Amazing Funding Strategies
Expert Advice on Getting Payors to Say Yes Case Study 1: Justifying a New Need for a Power Chair
By Paul Komishock, GM/Government Affairs, Pride Mobility Products
Medicare beneficiaries’ medical conditions are highly individualized. Some have a condition that remains fairly static throughout their entire lifetime, while others have a progressive condition that can change hour to hour. This broad range of scenarios is something that PMD providers encounter on a regular basis. The myriad of conditions and available solutions can make it a daunting task to ensure providers are getting proper reimbursement as their clients’ needs change.
Fortunately, there are things you can do to ensure that you’re obtaining the proper documentation. Make sure your referral sources understand what needs to be documented. A complete and compliant patient file will be able to stand up to any scrutiny. Let’s look at three cases where proper documentation is essential.1: Beneficiary Progresses from Manual Chair to Power Chair
For the client that currently uses a manual wheelchair, a progressive condition can dictate the need to move to a power wheelchair. Sometimes, the constant propulsion of a manual chair over time can contribute to issues with a patient’s upper extremities, especially the shoulders. As a result, a patient may end up being unable to self propel a manual wheelchair.
When a client moves from a manual chair to a power chair, documentation should clearly show this progression with special attention to quantitative measures of upper-extremity function, including strength measurements and range of motion. If the client can only self-propel short distances, make sure the referral source documents just what that distance is. An actual distance, as opposed to a generality, will not be open to interpretation by medical review.
With any progressive condition, a patient’s history should also be an integral part of the file. However, if the need for progression is due to a more acute condition or incident, such as a stroke, a patient’s history may be less important. Clear documentation of a client’s current condition in these situations plays a much greater role in proving the need to progress to a power chair.
One last consideration would be the need to rule out a scooter. This could be done from a clinical standpoint (e.g., patient is unable to operate tiller control), as well as from a home-use standpoint (i.e., the scooter is not appropriate due to the patient’s home setting). 2: Beneficiary Progresses from Scooter to Power Wheelchair
Moving from a scooter to a power wheelchair is different than moving from a manual wheelchair to a power wheelchair. In this case, you can already presume that a client is unable to self-propel in a manual chair. The reason for the move to a power wheelchair is what needs to be documented.
Three potential areas that might necessitate this move are seating needs, transfer issues or controller operation. If the client has developed the need for specialty seating or a pressure or positioning cushion, can no longer safely transfer to or from the scooter, or can no longer operate the tiller control due to arm fatigue or dexterity issues, the move to a power wheelchair may be justified. In this case, the referral source must clearly document, in detail, the exact reason for the need to progress to a power wheelchair, again providing quantitative measures.
There is one less common reason to move from a scooter to a power wheelchair. This would be when a client moves into a new residence where their scooter is no longer suitable. However, keep in mind that any time a provider is ruling out a scooter due to a patient’s residence, detailed measurements and even floor layouts should be documented in order to support that conclusion.3: Beneficiary’s Needs Change Progressively from Morning to Evening
Certain clients’ mobility needs can change not only day to day, but by the hour. They may have a certain degree of ambulatory ability in the morning, but be fatigued in the evening to the point where any ambulation is simply no longer possible.
Clinical evaluations and assessments for these types of clients have the potential to vary depending on when the assessment was performed. A morning clinical assessment will probably have a much more positive outcome than one performed after lunch or towards evening. In these cases, a clinical assessment done at a point in the day when the client is most likely to clearly demonstrate the need for mobility assistive equipment will make for a much stronger case for the proper provision of equipment.
In all of these cases, the more detail that assessment contains, the clearer a patient’s condition will be to someone in medical review. General statements like “too weak” and “short distances” can be subject to interpretation. “UE strength 2/5” and “Client can ambulate 5 feet before fatiguing” are much more objective and paint a much clearer picture for your payor sources.
The stronger your documentation is, the more likely your funding process will go smoothly. Keep the lines of communication with your referral sources open, and help educate them on the process. In the long run, the patient will be the one that benefits.
