postural alignmentPelvis neutral (or slightly anterior) and symmetricalTrunk erect with slight lumbar and cervical lordosis, slight thoracic kyphosisThighs and legs separatedKnees and ankles flexed to 90 degrees, with feet resting on floor or support surfaceHead upright and in midlineShoulders and arms relaxed and supported

Characteristics of normal postureProvides stable base of support; stability precedes mobilityActive and dynamic

Dynamic posture is crucial for function in or out of a chair. Mobility is superimposed on an active, responsive base. Quality of posture determines motor skill capability. Motor function is the interplay between posture and movement. Ball 1996

Allows horizontal gaze and optimal visual fieldAllows optimal arm and hand functionPelvic position largely determines posture


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Examination of resting posture in Wheelchair/Seating SystemNote position of

PelvisTrunk/spineHead/neckHips/legsKneesAnkles/FeetShouldersArms

Observe and palpate symmetry of bony landmarksShoulders

Ability to self-correct or move into neutral alignmentPostural changes with volitional/non-volitional movement

Examination in supinePelvic mobilityLower extremity flexibilityRange of motionSpinal flexibility


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Examination in sitting at edge of matSitting balance/trunk control

How much effort is required to maintain this neutral posture with the influence of

gravity?Posture

Note posture under the influence of gravity as compared to that observed when sittingin current seating system

Pelvis Trunk/spine Head/neck Hips/legs Knees Ankles/Feet Shoulders Arms

Note postural changes with volitional/nonvolitional movementObserve and palpate symmetry of bony landmarksReevaluate flexibility of deviations observed in supineProvide support to correct flexible deviations, accommodate fixed deformities, andallow individual to maintain neutral posture.

Location of needed corrective support was indicated during supine assessment. May require additional support, or support in other areas when influenced by

gravity. May require change in orientation (i.e. tilt-in-space)

Begin thinking of what type of supports may be necessary to replicate the supportiveforce.


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MOBILITY ASSESSMENT

Primary means of mobility

AmbulationManual wheelchairPower wheelchairScooterOther

Dependently carriedCrawling, creeping

AmbulationLevel of independenceType of assistive device usedDistanceEfficiency/energy expenditureSafety

Need to hold on to walls, furnitureFrequency and severity of falls

Functional for home or other environmentsImpact on Mobility Related Activities of Daily Living


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Manual wheelchairLevel of independence

Propulsion techniqueArmsLegsOne armArm/leg combination

DistanceEfficiency/energy expenditure

Postural changes during propulsionObstacle managementPerformance/safety on varied terrain

Flat, level surfacesCarpetRamps/inclinesGrass

GravelManeuvering/managing wheelchair during transfers


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Manual wheelchair (contd)Advanced skills

Loading wheelchair into vehicleCurbsRampsStairsFallingRighting the wheelchairCushion adjustmentNarrowing the wheelchairWheeliesGlides in a wheelieTurning on a dime

Impact on Mobility Related Activities of Daily Living


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Power wheelchairLevel of independenceAccess point

HandHeadChin/mouthOther body part

Input deviceHand control/joystickHead control

Chin controlPneumatic/sip&puffSwitches

DistanceEfficiencyPostural changes during operationObstacle management

Performance/safety on varied terrainFlat, level surfacesCarpetRamps/inclinesGrassGravel

Maneuvering/managing wheelchair during transfers


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Scooter/Power Operated VehicleLevel of independenceType of controlDistanceEfficiencyPostural changes during operationObstacle managementPerformance/safety on varied terrain

Flat, level surfacesCarpet

Ramps/inclinesGrassGravel

Maneuvering/managing scooter/seat during transfers


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_________________________________________________________________ EQUIPMENT OPTIONS

__________________________________________________________________


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S EATING INTERVENTION

Forms of postural support

Spinal fixation (i.e. Harrington rods)Intimate support (i.e. body jacket, corset)Adaptive seating

Goals of adaptive seating Support neutral posture or posture required for function. - J. Zollars Provide sufficient external support to restore normal sitting posture without

restricting function, and to maximize pressure distribution to prevent tissue trauma.- J. Minkel

Obtain optimal postural alignment. M. Ball Provide postural support for symmetrical biomechanical alignment Correct or accommodate postural deformities Inhibit abnormal tone and reflexes to prevent abnormal postural alignment and

deformities Improve safety Improve respiratory function Provide pressure relief or reduction to prevent compromise of skin integrity Equalize pressure distribution Increase sitting tolerance to level sufficient for requirements of daily activities Improve interaction with other individuals and the environment Improve function in ADL, self-care, mobility, and communication Improve comfort


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Classification of Support SurfacesPrimary

Cushion/seatBack

SecondaryHeadrestFootrestArmrestPelvic/thigh supportsTrunk supportsShoulder supports


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TYPES OF P RIMARY S UPPORT S URFACES (CUSHIONS /B ACKS )

Fluid/Flotation

AirContains one or multiple air bladders or cellsAdvantages

Excellent pressure relief Lightweight Easy to clean Air may flow between cells

Disadvantages High maintenance Poor durability May make transfers difficult

WaterSealed cushion with waterbased fluid insideNot a frequently used type of cushionAdvantages

Good pressure relief Reduces shearing Dissipates heat well

Disadvantages Heavy Assumes ambient temperature

CAN FREEZE CAN GET VERY HOT

May make transfers difficult


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Fluid/Flotation Cushions/Backs (contd) Viscous fluid

Gels or fluids contained in oversized flexible membranesTypically used in combination with some type of foam base/shellAdvantages

Good pressure relief Reduces shearing Easy to clean Dissipates heat well

Maintains fairly stable temperatureDisadvantages

Heavy Can be uncomfortable if sensation is intact May make transfers difficult

Elastomer gelFirm gel contained in flexible membranes (similar to Jello)Typically used in combination with some type of foam base/shellAdvantages

Dissipates heat well Maintains fairly stable temperature Reduces shearing

Disadvantages Poor durability Difficulty attaching to foam surface


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PolyfoamsPlanar

Flat surface, typically plywood covered with foam and upholstery.

