Justify It: Group 2 vs. Group 3 Power Wheelchairs

Knowing Documentation Requirements Is Key to Getting the Optimal Chair for a CRT Client

With robust expandability and designs built for long days of use, Group 3 power wheelchairs are among the complex rehab technology (CRT) industry’s signature interventions. But at first glance, Group 3 chairs can seem to have a lot in common with Group 2 chairs, also known as consumer power chairs. That confusion can lead to reimbursement difficulties, which in turn can mean reduced independence for CRT users.

Differences by Design

Group 2 and Group 3 power chairs are very different in their design and engineering, which creates differences in function. Some differences — such as captain’s-style seating on Group 2 chairs vs. rehab seating on Group 3s — are easy to see. Others related to performance are more difficult to discern.

Jim Stephenson, Reimbursement & Coding Manager for Permobil, listed several performance differences between the two groups: “Minimum top speed for Group 2 is 3 mph vs. 4.5 mph for Group 3. And minimum [battery] range for Group 2 is only 7 miles; Group 3’s is 12 miles. Suspension is one obvious thing that separates Group 2 and Group 3: You have to have a suspension on Group 3 [chairs]; it’s not a requirement on Group 2.”

Stephenson said the list goes on: A Group 2 chair is built to climb obstacles up to about 1.5" and can handle up to 6° of incline; Group 3 chairs can climb obstacles up to about 2" high and inclines up to 7.5°. Those differences relate directly to the needs of the client population that each power chair targets.

“Driving performance is just one of the items that helps differentiate Group 2 versus Group 3,” said Jeff Rogers, Senior Power Product Manager for Sunrise Medical. “For instance, greater climbing ability, obstacle climbing, and driving range [are] all characteristics aimed to increase the independence of the end user, which of course requires greater product development and research to ensure the product can achieve all of these standards. In addition, further advancement in electronics come into play, as Group 2 was designed for basic sit-and-drive (non-expandable electronics) by the end user, where Group 3 chairs start to evolve and allow for things like specialty controls and attendant controls (expandable electronics).”

Julie Piriano, PT, ATP/SMS, VP of Clinical Education and Rehab Industry Affairs & Compliance Officer for Pride Mobility Products Corp., pointed out that the differences between Group 2 and Group 3 correlate with the differing needs of their consumers. For example, she referred to the 3-mph top speed of a Group 2 chair compared to a Group 3 chair’s 4.5-mph top speed.

“Minimum top-end speed is important as it is used in bouts,” Piriano explained. “[So] 3 mph is roughly the average walking speed of adults, while 4.5 mph is a brisk walk, much like ambulatory individuals use when crossing the street. It is not needed all the time, but when it is needed, it is essential to have.”

She also compared battery range: “For an individual that will use their chair continuously, the range or distance per charge is extremely important, especially if they are traversing a multitude of terrains, are closer to the top end of the chair’s weight capacity, must cover long distances, or a combination of all three, which draws a lot more power from the batteries. For anyone that wears an activity tracker, you know that there are days when you barely get 10,000 steps in, but then there are days when you walk 10-plus miles because of the activities you are engaged in. Wheelchair users need the same capability.”

Group 2 chairs “are fine chairs for certain people; they’re not fine chairs for CRT people,” Stephenson said. “They’re very limited. You can put tilt on a Group 2 base, but it’s essentially a K0823 with a tilt. It doesn’t have the positioning accessories available and the different accommodations for seating. It’s limited in that regard. Powered seating added to a Group 2 [chair] uses up some of the battery range. When you put a powered seating system on [a Group 2 chair] and you’re spending the whole day in it, your 7 miles [of range] is probably down to 4.”

Clinical Considerations & Qualifications

Medicare’s qualifying criteria for Group 2 and Group 3 power chairs include diagnostic information, Stephenson said: “Medicare has one of the biggest differentials between Group 2 and Group 3, based on your medical condition and what is causing your mobility limitation. If your mobility limitation is due to a neurological condition, a myopathy or a congenital/skeletal deformity, you should be a Group 3 patient because these are the condition classes that they have identified as needing Group 3.”

