Positioning Update

Positioning is something we so casually take for granted that we usually don’t notice it as long as we can do it. We turn throughout the night while sleeping. Upon waking, we stretch. We squirm while commuting to work in our cars, cross/uncross our legs and lean back in conference room chairs during workday meetings, and shift our weight from side to side as we gossip at the water cooler.

 In rehab as well, repositioning works, not just to maintain or improve a client’s medical condition, but also as preventive medicine. And rehab professionals know it. Convincing people outside the industry can be much more challenging… which is why funding policies for positioning products continues to evolve.

Clinical Benefits of Alternate Positioning
Though there is considerable evidence that proper positioning has huge social and emotional benefits — whether from reducing pain and discomfort or giving a client the ability to look peers in the eye — funding sources continue to be primarily concerned with positioning’s medical benefits.

 Fortunately, those benefits are considerable, says Quantum Rehab’s Jay Brislin, MS PT: “Proper positioning is going to help a client in many ways, such as minimizing the progression of deformities, preventing development of postural deformities, promoting good skin integrity and ultimately encouraging healing of wounds that are present.

“The natural repositioning of one’s body is something we all do on a daily basis, just when we’re sitting in our desk chairs or in our cars. Power positioning or even just a proper seating system is really going to help that person weight shift and deter any sort of skin-integrity issues they may have.”

Stability is what comes to mind first, says Invacare Corp.’s Michael Babinec, OTR/L, ATP, when discussing proper positioning in a seating system. “Without stability in the seating system, you can’t function — period,” he notes. “You need that stable base, you need that pelvis controlled in order to allow any kind of functional activities. And this is in addition to dealing with any of the comfort issues or dealing with the pressure-management issues. Look for postural stability, which really starts at the pelvis.”

In powered seating systems, “pressure relief is probably the key clinical benefit,” Babinec says, “whether that’s dependent or independent pressure relief. Number two would be gravity-assisted positioning in the chair to allow gravity to hold them against the contours of the seating system for stability. A lot of times, people are performing a tilt cycle for pressure relief, but there are a lot of other reasons, such as managing muscle tone. Sometimes you need tilt just for the relaxation of high muscle tone or to address the fatigue associated with high muscle tone.

“If you can perform your weight shifts to address those kinds of issues, you can increase sitting tolerance in the course of the day,” Babinec adds, which of course leads to fewer transfers in and out of the chair, and less reliance on caregivers.

In the case of precline — in which the seat-to-back angle on the chair is closed to less than 90 degrees — Sunrise Medical’s Director of Education Sharon Pratt, PT, says users may require the position “for task performance or for visual orientation.”

In addition, today’s positioning philosophy focuses on meeting clients where they are, rather than automatically trying to achieve the infamous right-angle “90-90-90” sitting posture of the past.

Remembering his days as a physical therapist, Brislin says, “If you get someone in a 90-90-90, a lot of times, you’ll decrease their function. They may be windswept, and maybe in that windswept position, they’re able to reach their joystick or able to drive a chair. It may not be what we consider proper, but for that client, it might be proper. It might be the best utilization of how they’re able to function, or how they’re able to get through their day.”

 “Although we try to do all this seating to support posture and provide stability, we also need to allow people to move within that system,” Babinec says. “You need to be able to move to function. We need people to be able to move into a position of asymmetry for function and be able to come back to a position of support, so we need to make sure we’re less restrictive than we were 20 to 25 years ago. Twenty years ago, it would not have been unusual to see a child with cerebral palsy with a four-point belt on, with leather straps on her ankles, with her hands tied to the armrests, with a chest support on, and a strap around her head to hold her in a great posture in the chair. Obviously, that young child couldn’t do much… hopefully (today), that same child would be using just a pelvic strap in a chair with the right powered seating system and the right contour system to allow that freedom of movement and function… I think the trend now is more toward function and more toward comfort.”

Babinec also believes comfort is hugely important in determining whether positioning is successful.
“I know that nobody pays for comfort, but an issue that people sometimes tend to neglect is pain — addressing the pain associated with fatigue or poor positioning,” he says. “If you look at comfort from a social/emotional standpoint, anybody feels horrible when they’re in any kind of pain. You don’t feel like interacting with anybody, you don’t feel like doing anything. You just want to lie down and get rid of the pain. If you look at psychological disorders associated with lack of mobility and lack of proper positioning to be able to stay in the wheelchair, probably depression is one of the most frequent. If we could just keep somebody comfortable, sitting up in the chair, able to interact with their family and peers, you’re going to go a long way.”