Advantages Adjustable (i.e. for growth) Modular components Available from many manufacturers Offers minimal support Accommodates a wide variety of postures Lightweight Inexpensive Easiest to maintain Least interference with transfers

Disadvantages No pressure relieving properties Often result in localized pressure over bony prominences, with greater risk of

shearing forces developing under weighted areas Least surface contact Provide least support for maintaining neutral posture

Typical applications Good pelvic and trunk control Frequent changes in position Pediatric clients Progressive disabilities Short periods of sitting


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Polyfoams (contd) Contoured

Commercially fabricated contoured surface of predetermined size and shape basedupon anthropomorphic data. Typically a combination of molded plastic shell andcontoured foam, occasionally with pressure relieving gel or air inserts.Advantages

Pre-contoured for a generic body type Offers moderate support Greater pressure distribution Reduces risk of peak pressures under weighted soft tissues More forgiving than an intimately contoured surface Some adjustability

Disadvantages Offers minimal postural accommodation Not contoured to an individual s shape May have to add accessories to achieve adequate support May restrict postural adjustments

Components typically require constant monitoring to insure proper placement May require some maintenance

Typical Applications Fair trunk control and balance Specific body types and postural deformities compatible with specific products Need for pressure reduction or equalized pressure distribution Need for portability


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Polyfoams (contd) Molded

Contoured surface created to fit the exact contours of a single user.Advantages

Offers maximum support Best pressure distribution Best accommodation of deformities Individualized shape Least peak pressures and shear

Disadvantages Requires skilled clinician and supplier Reduced air flow between support surface and skin Total support may prevent development or improvement of postural control Restriction of movement prevents postural adjustments and weight shifting Minimal adjustability Labor intensive and costly

Typical Applications

Poor trunk control and balance Severe fixed deformities


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OscillatingContain air cells that alternately inflate and deflate, or alternately change mechanicalpressure.Advantages

Excellent pressure reduction, possibly promoting healing of open areas while allowingfor limited sitting time.

DisadvantagesVery costly


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TYPES OF S ECONDARY S UPPORT S URFACES (ACCESSORIES )

Pelvic and thigh control components

Medial thigh supportsLateral thigh supportsLateral pelvic supportsAnterior pelvic supports

ASIS pads/bar pelvic positionerPelvic beltSafety belt

Trunk control componentsLateral thoracic supportsPosterior lumbar supportsSacral supportsAnterior trunk support

Shoulder control componentsPosterior shoulder supportsAnterior shoulder supportsSuperior shoulder supports


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Head/neck control componentsPosterior neck supportPosterior head supportLateral head supportAnterior head supportCircumferential head/neck support (i.e. cervical collar)

Upper extremity control componentsArm supportArm troughTray

Provides support to the arms and upper extremities; can be used to assist upper trunkor arm positioning.


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Lower extremity control componentsPosterior calf support

Calf strapCalf pad

Foot supportFoot platform one pieceFootplates individual

Fixed angle Angle adjustable

Foot positioner Heel loops Ankle straps Toe straps Shoe holders

Anterior knee supportAnterior leg support


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DYNAMIC P RESSURE RELIEVING S EATING S YSTEMS

Tiltinspace

Seat-back angle is maintained as the seating system rotates around a fixed or slidingpivot point.

Typically tilt in a posterior direction to re-distribute and relieve pressure.

May also be used to provide rest from the upright position, and gravity assistedpositioning to improve posture and head control.

Manual Power Posterior tilt Anterior tilt Lateral tilt


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ReclineSeat-back angle to increase as the backposts are reclined.

Typically used for accommodation of severe hip extension contractures, orthostatichypotension, and pressure re-distribution for prevention of skin breakdown.

May result in tendency to slide forward in the seat.

May cause shearing at the sacrum and low back.

Manual Power Low Shear

StandersManual or power systems which move from the seated to standing positions.

Typically used for environmental access and pressure relief.


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MOBILITY INTERVENTION

Goals of Wheeled Mobility Provide a means of independent mobility Maximize performance of activities of daily living Allow access to all terrain and environments encountered during the course of the

day Provide support of neutral posture Provide orientation in space required for optimal posture and function Provide a base for the adaptive seating system Provide a means of pressure relief

Accommodate changes in size and weight


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TYPES OF MOBILITY BASES

Dependent mobility bases

StrollersTypically used for dependent community mobility for childrenSome models have higher weight limits suitable for small adultsVariety of seating options

Transport wheelchairs

Lightweight chair with small wheels used for dependent transportation over levelsurfacesVery few options


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Manual wheelchairsStandard

Medicare classification (K0001)

Traditional wheelchair with no adjustability and very few optionsVery heavy, requiring good strength and sitting balance to operate effectivelyVery durableFew options

Standard hemiMedicare classification (K0002)Traditional wheelchair with a lower seat heightAllows for propulsion with feet

Few optionsLightweight

Medicare classification (K0003)Similar in appearance to traditional wheelchair, but slightly lighter weightMay have some axle adjustability.Beneficial for individuals with slight upper extremity weaknessFew options

High-strength lightweight

Medicare classification (K0004)Lightweight wheelchair of durable constructionLimited axle adjustability; may have 1 or 2 positions, or some horizontal or verticaladjustabilityVariety of components available as optionsMost models have hemi optionSome models offer onearm drive mechanism


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Manual wheelchairs (contd) Ultra-lightweight

Medicare classification (K0005)Greatest degree of adjustability maximize user efficiency and functionAxle adjustability allows center of gravity of the user to be changed in relation to thewheel basePreviously used by high functioning usersFrequently used by individuals with severe weakness, fatigue, or complex positioningrequirements due to ability to maximize efficiency

Folding frames Traditional cross-brace frame Offers greatest ease of folding Greater shock absorbancy Can be narrowed to get through doorways Can be grown by replacing cross tubes and upholstery Less efficient propulsion

Rigid One-piece frame, typically with horizontal cross bars Offers greater durability Lighter weight Offers more efficient ride Less shock absorbancy May be difficult for some individuals to fold