Case Study 2:
All-Terrain Power Chairs
Q&A with Rick Michael, VP, Innovation In Motion
Tip 1: Don’t Assume the Denial
Since Medicare infamously purchases only medically necessary DME required by a beneficiary in his or her home, doesn’t that automatically rule out all-terrain power chairs? After all, how much sand, gravel, mud and snow could a kitchen or bedroom really contain?
Rick Michael, VP at Innovation In Motion, acknowledges that Medicare doesn’t traditionally pay for all-terrain chairs such as his company’s X4-Extreme. But, he points out, “(Beneficiaries) can file for an ABN (Advance Beneficiary Notice), and then basically they can pay the difference. So if they’re typically given $5,000 or whatever amount (in Medicare funding), they can apply it towards the cost of our chair and then pay the difference.”
Michael adds that other funding sources can be much more open to funding all-terrain chairs.
“We’ve had (successful funding from) workers’ comp, (private) insurance — it just kind of depends on the individuals’ circumstances,” he notes. “Vocational rehab is a huge funding source, to get people back out and working.”
Certainly, funding for all-terrain chairs can be more challenging to get versus funding for traditional chairs, but Michael says there have still been plenty of success stories: “Everybody’s different, so it depends on their individual circumstances, but we’ve (gotten funding from) every funding source out there.”
Tip 2: Know Why All-Terrain Is the Best Choice
Looks can be deceiving, Michael says, when it comes to all-terrain power chairs. For instance, Innovation In Motion’s X5-Frontier “is capable of going indoors; it’s an indoor chair with aggressive outdoor capabilities. People see those large tires and think that it’s an outdoor wheelchair only. But it does have the maneuverability of a conventional chair. Sometimes, it’s just getting people to see it.”
If you’re seeking funding for assistive technology that’s off the beaten path — in this case, a power chair with knobby tires — do your homework before trying to convince your funding source. Know the product’s abilities, why it would work better than other options on the market, and why this particular client would benefit.
Michael says those who have successfully won funding for all-terrain power chairs “are dealers, in conjunction with their therapists, who have really put together an extensive overview of the individual’s life and their daily living and what it entails.”
He suggests including examples of how the client’s medical conditions would be affected by using a power chair without all-terrain capabilities, and mentioning how a traditional chair could be damaged, or how chairs in the past have been damaged, have needed repairs, and have ultimately cost the funding source more than an all-terrain chair would have.
“When we first started, when we only had a 4-wheel-drive wheelchair, we thought erroneously that we were going to be cash only and this was going to be most people’s secondary chairs,” Michael says. “We were wrong in both instances. We’ve had every source of funding out there; everybody’s different, so it depends on their individual circumstances. And we’ve got a lot of people who are using even the X4 as their primary chair. That’s not the majority, but there are people out there. I hate it when people say, ‘Well, (the client is) not going to use it indoors.” You don’t know their circumstances; we have farmers who come in to the house for breakfast or lunch, and they’re right back out working. They’re not going to switch out to an indoor wheelchair. So it all depends.”
Case Study 3: Funding for Wheelchair Seat Cushions
Q&A with Sharon Pratt, PT, Sunrise Medical
Q: What types of diagnoses are commonly associated with wheelchair seat cushions?
A: Any diagnosis that leaves the client needing and qualifying for a manual or power wheelchair and that is included on the list of ICD-9 codes under Medicare Wheelchair cushion HCPCS coding eligibility requirements. See examples in the next question.
Q: What sorts of medical conditions, clinical needs, limitations, etc., make wheelchair seat cushions necessary? What are seat cushions designed to accomplish?
A: Typically, when thinking about wheelchair seat cushions and Medicare, for example, it is important to firstly understand the coverage criteria.
If funding is being requested for a skin and positioning cushion (Medicare HCPCS code E2607/8 for example), then it’s required that the client has a wheelchair and meets the Medicare coverage criteria for it, plus has a diagnosis on the published list of acceptable ICD-9 codes, as well as that the client has documented skin-integrity issues and postural asymmetries due to the specified ICD-9 codes.
Examples of the ICD-9 codes/diagnoses include multiple sclerosis, quadriplegia, hemiplegia, spina bifida, etc.