But don’t misread that a neurological condition, myopathy or congenital/skeletal deformity automatically qualifies a client for a Group 3 wheelchair. “Those medical conditions are not guaranteed Group 3 because it’s not a specific list of diagnosis codes,” Stephenson said. “Conditions that are considered neurological in the medical realm don’t classify as neurological for Medicare for mobility purposes. Like diabetic neuropathy, for example: That’s a neurological condition, but it doesn’t qualify for power mobility. There is no official list. None of these conditions automatically qualify you; you still have to rule out a Group 2 chair. But you have that in your favor, that you have a condition that has been aligned with Group 3.”

Piriano explained, “According to the Medicare Local Coverage Determination (LCD) for Power Mobility Devices (PMDs), an individual must have a neurological condition, a myopathy or a congenital skeletal deformity to qualify for coverage and reimbursement of a Group 3 PWC [power wheelchair]. Typically, individuals that fall into one of these diagnostic categories will, in fact, use their chair all day, every day as their only way of moving about for the 12-18 hours they are up out of bed. However, there are many other individuals that do not have a diagnosis that fits in one of these categories — such as, but not limited to, rheumatoid arthritis, multiple limb amputations, etc. — who may also use their PWC on a continuous basis and require the performance of a Group 3 base for safe, timely and independent mobility.

“In fact, many other third-party payors may provide funding for a Group 3 PWC for the health, safety and well-being of the individual, especially when it allows them to live in the ‘least-restrictive environment possible (i.e., home and community).’”

Getting Clinicians Involved

Aside from added functionality and customization possibilities as you ascend the power chair ladder of HCPCS codes, more complex power chairs require the participation of professionals certified in complex rehab.

“Clinically speaking,” Piriano said, “the majority of individuals with a permanent need for a power wheelchair that use it for 12-18 hours per day require the performance characteristics and capabilities of the Group 3 base, regardless of diagnosis, to safely navigate all settings of actual and anticipated use. If there is a medical need for power tilt and/or power recline or the need for alternative drive controls, the provision of a Group 3 PWC becomes imperative, even though Group 2 chairs technically must have the capability to support power seat functions, upgraded electronics and alternative drive controls, according to the policy article associated with the PMD LCD.

“Group 2 PWCs with power seat functions and all Group 3 PWCs require a specialty evaluation by a licensed/certified medical professional, such as a PT [physical therapist] or OT [occupational therapist], who has knowledge and skills in wheelchair evaluations and does not have any financial relationship with the supplier. From the supplier perspective, there must be a W2-employed, RESNA-certified Assistive Technology Professional (ATP) directly involved in the evaluation and recommendation process for these same bases. Both of these two professionals are bound by a standard of practice and code of ethics that mandates they do no harm. During the evaluation and technology assessment, it is imperative that the team consider the physical, functional and environmental needs of the individual. The question is, what group will accommodate the consumer’s daily routine in all settings of anticipated use — and why?”

Mobility assessments can be quite different depending on whether the client is a Group 2 or a Group 3 power chair user.

“In most cases,” Rogers said, “Group 3 clients generally require more time during the evaluation process to ensure the product can be ordered to fit them properly, but also [to] ensure the product can work most appropriately for them. Group 2 tends to be less involved due to the fact that many of the patients have less-involved presentations and can be fitted in a fraction of the time.”

Choosing between a Group 2 and a Group 3 power chair can be tricky with some client presentations. Multiple sclerosis (MS), with its varying rates of progression and presentations that can change by the hour, is an example of a diagnosis in which the client’s seating and mobility needs can substantially fluctuate in a short period of time.

“If you put an MS client into a Group 2 chair today,” Stephenson said, “and they progress to where they need power tilt and recline, and maybe they need an alternative drive control to drive their chair — most Group 2s can’t accommodate that. Their medical condition isn’t changing; the condition is just progressing, so you can’t get them a new chair once they’ve progressed because their condition hasn’t changed.”