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Heavy-dutyMedicare classification (K0006)Traditional wheelchair with no or limited adjustabilityDurable construction for users weighing more than 250#Very few optionsVery heavy

Extra Heavy-dutyMedicare classification (K0007)Traditional wheelchair with no or limited adjustabilityDurable construction for users weighing more than 300# Very few optionsVery heavy

CustomMedicare definition (K0008)

Uniquely constructed or modified for the specific beneficiary Feature needed not available on an already manufactured base Must be customization of the frame, not components


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Wheelchair ComponentrySeat

UpholsteryNYLON NAUGAHYDE

Solid Adjustable angle

Back Upholstery

NYLON NAUGAHYDE ADJUSTABLE TENSION

Can accommodate slight postural deviations

Can be kept tight to prevent sling over time Back-posts

S TRAIGHT BACK -POSTS 8-10 DEGREE BEND ADJUSTABLE ANGLE P USH HANDLES


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Legrests Select based upon functional need

ALLOW FOR TRANSFERS ACCOMMODATE KNEE CONTRACTURES REDUCE EDEMA REDUCTION OF SPASTICITY /TONE

Swing-awayEASIEST TO REMOVE FOR TRANSFERS CAN BE REMOVED TO INCREASE ACCESSIBILITY MECHANISM MAY BE DIFFICULT TO MANEUVER , AND MAY WEAR -OUT WITH TIME

Rigid/fixedGREATER DURABILITY MAY MAKE TRANSFERS DIFFICULT CANNOT REMOVE TO IMPROVE ACCESSIBILITY

Semi-rigidS WING -AWAY LEGRESTS JOINED TOGETHER AT THE FOOTPLATE IMPROVES DURABILITY

ElevatingUSEFUL IN CASES OF LIMITED ROM, EDEMA INCREASES OVERALL CHAIR LENGTH MAY COMPROMISE PELVIC POSITION BY STRETCHING HAMSTRINGS QUESTIONABLE BENEFIT FOR EDEMA REDUCTION INCREASES LENGTH OF CHAIR , DECREASES ACCESSIBILITY MECHANISM DIFFICULT TO OPERATE

ArticulatingLEGRESTS EXTENDS AS IT ELEVATES , ALLOWING TRUE ELEVATION WITHOUT CAUSINGTHE KNEE TO FLEX

TaperedINCREASED ACCESSIBILITY IMPROVED LEG ALIGNMENT DECREASED CALF SPACE

Hanger angle


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Footplates Composite or Aluminum Flip-up Extended Platform Angle adjustable Tubular High-mount

Armrests Selection based upon how used by individual

S TABILIZATION OF TRUNK S TABILIZING POINT FOR PUSHING UP TO STAND OR FOR PRESSURE RELIEF ATTACHMENT POINT FOR TRAY

Fixed Height

Adjustable height Removable vs. Flip-back Tubular/swing-away Desk length vs. full length

Axle Non-adjustable/single position Semi-adjustable Adjustable/multi-position Amputee/extended Quick release

ALLOWS REMOVAL OF REAR WHEELS REQUIRES GOOD HAND FUNCTION

Quad releaseALLOWS PERSON WITH LIMITED HAND FUNCTION TO REMOVE REAR WHEELS MAY ACCIDENTALLY DISENGAGE

One-arm drive


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Wheels Spoke Mag Composite

Tires Diameter and composition affect rolling resistance Solid/polyurethane

GOOD FOR INDOOR USE NO MAINTENANCE DURABLE ROUGH RIDE OUTDOORS HEAVY HIGH OR LOW PROFILE

High profile offers some traction

PneumaticLESS ROLLING RESISTANCE GOOD ON ROUGH TERRAIN GOOD TRACTION LIGHTWEIGHT AIR PRESSURE MUST BE MAINTAINED FOR PERFORMANCE

Airless/foam insertsMAKES PNEUMATIC TIRES FLAT -FREE ADDS WEIGHT

Kevlar

REINFORCED

,PUNCTURE RESISTANT TIRE

KnobbyALL TERRAIN TIRE WITH SIGNIFICANT TREAD INCREASED TRACTION P UNCTURE RESISTANT

High-pressureHIGH PERFORMANCE LIGHTWEIGHT REQUIRES PRESTA VALVE (SMALL BICYCLE -TYPE VALVE )


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Handrims Anodized aluminum/chrome Plastic coated Molded Projections

Wheel locks Push-to-lock Pull-to-lock Scissor High-mount Low-mount

Casters Small front wheels attached to fork, swivels about stem bolt Large casters (6-8)

LEAST ROLLING RESISTANCE IMPROVED MANEUVERABILITY OVER UNEVEN TERRAIN INCREASED CLEARANCE BETWEEN FOOTPLATE AND GROUND CAN BE USED TO ACHIEVE POSTERIOR TILT -IN-SPACE

Small casters (3-5)MORE RESPONSIVE TO QUICK TURNS AID IN CURB MANEUVERABILITY INCREASED CLEARANCE BETWEEN FOOTPLATE AND CASTER LESS SHIMMY (SIDE -TO -SIDE FLUTTER AT HIGH SPEEDS )GREATER ROLLING RESISTANCE DECREASED ABILITY TO ROLL OVER OBSTACLES

SolidNO MAINTENANCE LEAST ROLLING RESISTANCE


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Casters (contd)

PneumaticMOST SHOCK ABSORPTION OFFER SMOOTHER RIDE EASE OF MANEUVERING OVER UNEVEN SURFACES

Semi-pneumaticNO MAINTENANCE COMPROMISE BETWEEN ABOVE

Caster stem boltLONG STEM BOLT IMPROVES CLEARANCE BETWEEN FOOTPLATE AND FLOOR INCREASES TILT WITHOUT CHANGING CASTER

Caster forkLONGER FORK INCREASES TILT WITHOUT CHANGING CASTER DECREASES CLEARANCE BETWEEN HEEL AND CASTER

Quick release castersUSEFUL FOR THOSE WHO EXCHANGE FRONT CASTERS FOR DIFFERENT ACTIVITIES

