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“Complex Rehab” vs. “Standard” Mobility. Standard Manual Wheelchairs Standard Manual WCs (94% of Medicare Intended for Short Term use Complex Manual Wheelchairs.

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Presentation on theme: "“Complex Rehab” vs. “Standard” Mobility. Standard Manual Wheelchairs Standard Manual WCs (94% of Medicare Intended for Short Term use Complex Manual Wheelchairs."— Presentation transcript:

1 “Complex Rehab” vs. “Standard” Mobility

2 Standard Manual Wheelchairs Standard Manual WCs (94% of Medicare Intended for Short Term use Complex Manual Wheelchairs Complex Manual WCs (6% of Medicare) Intended for long‐term use

3 Standard Power WCs Standard Power WCs (93% of Medicare) Intended for Ambulatory Limitations Complex Power Wheelchairs Intended for Progressive Diagnoses Advanced Electronics and Controls

4 Complex Rehab Technology (CRT) Facts and Figures Complex Rehab Technology (CRT) products and services are significantly different than standard Durable Medical Equipment (DME)‐ The DME benefit was created over forty years ago to address the medical equipment needs of elderly individuals. Over the years technology has advanced and now includes complex rehab power wheelchairs, highly configurable manual wheelchairs, adaptive seating and positioning systems, and other specialized equipment.

5 CRT These products are classified as Complex Rehab Technology. Suppliers who furnish CRT provide highly specialized products and services which are much different than standard DME. These specialized products are used by a small population of children and adults who have significant disabilities and medical conditions‐ Individuals who require CRT will typically have a complex disability or medical condition such as, but not limited to, Cerebral Palsy, Muscular Dystrophy, Multiple Sclerosis, Spinal Cord Injury, Amyotrophic Lateral Sclerosis, or Spina Bifida

6 Complex Rehab Technology (CRT) Facts and Figures CRT products enable these individuals to deal with their daily physical, functional and cognitive challenges and play a critical role in addressing the complex medical needs of these children and adults and in keeping them active and functional within their homes and communities. These products not only supply independence and function, but also keep the overall cost of healthcare down by reducing additional medical complications and caregiver requirements.

7 Process of Providing CRT Products The provision of CRT is typically done through an interdisciplinary team consisting of, at a minimum, a Physician, a Physical Therapist or Occupational Therapist, and a credentialed Rehab Technology Professional. The team collectively provides clinical services and technology‐related services designed to meet the specific and unique medical and functional needs of the individual. The activities of the supplier are labor intensive and include initial assessment, trial equipment and simulation, technology assessment, home assessment, research and recommendation, documentation and funding approval, purchasing, assembly, delivery, fitting, adjusting, product training, short term follow‐up, and, finally, ongoing repair and maintenance.

8 MEDICARE: IN HOME RULE Wheelchairs are only covered if required for use in home and: The beneficiary has 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

9 Face to Face Examination Manual Wheelchair F2F For certain specified items of durable medical equipment the Affordable Care Act requires that an in-person, face-to-face examination (F2F) documenting the need for the item must have occurred sometime during the six (6) months prior to the order for and delivery of the item id=2581 id=2581

10 MOBILITY LIMITATION Prevents the beneficiary from accomplishing an MRADL entirely, or Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or Prevents the beneficiary from completing an MRADL within a reasonable time frame

11 Manual Wheelchair Use of a manual wheelchair will significantly improve the beneficiary’s ability to participate in MRADLs and the beneficiary will use it on a regular basis in the home. The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in the home.

12 Manual Wheelchair The beneficiary’s mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker The beneficiary’s home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided

13 Manual Wheelchair The beneficiary has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair that is provided in the home during a typical day. Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function

14 Manual Wheelchair The beneficiary has a caregiver who is available, willing, and able to provide assistance with the wheelchair If the manual wheelchair will be used inside the home and the coverage criteria are not met, it will be denied as not reasonable and necessary

15 Manual Tilt in Space WC A manual wheelchair with tilt in space (E1161) will be covered if the beneficiary meets the general coverage criteria for a manual wheelchair and The beneficiary must have a specialty evaluation that was performed by a licensed/certified medical professional (LCMP) and that documents the medical necessity for the wheelchair and its special features

16 FACE-TO-FACE EXAMINATION PMD For POVs and PWCs: What is this beneficiary’s mobility limitation and how does it interfere with the performance of activities of daily living? For POVs and PWCs: Why can’t a cane or walker meet this beneficiary’s mobility needs in the home? For POVs and PWCs: Why can’t a manual wheelchair meet this beneficiary’s mobility needs in the home? For POVs: Does this beneficiary have the physical and mental abilities to transfer into a POV and to operate it safely in the home? For PWCs: Why can’t a POV (scooter) meet this beneficiary’s mobility needs in the home? For PWCs: Does this beneficiary have the physical and mental abilities to operate a power wheelchair safely in the home?