Angie Kiger, M.Ed., CTRS, ATP/SMS, Clinical Strategy & Education Manager for Sunrise Medical, said about such conditions, “When I first started with power wheelchairs, it was ‘Plan for today with tomorrow in mind.’” Admittedly, though, payors often focus more on the present, which can mean that clinicians and ATPs have to be smart and creative to be sure they’re getting a full and accurate picture of what their clients need.

“When you’re evaluating somebody,” Stephenson said, “you have to ask the question: Is this your typical performance of these activities, or is it because you’re well rested, or maybe your medication is working especially well today? You need to differentiate: Is this your normal day-to-day, or are you performing so well because you feel better than normal today, right now?”

Kiger agreed that asking questions to get a fuller perspective is critical. With MS, for instance, “you’ve got to think about what they look like on their best day and what they look like on their worst day,” she said. “And you have to look at their comorbidities.”

Kiger also references “White Coat Syndrome,” the subconscious reaction that makes patients’ blood pressure rise and makes them behave differently in front of medical personnel. So, “you have to try to paint a picture, rather than just looking at how they are in that moment,” Kiger said. “I ask, ‘Do you have any pictures of you out and about in the community?’ I just want to see what they look like as opposed to that day, when they’re probably going to be dressed a little nicer, they’re probably going to be looking better. See if they’ve got videos [of themselves] on their phone; they often do, like ‘This was me at my grandchild’s picnic.’ While you’re looking at those, you’re able to see what they look like on a Saturday afternoon when they went to their grandchild’s birthday party.”

Obligations to Payors & Patients

Even when the client has a diagnosis that, as Stephenson said, has been aligned with a Group 3 power chair, it’s still necessary to demonstrate why a lesser mobility device won’t suffice.

“We have to always rule out the lesser equipment,” Kiger said. “It’s like climbing a ladder: This is why a cane’s not going to work, this is why a walker’s not going to work, this is why a manual chair won’t work. The same thing happens with power chairs: You have to look at maybe they can do a sit-and-drive wheelchair now, but if it’s a progressive condition? How fast are they going to progress? What road are we headed down?”

Due to the higher prices associated with Group 3 chairs, substituting a Group 2 chair can be a great temptation to payors. At times, CRT providers have provided more robust power chairs, then down-coded them to the funding source. Why isn’t that an optimal practice?

“The only payor where ‘down-coding’ would be required,” Piriano said, “in certain circumstances, is traditional Medicare, otherwise known as Part B or Medicare Fee for Service, as they are bound by law to the Social Security Act. Every other payor — including but not limited to Medicare Part C, Medicaid and commercial payors — has the ability to make coverage and reimbursement decisions on a case-by-case basis, based on the identified needs of the individual and technology solutions necessary to address them. In addition, each of these payors has a true prior authorization process. Even when they ‘follow Medicare guidelines,’ they have the discretion to consider what recommendation best meets the overall needs of the person, regardless of diagnosis.

“The devil is in the details of the documentation, and it typically comes down to when, where, why and how the individual will use the chair. If the payor can ‘see’ that the person needs powered mobility but does not understand the distances that will be traveled, the terrains, obstacles and inclines that will be encountered, or the significant importance drive-wheel suspension has for the end-user, then they ‘assume’ that a Group 2 PWC would be sufficient, and show cost savings to their bottom line.”

But Piriano said the CRT industry has a responsibility to advocate for the technology that will provide the best outcome for the client, based on that client’s needs.

“When a Group 3 PWC is necessary,” she said, “we have an obligation to our patient to highlight why a Group 3 PWC is medically necessary, detail any safety concerns associated with the provision of a lower-level chair, and submit what they need for prior authorization. If the payor denies the request, or down codes it, we have an opportunity to figure out what information we did not provide so that they could see why the recommended Group 3 base is needed.

“When we assume the payor will not consider our request for the Group 3 PWC with any payor, other than traditional Medicare, we are not fulfilling our obligation to the consumer, or from a provider perspective, to the business.”

Editor’s Note: For more about comparing/contrasting Group 2 and Group 3 power chairs, and their documentation requirements, check out https://tinyurl.com/sunrisemedicalpowerwheelchair and https://tinyurl.com/permobilpowerlmn.