Caster pin locksP ROVIDE ADDITIONAL STABILITY OF WHEELCHAIR DURING TRANSFERS DIFFICULT TO MANAGE


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Accessories Anti-tippers

MAY INTERFERE WITH NEGOTIATION OF ROUGH TERRAIN ; DECREASES GROUNDCLEARANCE

REAR

FRONT Brake extensions

BRAKE IS EASIER TO REACH AND ENGAGE USEFUL FOR HEMIPLEGICS DECREASE BRAKE DURABILITY MAY INTERFERE WITH TRANSFERS AND PROPULSION

Grade aidsP REVENTS WHEELCHAIR FROM ROLLING BACKWARD WHEN ASCENDING INCLINES MUST BE USED ON TIRE WITH TREADS (I.E. PNEUMATIC )DIFFICULT TO PROPEL WHEN ENGAGED MAY ENGAGE INADVERTENTLY MAY PREVENT RECOVERY FROM BACKWARD FALL P OOR DURABILITY

Clothing guardsP REVENT HIPS AND THIGHS FROM RUBBING TIRES CAN BE USED TO CENTER CUSHION OR PERSON IN SEAT

R IGID Must remove for lateral transfersLimit use of larger cushion if increased width needed

CLOTH Does not need to be removed for transfersAllows for use of wider cushion if necessaryNeeds to be tightenedAllows for slipping of cushion


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Accessories (contd)

Spoke guardsP ROTECTS FINGERS FROM INJURY

PREVENTS DAMAGE TO SPOKES

MAY NEED TO REMOVE IN ORDER TO TIE -DOWN IN VEHICLE MAY RATTLE IF NOT TIGHT

Leg straps/heel loopsMAINTAIN FOOT POSITION MAY BE USEFUL DURING TRANSFERS BETWEEN CHAIR AND FLOOR MAY MAKE TRANSFERS DIFFICULT


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TYPES OF MOBILITY BASES (CONT D)

Scooters/Power Operated VehiclesTypically steered with a tillerSpeed is controlled by thumb leverTypically used for community mobility by individuals with limited ambulatory functionThree-wheeled

Narrow base of supportHigh center of gravityUnstable

Requires good trunk control and good upper extremity functionLarge turning radius

Four-wheeledMore stableRequires good trunk control and good upper extremity function

Large turning radius


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Power Wheelchairs (contd) All Group 2 PWC; K0820 K0843

Standard integrated or remote proportional joystick May have crossbrace construction Accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports) (except captains chairs) Length - less than or equal to 48 inches Width - less than or equal to 34 inches Minimum Top End Speed - 3 MPH Minimum Range - 7 miles Minimum Obstacle Climb - 40 mm Dynamic Stability Incline - 6 degrees

Group 2 No Power Options PWC; K0820 K0829 Non-expandable controller Incapable upgrade to expandable controller Incapable of upgrade to alternative control devices Incapable of accommodating a power tilt, recline, seat elevation, standing system Accommodates non-powered options and seating systems (e.g., recline-only

backs, manually elevating legrests) (except captains chairs)


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Power Wheelchairs (contd)

All Group 3 PWC; K0848 K0864 Standard integrated or remote proportional joystick Non-expandable controller Capable of upgrade to expandable controller Capable of upgrade to alternative control devices May not have crossbrace construction Accommodates seating and positioning items (e.g., seat and back cushions,

headrests, lateral trunk supports, lateral hip supports, medial thigh supports)(except captains chairs)

All Group 3 PWC; K0848 K0864 (2) Additional requirements: Drive wheel suspension to reduce vibration Length - less than or equal to 48 inches Width - less than or equal to 34 inches Minimum Top End Speed - 4.5 MPH Minimum Range - 12 miles

Minimum Obstacle Climb - 60 mm Dynamic Stability Incline - 7.5 degrees


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Power Wheelchairs (contd) Group 4 PWCs K0868 K0886

Have added capabilities not needed for home use If provided and coverage guidelines met for Group 2 or 3, allowance based on least

costly alternative medically appropriate PWC If billed with KX modifier, allowance based on comparable group 3 PWC

Group 5 PWC; K0890 K0891 Standard integrated or remote proportional joystick Non-expandable controller Capable of upgrade to expandable controller Capable of upgrade to alternative control devices Seat Width: minimum of 5 one-inch options Seat Depth: minimum of 3 one-inch options Seat Height: adjustment requirements- 3 inches Back Height: adjustment requirements minimum of 3 options Seat to Back Angle: range of adjustment-minimum of 12 degrees Accommodates non-powered options and seating systems


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Power Wheelchairs (contd) Group 5 PWC; K0890 K0891 (2)

Additional requirements: Accommodates seating and positioning items (e.g., seat and back cushions,

headrests, lateral trunk supports, lateral hip supports, medial thigh supports) Adjustability for growth (minimum of 3 inches for width, depth and back height

adjustment) Special developmental capability (i.e., seat to floor, standing, etc.) Drive wheel suspension to reduce vibration Length - less than or equal to 48 inches Width - less than or equal to 34 inches Minimum Top End Speed - 4 MPH Minimum Range - 12 miles Minimum Obstacle Climb - 60 mm Dynamic Stability Incline - 9 degrees Crash testing - Passed


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Power Wheelchairs (contd)

Power seating optionsDynamic pressure relieving seating system

Power tiltS EAT -BACK ANGLE MAINTAINED AS SEATING SYSTEM ROTATES AROUND A FIXED ORSLIDING PIVOT POINT MAINTAINS SITTING POSTURE WHILE ORIENTATION TO GRAVITY IS CHANGED TYPICALLY REQUIRES A LONGER , HEAVY BASE NEW FORWARD SLIDING SYSTEMS ALLOW USE OF SHORT BASE

Power reclineS EAT -BACK ANGLE INCREASES AS THE BACK -POSTS ARE RECLINEDTYPICALLY REQUIRES A LONGER , HEAVIER BASE MAY INCLUDE SELF -ELEVATING LEGRESTS (AUTOMATICALLY ELEVATE AS BACKRECLINES )