 Therefore, an effective seating & positioning system optimizes a client’s overall, all-day functionality.

“If a client is properly positioned and given appropriate postural stability, it is not ‘work’ for them to maintain that position,” says Pratt. “They can then engage in other activities, whether that is ADL’s, vocational or recreational activities. This allows for social and peer interaction, which is thought to have positive social and psychological benefits. It is also important that the client be comfortable and not have too many supports/positioning devices, which may have the reverse effect of being restrictive.”

Funding for Tilt & Recline
What’s the current state of funding for power positioning equipment such as tilt and recline? Are the clinical benefits translating into greater willingness by funding sources to pay for positioning equipment?

 “We haven’t really heard of any Medicare providers having a problem with this right now, for any power positioning systems, other than power elevating seats,” Brislin says. “A provider uses a KX modifier, so Medicare probably won’t see any documentation until there is an audit, although usually with these kinds of clients, this doesn’t happen too often. The other issue here is that there’s now criteria in the accessory policy, and it basically says if you need pressure relief, self-catheterization or have any increased tone or spasticity, you can get a tilt, recline or tilt and recline. Of course, for any of these items, you need a therapist’s assessment. Medicare has loosened the coverage a little bit, but it’s really going to be a therapist’s call. If a therapist can justify the need for multiple power positioning, we haven’t heard of any issues.”

Quantum Rehab’s Cody Verrett, ATS, emphasizes the therapist’s role in the funding picture: “(The Centers for Medicare & Medicaid Services) would definitely look for one of those three coverage criteria somewhere in the assessment or medical records. There are no guarantees, but the regulations have improved for multiple power positioning over where it was a year and a half ago. (CMS) made these additions of specific criteria in the accessory policy, and by doing that they gave the industry and ultimately clinicians the green light to justify multiple power when necessary. It’s wonderful news.”

 “It’s getting better, but it’s got a ways to go yet,” Babinec says about the funding landscape. “It was not unusual eight years ago to hear funding sources categorically deny tilt-in-space chairs, manual or power. You don’t hear that much anymore; I think clinicians are much better at getting the information in front of funding sources (to explain) how this is going to benefit the user. It seems tilt and recline systems together are getting covered, provided the seating team can justify the reason for the tilt AND the recline separately. But I think there are still some reluctant individuals out there who want more proof.”

Pratt says, “It may be difficult to get recline funded for stand-alone reasons such as pain relief, fatigue or to increase out-of-bed tolerance, which although are good clinical justifications, are not always recognized as medically necessary by funding sources… Good documentation of medical necessity is always key.”

Standing: A Slow Conversion Process

The funding picture is not yet as rosy for standers and standing systems, says Altimate Medical’s Funding Specialist Nancy Perlich (COTA/ATS), explaining that DME payors continue to want more evidence of medical need.

 “It’s very frustrating; it’s kind of like three steps forward and four steps back,” Perlich notes. “I think therapists and physicians are really understanding what they need to do to justify (standing equipment) more and more. We have codes now — universal coding mandated that — so we have codes for standing devices, and now we’ve also submitted for accessory codes. So that’s all wonderful, but obviously alternate positioning does not take precedence over power chairs, manual chairs or anything else. Those are getting coded first and put in line first.

“But that said, we already have these codes, but they’re being interpreted across the board totally differently by different payor sources. Universal coding mandated that there be codes; now my understanding is that all payors have to accept the codes, but they don’t have to implement them. And/or, they can choose to implement them however they choose — that’s what I’m seeing.”

 The confusion, Perlich says, is exacerbated by the fact that many funding sources have become accustomed to looking at Medicare’s example, which doesn’t apply to standing equipment.

“Right now, the stander codes do not exist for Medicare, just for Medicaid — so that kind of makes it confusing for some of the other payors, because they can’t just follow what Medicare does exactly,” Perlich says. “So the codes exist, and for awhile the first two codes that came out had fees attached and were on the fee schedule. What (some payors) have done is grab those fees — even though they’re no longer on the fee schedule — and tried to utilize those in some way, shape or form. One code — E0638, standing frame, one position — had an allowable that was only (approximately $800). So if (payors) only have to pay 80 percent of $800, they thought that was a nifty code.