Postural asymmetries include posterior pelvic tilt, pelvic obliquity and anterior pelvic tilt, to name a few.
Examples of the skin-related issues that need to be documented are current pressure ulcers and/or past history of pressure ulcers on the sitting surface (remember, Stage 1 is important to document), absent or impaired sensation, or inability to carry out a functional weight shift due to the documented accepted ICD-9 code.
The equipment prescribed for this type of client should clearly be designed to maximize the surface contact area, reduce peak pressures on the prominent bony areas, provide lateral and forward stability as well as be capable of accommodating all the clients’ unique postures and /or range-of-motion limitations that are necessary to sit.
Q: What sorts of background info is helpful for referral sources such as physicians and OTs/PTs to include when they recommend this equipment? What kinds of notes should they provide to help suppliers win funding?
A: When writing justification letters, a good practice is to always ask ourselves if we have provided clarity on the facts and reduced the story.
Have we left the reader with a clear picture of the consequences to the client in the absence of having the recommended equipment?
Have we specified that the recommended equipment is in fact the minimal equipment essential to this client, that policy has been adhered to and that what we are recommending is in fact the least costly alternative? Have we demonstrated how we have ruled out anything lesser? We could break this down to 3 steps:
• Diagnose the cause before developing a treatment plan/prescription recommendation as opposed to just reacting to the symptoms that we see in front of us: To diagnose, use the appropriate tools that as professionals we should be very familiar with, i.e., a mat evaluation, etc.
• For supporting documentation, clearly articulate and connect the diagnoses and presenting posture, function and skin analysis to the treatment plan/prescription recommendation being forwarded. Use the correct clinical terms and descriptors, pointing out it fits with policy, and…
• Detail what equipment is essential to meet the need and that anything different or less has a high likelihood of failing. Include what the consequences of failure can potentially cause.
Firstly, diagnose the cause before developing a treatment plan/equipment recommendation as opposed to just reacting to the symptoms that we see in front of us.
Which is more typical — a referral for seating that says, “The client is sliding out of their chair no matter what we do,” or “The client has limited hip flexion, a compensating posterior pelvic tilt and some kyphosis. This is contributing to their sliding out of their chair”?
My guess is that the more typical is the first example. Let’s take a look at this...
“The client is sliding” – now, if we just thought about that, we might find ourselves reaching for technology items such as straps, trays (upper-extremity supports), pommels (medial thigh supports), wedge cushions, knee blocks, etc., just to name a few!
How successful would we be? In all likelihood we would not be truly successful. Yes, maybe, just maybe, the client would not slide out of the seat because they have reached the pommel combined with the tray and strap — but at what cost? What have we done to comfort (sitting tolerance), skin integrity and quality of life? Is it a long-term solution? By providing this now, what have we done to the client’s funding pot?
Did we not just reach for the Band-Aids, without actually having a good understanding of the cause of the symptom? There could be many causes for sliding. Quite often, we slide when our body angles, shapes and relationship with gravity have not been adequately assessed and therefore addressed. We must match body angles with technology angles and then understand the relationship that the body mass with the sitting center of gravity has on how successfully one can sit and for how long.
We also need to match the body shapes to the technology (in this example, the cushion) shapes. This is where my idea of footprint comes to play.
I love to imagine the sitting footprint for everyone I see! Great questions to ask: Where are all our loading surfaces when sitting? Can the ischials take the great load that is enforced upon them when sitting upright on a firm, flat surface? Can the femurs take load and share some of the load from the ischials? Has the contact area been maximized? Are the materials used and the design of the cushion being considered optimal to allow this to happen? Is the surface tension of the cushion materials including the cover allowing optimal immersion and envelopment? Have peak pressures been reduced?”
How about the feet? Are they loaded to the best of our ability? (Loaded feet are usually happy feet unless load is contraindicated.)
How about the spine and back area from the pelvis to the head? How is the footprint there, and can it be better? Remember that even the best cushion cannot perform optimally in the absence of posterior pelvic support at a minimum…
The end result is that the client has been fully assessed; the presenting postures as well as whether or not they are tolerant of correction has been identified. The desired and necessary posture for safety and function has been established. The client’s risks for skin integrity issues are clear, and we have matched the technology angles, shapes, materials and orientation to the clinical findings.