Power standS EATING SYSTEM MOVES FROM SITTING TO STANDING ALLOWS INDIVIDUAL TO COME TO A STANDING POSITION FOR ADLS MAY OR MAY NOT BE ABLE TO BE DRIVEN IN STANDING POSITION

Power elevating seatS EATING SYSTEM IS RAISED OR LOWEREDALLOWS FUNCTIONAL HEIGHT FOR ADLS , TRANSFERS , INTERACTION WITH OTHERS

Power elevating legrestsLEGRESTS ELEVATE EXCLUSIVE OF THE SEATING SYSTEM ALLOWS INDEPENDENT LOWER EXTREMITY ELEVATION FOR EDEMA REDUCTION ORPOSITIONING


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Power wheelchair componentsInput devices

Allow user to input the speed, direction, and command to stop the wheelchair Proportional

DIRECTION AND SPEED OF THE CHAIR ARE IN PROPORTION TO AMOUNT OF MOVEMENTAT THE INPUT DEVICE J OYSTICK

Hand controlChin controlHead controlled joystick

P EACHTREE HEAD CONTROL Digital

S WITCHES ARE EITHER ON OR OFF NON -PROPORTIONAL BODY /CONTACT SWITCHES

Switch activated by direct pressureEach switch controls a direction or functionMay be used at nearly any access point, in any combination

P ROXIMITY /NON -CONTACT SWITCHES Switch activated by movement toward or away from the switch

Each switch controls a direction or functionMay be used at nearly any access point, in any combinationP NEUMATIC (SIP &PUFF )

Motors Allow movement of the chair Belt or direct drive Mounted to front, mid, or rear wheels


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Controller Brain of the wheelchair Allows adjustment of parameters (how wheelchair responds to input from the user)

MAXIMUM SPEED

LOW SPEED ACCELERATION DECELERATION TURNING SPEED TREMOR DAMPENING

Also called sensitivityMakes wheelchair more or less responsive to joystick movementUseful in cases of tremor or extraneous movement

J OYSTICK THROW Amount of joystick movement necessary to obtain full speed and directioncontrolOften reduced for users with limited ROM

MOMENTARY CONTROL Chair operates as long as input is providedChair stopped when no input

LATCHED CONTROL Either on or offChair operates continuously in response to single activation of switchSubsequent activation of switch stops movement


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INTEGRATION ISSUES Tilt/recline systems

Compatibility with various manufacturers

Variations in tilt systemsBasic tiltCenter of gravity tiltForward sliding/weight shifting tilt

Additional seat heightAttachment of after-market backsPinch pointsDrive lock-out

Transportation issuesTie-down systemLift/loadingTransfersDriving

Alternative methods of accessCompatible electronicsSufficient access sites for all devices

Communication devices/computer accessCompatible electronicsMounting of system to wheelchairPlacement of cablesSeat height


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OTHER MOBILITY DEVICES

Pushrim activated power assist

Attach to manual wheelchair framesMotor turns rear wheelsAllows use of wheelchair as manual or powerWeight negatively affects use as manual wheelchairEasily removed to allow folding of wheelchair for transport

Beach wheelchairs

Handcycles

Sports wheelchairs


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_________________________________________________________________ TRIALS

_________________________________________________________________ Start with least expensive mobility option that may meet their mobility and positioningneeds

Wheelchair Wheelchair componentry

Add least expensive seating intervention that will provide amount of support deemednecessary from the mat assessment

Primary support surfaces Secondary support surfaces

Attempt to match the individual s dimensions as closely as possible

Assess for each option evaluated: Fit Comfort Positioning Mobility Transfers Functional abilities


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_________________________________________________________________

TRIALS (cont d) _________________________________________________________________

Determine effectiveness of least costly options, noting reasons why they did or notwork

Progress to other mobility and seating options, concluding when you have determinedthe least costly option that will meet the individual s mobility, positioning, comfort, and

functional needs.

If no objective or subjective difference between options, chose the least costly option.


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_________________________________________________________________

EQUIPMENT SPECIFICATION _________________________________________________________________

While positioned in the least costly, most appropriate intervention, verifythe individuals measurements in the context of the equipment

Collaborate with the client and RTS/dealer to

Determine appropriate equipment dimensionsComplete wheelchair and seating system order formsSpecify all componentsSpecify type and size of primary support surfacesSpecify type and size of secondary support surfacesEnsure client s understanding of all options specified

Incorporate info from Vendor home assessment


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_________________________________________________________________

CASE STUDIES _________________________________________________________________

ManualC7 complete tetraplegia50 woman with hemiplegiaBilateral LE amputeeDecreased visionMS, limited ambulation, impaired coordination400 poundsTriplegia (i.e. only left arm function)Profound MR, severe scoliosis, pelvic obliquityPoor judgmentInability to perform pressure reliefsClient drives own car


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_________________________________________________________________ CASE STUDIES

_________________________________________________________________

PowerCOPD, oxygen dependentSevere trunk and UE ataxiaC4 complete tetraplegiaExtreme startle reflexesImpaired vision

400 poundsInability to perform pressure reliefsDistractibility, poor judgmentRapidly progressing ALSUse of public transportationClient drives own van


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_________________________________________________________________ FUNDING AND DOCUMENTATION

_________________________________________________________________

THE OLD DAYS :

Medically NecessaryDurable Medical Equipment is required for the treatment of the client s documentedmedical condition

Prescribed by a PhysicianPhysician attests to the documented medical need of the covered device.


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EVOLUTION OF MEDICARE COVERAGE

Typically covers older adults or people with long term disabilities

Policies largely determine industrywide reimbursementCoverage Considerations:

Medicare is a defined benefit program.An item or service must fall within one or more benefit categories, and not otherwisebe excluded by statute from coverage. Section 1861(n) of the Social Security Act listsitems that are included as durable medical equipment (DME), including wheelchairs.MAE is covered under the benefit category of DME. DME is defined as equipment that

1) can withstand repeated use,2) is primarily and customarily used to serve a medical purpose,3) generally is not useful to an individual in the absence of an illness or injury, and4) is appropriate for use in the home (42 C.F.R. 414.202).

CMS has several national coverage determinations (NCD) regarding various mobilityassistive equipment.