 “That’s been really frustrating: There’s coding, but for Medicaid and private payors, some are using the codes and some are not. Some are using miscellaneous codes… the interpretations are all over the board. Blue Cross, the different HMOs, they can all have different interpretations also.”

Because there are multiple payors, Perlich notes that funding inconsistency can reign not only on a national level, but even within a regional area.

 “In Minnesota or the Midwest, maybe you have a decent consortium of funding sources that get together, both Medicaid and private, and they work together,” Perlich says as an example. “So you might find pockets of continuity. But then you’ll find pockets that are just all over the place.”

If there’s a bright spot in the standing world, it’s in what a standing regimen can accomplish. Perlich says that depending on the client and diagnosis, benefits can include contracture prevention, maintained or improved range of motion, decreased spasticity, osteoporosis prevention, balance restoration, pressure relief and improved social skills and cognition, possibly because respiratory functions and strength can improved.

 She also says clients have noticed improvements in bowel and bladder functions, which to date have not been studied as thoroughly as bone-density and other improvements.  “Some of this is documented research, and some are single case studies — but the minute you put some of these people in standers, they’ll say, ‘My bowel program is so much easier now,’ or ‘I’ve got decreased UTIs (urinary tract infections),’” Perlich says.

Now the goal is to have standing’s benefits understood and acknowledged across the health-care industry. “I think the medical community agrees with this, but the medical payor community wants documented evidence and research studies,” Perlich says. “There are some studies out there that exist, and there’s some good research out there. But a lot of it tends to be looking at osteoporosis and bone-density issues.” Some payors accustomed to huge, well-financed pharmaceutical studies unrealistically expect similar studies from the DME industry, which is much smaller and not nearly as well funded. In addition, while pharmaceutical companies likely have no trouble finding thousands of, for instance, middle-aged, sedentary and moderately overweight subjects when they want to do a blood pressure study, the unique nature of rehab makes it tough to find large numbers of study subjects.

 “Some of the payors want studies on DME that are drug-like, and I’m not sure how you do that rapidly,” Perlich agrees. “They want this really high-tech, high-end study, but they want it quick.” In rehab, Perlich says, “You can have (multiple clients) with the same diagnosis and be very different in what you end up doing for them. This is a small industry, and high-end rehab is a smaller portion yet. How do you do a study like that?”

Seat Elevation: Uphill Battle
And still at a Medicare funding impasse is seat elevation. Notoriously considered not medically necessary by funding sources, seat elevation is just as vehemently defended by many rehab professionals and clinicians, who site numerous benefits, mostly in a user’s ability to more safely and easily care for themselves by being able to reach, for instance, food in a pantry and dishes in kitchen cabinets.

 Prolonged reaching overhead, Pratt says, comes with a price: “There is a body of evidence to support the fact that shoulder elevation and overhead reaching activities are a significant factor in shoulder pathology, specifically rotator cuff injuries (and) impingement syndromes. In recent years, seat-to-floor heights of power wheelchairs have gotten lower, thereby increasing the need for overhead reaching for some individuals. It follows then that seat elevators may reduce shoulder pain by limiting overhead activities. They also allow for level surface or downhill transfers, which reduce the strain on the UE joints and musculature.”

 “We feel it should be changed,” Cody Verrett says of Medicare’s traditional refusal to pay for seat elevators. “We believe power elevation is a critical power positioning component for access and independence for individuals with disabilities. While its physiological benefits are not consistent with those from tilt and recline, seat elevation provides improved access over the entire environment, which is tremendously important for MRADLs (mobility-related activities of daily living).” Verrett says Quantum Rehab is going forward with such offerings as a combination lift/tilt because “if Medicare doesn’t find it medically necessary now, hopefully some day they will and give us justification for it.” Verrett adds that some other payors, including Veterans Affairs, worker’s compensation and vocational rehab, “will cover these types of items when justified.”

Babinec says he is “frustrated” seat elevators aren’t typically funded; he points out the benefits can include easier, more independent transfers (because nearly all wheelchair users can more easily transfer from a higher surface to a lower one) and the ability to accomplish “those everyday things we have to do, like meal preparation or at the very least, retrieving those meals.” On the bright side, Babinec says, the industry is working to change CMS’ policy: “RESNA has provided position papers on seat elevators and position papers on standers.”
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