Positioning Update
Catching Up on Funding & Educational Progress, from Tilt & Recline to Standing & Elevation
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.”
This article originally appeared in the November 2007 issue of Mobility Management.