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Recent EventsExcerpted from May 5, 2005 CMS Decision Memo for Mobility Assistive Equipment(CAG-00274N)

On December 15, 2004, CMS opened an NCD on mobility assistive equipment toexamine and set the clinical criteria for the provision of this equipment.Recent allegations of wheelchair fraud and abuse have focused considerable publicinterest on the provision of wheelchairs under the Medicare benefit. The agency hasresponded with a multifaceted plan to ensure the appropriate prescription ofwheelchairs to beneficiaries who need them. One facet of this plan is thedelineationof suggested clinical conditions of wheelchair coverage .

Many advocacy groups have suggested that the agency adopt a functionbasedinterpretation of its historicalbed or chair confined criterion for wheelchaircoverage.

Historically, wheelchairs have been covered if [the] patient's condition is such thatwithout the use of a wheelchair he would otherwise be bed or chair confined. Anindividual may qualify for a wheelchair and still be considered bed confined.

Wheelchairs (power operated) and wheelchairs with other special features are coveredif [the] patient's condition is such that a wheelchair is medically necessary and thepatient is unable to operate the wheelchair manually.


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In June of 2004, CMS formed a workgroup (the Interagency Wheelchair Work GroupIWWG) of Federal employees to review its current policy for wheelchair provision andto analyze the published scientific literature on the use of wheelchairs. The IWWGmade several recommendations for the clinical interpretation of CMS statutory,

regulatory and clinical guidelines, including the adoption of a functionbaseddetermination of medical necessity. A functionbased determination might considerthe beneficiarys inability to safely accomplish activities of daily living, such astoileting, feeding, dressing, grooming, and bathing with and without the use ofmobility equipment, such as a wheelchair.

On December 15, 2004, CMS initiated the national coverage determination to addressthe appropriate prescription of Mobility Assistive Equipment.

Consistent with IWWG recommendations and our internal review, CMS chose to useactivities of daily living such as toileting, feeding, dressing, grooming, and bathing asthese are activities necessary to serve a medical purpose in the home. We collectivelynamed these mobility related activities of daily living (MRADLs).


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RESULTING RECOMMENDATIONS FOR ASSESSMENT /P RESCRIPTION Excerpted from May 5, 2005 CMS Decision Memo for Mobility Assistive Equipment(CAG-00274N)

Appropriate Prescription of Mobility EquipmentAn assessment of the beneficiary s physical, cognitive, and emotional limitations andabilities, willingness to use mobility assistive equipment on a routine basis, and thebeneficiary s typical home environment is recommended to determine the appropriateprescription of mobility equipment.

In order to facilitate the application of the new functional criteria, the IWWG proposedthe following suggestions for the provision of wheelchairs.


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Provision of Mobility Assistive Equipment Under Medicare Should IncludeAll Five Points Below

The beneficiary s physical limitations (diminished strength, speed, endurance, rangeof motion, coordination, sensation, deformity) prevent the beneficiary fromaccomplishing mobility-related activities of daily living in the home.

The beneficiary s mental capabilities (cognition, orientation, communication, judgment, memory, comprehension, affect, and suitable behavior) are sufficient forsafe and adequate performance of mobility-related activities of daily living with the useof mobility assistive equipment.

The beneficiary s physical capabilities (strength, speed, endurance, range of motion,

coordination, sensation) are sufficient for safe and adequate performance of mobility-related activities of daily living with the use of a mobility assistive equipment.

The characteristics of the beneficiary s typical home environment in which theactivities of daily living are encountered (surfaces, presence or absence of surfaceaccommodations, obstacles, accessibility, changes in grade, and distances covered)are suitable for use of the appropriate equipment.

The beneficiary demonstrates willingness to use the equipment routinely.


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Clinical Criteria for Wheelchair PrescribingThe beneficiary, the beneficiary s family or other caregiver, or a clinician will usuallyinitiate the discussion and consideration of wheelchair use.

Sequential consideration of the questions below provides clinical guidance for theprescription of a device of appropriate type and complexity to restore the beneficiary sability to perform mobility-related activities of daily living.

These questions correspond to the numbered decision points on the accompanyingflow chart.


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#1: Mobility limitation?

Clinical Criteria Algorithm for Wheelchair Prescribing

Request initiated for mobilitydevice for willing patient

#5: Canes/walkers?

#2: Other limitations?

#8: POV?

#3: Compensated?

Exit

No

Yes

Yes

No

# 6: Environment ?

#7: Self-propel?

#4: Capable of safe use?

Safe?

#9: PWC appropriate? Power wheelchair

Appropriatemanual

wheelchair configuration

POV

Canes

or walkers

Yes Yes

No

Yes

No

No

No

Safe?

No

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

Yes

Safe?

Safe?

No

Yes

No

No


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Does the beneficiary have a mobility limitation causing an inability to perform one ormore mobilityrelated activities of daily living in the home? A mobility limitation is onethat

Prevents the beneficiary from accomplishing the mobility-related activities of dailyliving entirely, or

Places the beneficiary at reasonably determined heightened risk of morbidity ormortality secondary to the attempts to perform mobility-related activities of dailyliving, or

Prevents the beneficiary from completing the mobility-related activities of dailyliving within a reasonable time frame.

Are there other conditions that limit the beneficiarys ability to perform mobility

related activities of daily living at home? Some examples are significant impairment of cognition or judgment and/or vision. For these beneficiaries, the provision of a wheelchair might not enable them to

perform mobility-related activities of daily living if the comorbidity prevents effectiveuse of the MAE or reasonable completion of the tasks even with a wheelchair.

If these other limitations exist, can they be ameliorated or compensated sufficientlysuch that the additional provision of a mobility equipment will be reasonablyexpected to materially improve the beneficiary s ability to perform mobility-relatedactivities of daily living in the home?


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Does the beneficiary demonstrate the capability and the willingness to consistentlyoperate the device safely?

Safety considerations include personal risk to the beneficiary as well as risk toothers.

The determination of safety may need to occur several times during the process asthe consideration focuses on a specific device.

A history of unsafe behavior in other venues may be considered.