17 MEDICARE: PMD GUIDELINES PMD: Powered Mobility Device: Scooter or Power Wheelchair In addition to the Manual WC Criteria: The beneficiary does not have sufficient upper extremity function to self-propel an optimally- configured manual wheelchair in the home to perform MRADLs during a typical day.

18 Power Operated Vehicle The beneficiary is able to: Safely transfer to and from a POV, and Operate the tiller steering system, and Maintain postural stability and position while operating the POV in the home. Use of a POV will significantly improve the beneficiary’s ability to participate in MRADLs and the beneficiary will use it in the home.

19 Power Wheelchair Use of a power wheelchair will significantly improve the beneficiary’s ability to participate in MRADLs and the beneficiary will use it in the home. For beneficiaries with severe cognitive and/or physical impairments, participation in MRADLs may require the assistance of a caregiver

20 Group 2 PMD CRT (complex rehab technology) The beneficiary requires a drive control interface other than a hand or chin-operated standard proportional joystick The beneficiary meets coverage criteria for a power tilt or a power recline seating system The beneficiary has had a specialty evaluation that was performed by a licensed/certified medical professional The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the beneficiary.

21 Group 3 CRT PMD The beneficiary's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity; The specialty evaluation provides detailed information explaining why each specific option or accessory – i.e., power seating system, alternate drive control interface, or push-rim activated power assist – is needed to address the beneficiary’s mobility limitation

22 Wheelchair Seating A skin protection seat cushion (E2603, E2604, E2622, E2623) is covered for a beneficiary who meets both of the following criteria: The beneficiary has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the beneficiary meets Medicare coverage criteria for it; and The beneficiary has either of the following: Current pressure ulcer (ICD-9-CM codes , , ) or past history of a pressure ulcer (707.03, , ) on the area of contact with the seating surface; or

23 Seating Absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift due to one of the following diagnoses: spinal cord injury resulting in quadriplegia or paraplegia ( ), other spinal cord disease ( ), multiple sclerosis (340), other demyelinating disease ( ), cerebral palsy ( ), anterior horn cell diseases including amyotrophic lateral sclerosis ( , ), post polio paralysis (138), traumatic brain injury resulting in quadriplegia (344.09), spina bifida ( ), childhood cerebral degeneration ( ), Alzheimer's disease (331.0), Parkinson's disease (332.0),muscular dystrophy (359.0, 359.1), hemiplegia ( – , ), Huntington's chorea (333.4), idiopathic torsion dystonia (333.6), athetoid cerebral palsy (333.71), arthrogryposis (728.3 or ) osteogenesis imperfecta (756.51), spinocerebellar disease ( ) or transverse myelitis (323.82)

24 Positioning Cushion A positioning seat cushion (E2605, E2606), positioning back cushion (E2613-E2616, E2620, E2621), and positioning accessory (E0955-E0957, E0960)is covered for a beneficiary The beneficiary has any significant postural asymmetries that are due to one of the diagnoses listed in criterion 2b above or to one of the following diagnoses: monoplegia of the lower limb ( , ) due to stroke, traumatic brain injury, or other etiology, spinocerebellar disease ( ), above knee leg amputation ( ), osteogenesis imperfecta (756.51), transverse myelitis (323.82).

25 Custom Seat/Back Cushion A custom fabricated seat cushion (E2609) is covered if criteria (1) and (3) are met. A custom fabricated back cushion (E2617) is covered if criteria (2) and (3) are met: Beneficiary meets all of the criteria for a prefabricated skin protection seat cushion or positioning seat cushion Beneficiary meets all of the criteria for a prefabricated positioning back cushion There is a comprehensive written evaluation by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), which clearly explains why a prefabricated seating system is not sufficient to meet the beneficiary’s seating and positioning needs. The PT or OT may have no financial relationship with the supplier.

26 POWER TILT AND/OR RECLINE SEATING SYSTEMS A specialty evaluation that was performed by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT) or physician who has specific training and experience in rehabilitation wheelchair evaluations documents the beneficiary’s seating and positioning needs The seating system is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in rehabilitation wheelchairs and who has direct, in-person involvement in the selection of the seating system for the beneficiary; and

27 Power Tilt and/or Recline The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functionalweight shift; or The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed; or The power seating system is needed to manage increased tone or spasticity.

28 References NHIC DME MAC Region A NHIC LCD List NHIC Face-to-Face and Written Order Requirements for High Cost DME NHIC: Power Wheelchairs and Power Operated Vehicles - Documentation Requirements

29 Additional Resources NCART: National Coalition for Assistive and Rehab Technology; Ensuring an Individual's Right to Appropriate Complex Rehab Technology American Association for Homecare https://www.aahomecare.org/ RESNA: Rehabilitation Engineering and Assistive Technology Society of North America


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