The next step is trial, and the big question is “Have the original identified goals been met?”
Second: For supporting documentation, clearly articulate and connect the diagnoses and presenting posture, function and skin analysis to the treatment plan/prescription recommendation being forwarded. Use the correct clinical terms and descriptors, pointing out it fits with policy.
Our documentation for this section of the assessment might read like this…
“Client has a diagnosis of X (must meet coverage criteria policy) and presented in their existing seating system as a sacral sitter who was sliding out of the chair and needing constant repositioning.
“Due to this, the client is unsafe and falling as well as at risk for skin-integrity issues. On evaluation, the client was found to have Stage 1 pressure ulcers on the sacral area, and bilateral limitations in hip flexion that are not tolerant of correction, which means that the seat-to-back angle on the chair needs to be at xxx degrees (matching the body’s femur to pelvic angle). To overcome the impact of gravity in this angle, the client also needs 10-15° of tilt. The client cannot do an effective consistent weight shift. This is a single stand-alone risk factor for skin breakdown. Therefore, the client needs a minimum of 45° of tilt (for example) every hour for 15 minutes. For optimal stability, function and safety as well as skin-integrity preservation, the client needs a cushion with the following features” — spelled out in the language of contour, materials and cover.
“A back support with shape and angle for optimal loading and contact area in the pelvic/lumbar and lumbar/thoracic areas is also essential.”
Third: Detail what equipment meets the need and that anything different or less has a high likelihood of failing, as well as what the consequence of failure can potentially cause:
“The following equipment that has the essential features as described above has been tried” (name each piece of equipment). “Please see the attached pressure mapping images that highlight the client with their old seating, on a mat table as well as in the recommended seating. Highlighted is the difference in surface contact area and reduction in peak pressures for all three situations. This, combined with reduced redness on the sacrum and no further sliding, clearly demonstrates that these goals have been achieved. In the absence of these features, the client will slide, be unsafe and will have continued skin breakdown. This is the least costly equipment that is essential for this client.”
Q: When claims for this type of equipment are denied, what are some common reasons why? Are there any common omissions or mistakes that suppliers or clinicians make that lead to denials from payors?
A: Among the changes taking place in the industry has been the need for fact-based supporting documentation. The letter of medical necessity has to be accurate, to the point, diagnoses driven and clinically worded.
It also has to simply connect the diagnoses and subsequent “treatment plan” with plain logic. Some of the issues I see repeatedly are related to our inability to stick with the facts and identify the causes rather than get bogged down with the symptoms our clients present with.
Quite commonly, a reason for rejection and/or down-coding is a poorly written letter of medical necessity. I strongly recommend utilization of references such as the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) position papers, for example, when evidence-based practice can help support the recommendations being made.
RESNA, with input from RTS’s, clinicians and academicians, has so far developed four position papers on the following topics:
• Application of Tilt, Recline and Elevating Legrests for Wheelchairs
• Application of Power Wheelchairs for Pediatric Users
• Application of Seat-Elevating Devices for Wheelchair Users
• Application of Wheelchair Standing Devices
Each of these papers presents physiologic and functional justification, best practice standards and other invaluable information in justifying the client needs for these classes of equipment. One of the locations at which these papers can be found is www.rstce.pitt.edu listed under Resources.
In conclusion I would like to restate the three steps that may help guide successfully doing an evaluation and putting together the supporting letter of medical necessity:
• Diagnose the cause before developing a treatment plan/prescription recommendation, as opposed to just reacting to the symptoms we see in front of us.
• Articulate and connect the diagnoses and presenting posture, function and skin analysis to the product parameter recommendations being forwarded. Use the correct clinical terms and descriptors, pointing out it fits with policy.
• Detail what equipment is essential to meet the need, point out that anything different or less has a high likelihood of failing, and what the consequences of failure can potentially be.
This article originally appeared in the March 2009 issue of Mobility Management.