Can the functional mobility deficit be sufficiently resolved by the prescription of a caneor walker?

The cane or walker should be appropriately fitted to the beneficiary for thisevaluation.

Assess the beneficiary s ability to safely use a cane or walker.

Does the beneficiarys typical environment support the use of wheelchairs orscooters/POVs?

Determine whether the beneficiary s environment will support the use of thesemobility assistive equipment.

Keep in mind such factors as temperature, physical layout, surfaces, andobstacles, which may render an item of mobility assistive equipment unusable inthe beneficiary s home.


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Does the beneficiary have sufficient upper extremity function to propel a manualwheelchair in the home through the course of the performance of mobilityrelatedactivities of daily living during a typical day?

The manual wheelchair should be optimally configured (seating options,wheelbase, device weight and other appropriate accessories) for thisdetermination.

Limitations of strength, endurance, range of motion, coordination and absence ordeformity in one or both upper extremities are relevant.

A beneficiary with sufficient upper extremity function may qualify for a manualwheelchair. The appropriate type of manual wheelchair, i.e. light weight, powerassisted, etc. should be determined based on the beneficiary s physicalcharacteristics and anticipated intensity of use.

The beneficiary s home should provide adequate access, maneuvering space andsurfaces for the operation of a manual wheelchair.

Assess the beneficiary s ability to safely use a manual wheelchair.

Does the beneficiary have sufficient strength and postural stability to operate a poweroperated vehicle (POV/scooter)?

A POV is a 3 or 4-wheeled device with tiller steering and limited seat modificationcapabilities. The beneficiary must be able to maintain stability and position foradequate operation.

The beneficiary's home should provide adequate access, maneuvering space andterrain for the operation of a POV.

Assess the beneficiary s ability to safely use a POV/scooter.


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Are the additional features provided by a power wheelchair needed to allow thebeneficiary to perform one or more mobilityrelated activities of daily living?

These devices are typically controlled by a joystick or alternative input device, andcan accommodate a variety of seating needs.

The beneficiary's home should provide adequate access, maneuvering space andterrain for the operation of a power wheelchair.


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Specific Documentation Requirements for Each Category of MAE

See Noridian Documentation checklists (appendix) Manual wheelchairs Power wheelchair: Group 1/Group 2, no power options Power wheelchair: Group 2 Single/Multiple power options Power wheelchair: Group 3 Single/Multiple power options Power wheelchair: Group 3 No power options POV and Push-rim Activated Power Assist Device

See Noridian Power Wheelchair Documentation Requirements (appendix)


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OTHER P AYORS

Medicaid

Coverage based upon income; low-income and disabledMedicaid requires pre-authorization on certain items; this provides client anddealer/supplier with verification of coverage prior to ordering

DME must be medically necessary; intended for use in home environment

Requires specific medical justification for different types of DME

Payor of last resort; must go through other sources first

Covers DME at allowable charge (payment made to supplier/dealer); opportunity forindividual considerationCovers repairs

Covers DME for people in skilled nursing facilities through MAP 122 process

Coordinated by nursing facility social worker

Supplier/dealer must be willing to accept MAP 122 assignment (small monthlypayments over an extended time period)

DME for people in intermediate care facility, personal care homes, and adult homes ishandled through normal process

DME is owned by the client


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Commercial InsuranceCovers individuals under employers group plan, responsible for paying their portion ofthe premium

Also may be Medicare Supplemental planCoverage handbook typically offers vague summary of items covered

Most offer pre-authorization

DME must be medically necessary

Most require specific medical justification for DME, some require MD prescription orletter only

May require use of a participating supplier/dealer

Covers DME at certain percentage (i.e. 80%) of a reasonable" allowable charge;often subject to a small cap

The supplier/dealer will bill the remaining percentage of the balance (i.e. 20%) to thesecondary insurance or to the client

Some cover repairs

Most do not cover DME for people in skilled nursing facilities

DME for people in intermediate care facility, personal care homes, and adult homes ishandled through normal process

DME is owned by the client


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Workers CompensationCovers individuals with work-related injuries

Typically offers pre-authorization, but must be coordinated through case manager

Equipment must be medically, vocationally, or functionally necessary (broad definitionof what is acceptable)

Most require some level of justification for equipment; some may required MDprescription for certain items

May require use of a participating supplier/dealer

Covers equipment at 100%, but may obtain bids from several suppliers/dealers

Covers repairs

Equipment is owned by client


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Division of Vocational RehabilitationCovers individuals with an intent to return to work or schoolTypically offers pre-authorization, but must be coordinated through field counselor

Equipment typically must be vocationally necessary, but often cover items medicallyor functionally necessary (broad definition of what is acceptable)Requires written justification of need for equipmentMay require use of a contract supplier/dealerCovers equipment at 100%, but must often obtain bids from several suppliers/dealersCovers repairsEquipment is owned by DVR

Other SourcesDepartment of Veterans Affairs

Self-payPublic SchoolsDepartment of the Visually HandicappedCommunity Service FundCommunity Service BoardPhilanthropic organizationsChurchesPrivate/community fund raising


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DOCUMENTATION

Equipment Specifications/Quote

Therapist Evaluation Report / Letter of Medical NecessityPhysician Prescription

Medicaid: Certificate of Medical Necessity

Medicare: (see Noridian checklists)7 point physician prescription

Face-to-face examination by physicianPhysician chart notes


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_________________________________________________________________

DELIVERY AND FOLLOW-UP_________________________________________________________________

FITTING

Collaborate with the RTS/dealer to ensure that all equipment is asrecommended and configured appropriately prior to scheduling delivery

Attach primary and, if possible, secondary support surfaces to mobility baseprior to client arrival

A


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ADJUSTMENTS

With client positioned in seating/mobility system, ensure that allequipment is adjusted properly

Cushion positionBack positionArmrest heightLegrest positionSecondary supports

Headrest Lateral supports Pelvic positioning belts

Controls/switches

Securely attach all equipment once final position is achieved

Reassess seating/mobility system for:FitComfortPositioningMobilityTransfersFunctional abilities


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TRAINING

Make sure client/family/caregiver is able to position client properly inseating/mobility system

Make sure client/family/caregiver is able to disassemble/ reassemble andadjust all necessary parts

LegrestsArmrestsCushionBack

WheelsOn/offAir pressure

Folding/loading wheelchair for transportCharging wheelchair batteries

Recommend therapy program for additional mobility training if necessary


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EDUCATION

Warranty information

Care of equipmentRepairsCleaning

Contact person for additional questions/concerns regardingseating/mobility system (usually RTS/dealer)

FOLLOW -UP

Encourage coordination of equipment issues directly with RTS/dealer

Provide client with therapist contact information should any issues arisethat are beyond the scope of the RTS/dealer

Phone followup at regular intervals is strongly encouraged


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_________________________________________________________________

REFERENCES _________________________________________________________________

Ball, M. (1996) A Multidisciplinary Approach to Dynamic Seating of the MultiplyInvolved Client. Conference sponsored by Freedom Designs, Charlotte, NC.

Center for Assistive Rehabilitation Technology Training and Evaluation (CARTE),Central Region Training Manual (1996). Virginia Department of RehabilitativeServcies, Virginia Assistive Technology System, University of Virginia, WoodrowWilson Rehabilitation Center.

Engstrom, B. (1993) Ergonomics: Wheelchairs and Positioning. Posturalis,Hasselby, Sweden.

Hoppenfeld, S. (1976) Physical Examination of the Spine and Extremities. Appeton-Century-Crofts, Norwalk, CT.

Huss, D. et al (1994) Recreating the Wheel: How s and Why s of Wheelchairs andSeating for Neurologically Impaired Adults. Conference sponsored by WoodrowWilson Rehabilitation Center, Department of Physical Therapy, Fishersville, VA.

Kapandji, A. (1974) The Physiology of the Joints, Vol. 3: The Trunk and VertebralColumn. Churchill Livingstone, New York, NY.


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Kreutz, D. (1998) Fundamentals in Assistive Technology, 2 nd Edition: Module VIII -Characteristics of Seating and Positioning Technologies. RESNA Press, Arlington,VA.

Maurer, L.E., and Vanhoy, M. (1998) AHCA Assistive Technology Services AssistiveTechnology Training Program Manual, Module 1: Seating and Mobility. AmbulatoryHealthCare Corporation of America, Fredericksburg, VA.

Maurer, L.E., and Vanhoy, M. (1998) UVA-HealthSouth Seating and Mobility TrainingCurriculum Manual. University of Virginia-HealthSouth Rehabilitation Hospital,Charlottesville, VA.

Medhat, M.A., and Hobson, D.A. (1992) Standardization of Terminology andDescriptive Methods for Specialized Seating: A Reference Manual. RESNA Press,Arlington, VA.

Minkel, J.L. (1996) Sitting Solutions: Principles of Wheelchair Positioning andMobility Devices. Conference sponsored by Therapeutic Service Systems, Baltimore,MD.

Nixon, V. (1985) Spinal Cord Injury: A Guide to Functional Outcomes in PhysicalTherapy Management. Aspen Publishers, Inc., Rockville, MD.

Schuch, J. and Sprigle, S. (1995) Wheelchair Seating and Positioning: ImprovingYour Services from Assessment Through Follow-Up. UVA Rehabilitation EngineeringWorkshop, University of Virginia , Charlottesville, VA.

Zollars, J.A. (1996) Special Seating: An Illustrated Guide. Otto Bock OrthopedicIndustry, Inc., Minneapolis, MN.


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_________________________________________________________________

RESOURCES _________________________________________________________________

Centers for Medicare and Medicaid ServicesMay 5, 2005 Decision Memorandumwww.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=143

Clinical Criteria for MAE Coverage

www.cms.hhs.gov/CoverageGenInfo/Downloads/MAEAlgorithm.pdf

NORIDIAN Administrative Services, LLC (Medicare Administrative Contractor,Jurisdiction D)

Documentation Checklistswww.noridianmedicare.com/dme/coverage/

NAMES National Association of Medical Equipment Suppliers

625 Sister Ln., Suite 200Alexandria, VA 32314(703) 836-6263

An organization of suppliers of various types of medical equipment. TheirRe/habilitation Section has established Standards of Practice for RehabilitationTechnology Companies. They sponsor and participate in several trade shows.

NRRTS National Registry of Rehabilitation Technology Suppliers


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NRRTS National Registry of Rehabilitation Technology Suppliers3223 South Loop 289, Suite 600Lubbock, TX 79423(800) 976-7787

An organization composed of Rehabilitation Technology Suppliers, dedicated to theprovision of high quality rehabilitation technology services to people with disabilities.All NRRTS members meet specific professional membership requirements and agreeto adhere to the NRRTS Code of Ethics and Standards of Practice.

RESNA Rehabilitation Engineering and Assistive Technology Society ofNorth America

1700 N. Moore St., Suite 1540Arlington, VA 22209-1903(703) 524-6686http://www.resna.org/resna/reshome.htm

An interdisciplinary association of professionals, providers, and consumers withinterests in disability and assistive and rehabilitative technology. RESNA promotesresearch, development, education, advocacy, and provision of technology.


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_________________________________________________________________ APPENDICES

_________________________________________________________________ Providence Alaska Medical Center, Wheelchair and Seating Clinic Referral Form

Noridian Documentation Checklistswww.noridianmedicare.com/dme/coverage/docs/checklists/manual_wheelchairs.pdf

www.noridianmedicare.com/dme/coverage/docs/checklists/group_1_pwc_and_group

_2_pwc_no_power_options.pdf

www.noridianmedicare.com/dme/coverage/docs/checklists/group_2_single_power_option_group_2_multiple_power_option.pdf

www.noridianmedicare.com/dme/coverage/docs/checklists/group_3_single_and_multiple_power_options.pdf

www.noridianmedicare.com/dme/coverage/docs/checklists/group_3_power_mobility _device_no_power_options.pdf

Documentation Requirements for K0823 Power Wheelchair Claims. Noridian, 2009.

Documents

MSATC Wheeled Mobility 080509