ATP Series

Justify It! Tilt & Recline

Having Both Functions on the Same Wheelchair Can Yield Clinical Benefits -- But Opposition from Payors

Tilt & ReclineAt a time when all funding sources are aiming to pay less for more, putting tilt and recline systems on the same wheelchair can be a real reimbursement challenge. And yet for many wheelchair users, being able to tilt and recline can be the difference between being functional and being in pain, or being active with healthier skin and being bed bound by pressure ulcers.

As in so many cases, then, the difference between a consumer getting the technology he/she needs and trying to get by with less comes down to the case that the seating & mobility team can make when submitting that claim to the funding source.

The Clinical Case for Tilt & Recline

Being able to tilt and recline on a single mobility base offers a client a number of potential advantages, says Magdalena Love, OTR, clinical education specialist for Permobil.

“Clinical benefits to having both tilt and recline on the same wheelchair include pressure relief, maintaining range of motion, helping to manage spasticity, and increasing sitting tolerance,” she says. “In terms of pressure relief, combining tilt and recline leads to better pressure distribution than either seat function on its own (Aissaoui, Lacoste, & Dansereau, 2001). A more recent study by Jan, Crane, Liao, Woods, & Ennis (2013) found that 25° tilt combined with 120° recline was effective in providing both muscle and skin perfusion at the ischial tuberosities (ITs).”

Changing positions throughout the day impacts other body functions as well, says Julie Piriano, PT, ATP/SMS, director of rehab industry affairs for Quantum Rehab.

“While pressure redistribution, skin and muscle tissue reperfusion are often cited as the primary reason for using power tilt, recline or the combination of tilt and recline, the ability to change one’s body position against the forces of gravity over the course of a 12- to 14-hour day in a wheelchair is essential for the user’s physiological and psychological health,” she says.

“Individuals with ALS consistently rate power tilt, recline and leg elevation as critical components of their wheelchair, especially since sensation remains intact as the combination of power seating functions allows them to independently change joint angles, muscle lengths and pressure points throughout the day. In addition, the multitude of angles and positions that can be achieved relative to the forces of gravity allows these individuals to find the necessary balance between stability and mobility for function. As their condition progresses, use of power tilt and recline is used to position and stabilize the trunk for the diaphragm to work as efficiently as possible and to support the effective use of alternative breathing methods.”

In and of itself, being able to move regularly is critical to maintaining an active way of life, Love says.

“Comfort requires movement,” she notes. “If any of us have ever been on a long flight, we know this. While we can’t officially use that ‘c’ word — comfort — on any Medicare documentation, it is our duty as therapists and providers to consider comfort and well-being of our clients! Without providing as many varying positions as possible, our clients risk spending more time in bed or finding more comfortable positions that may place them at risk for asymmetries that lead to scoliosis and/or unilateral pressure issues.”

Tilt, Recline & Activities of Daily Living

Tilt and recline can also enable clients to achieve more comfortable and functional positions while performing activities of daily living (ADLs).

“Bowel/bladder care and lower-extremity dressing assistance are the bread and butter of recline,” Love says. “Many clients are unable to complete the functional tasks without opening the back angle. Even individuals who are not completely independent in this ADL benefit from having power recline and elevating legrests (ELRs) to easily achieve a position that can facilitate rolling side to side for caregiver-assisted lower-extremity dressing, bowel or bladder care.”

Piriano says, “While one of Medicare’s coverage criteria for a power seating system states, ‘The patient utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed,’ the use of power tilt and recline in combination is also beneficial for individuals who use an indwelling catheter or wear absorbent undergarments.

“This is especially true for people with orthostatic hypotension, as low blood pressure can decrease the amount of urine produced by the kidneys. Urinary output is improved when the individual tilts and reclines due to the increase in blood pressure that occurs. With a tilt-only system, catheter tubing can easily become kinked, there is a heightened risk of urinary backup or retention, and the individual must be transferred from the chair to manage protective undergarments and clothing, which puts them and their caregiver(s) at heightened risk for injury.”

Tilt and recline in tandem can also help at mealtimes.

“Another functional task aided by power seat functions is getting under a table,” Love says. “Sounds simple enough, right? In individuals with good trunk balance, simply placing the chair at 0° tilt is usually low enough to get under a table — and a very functional position. In individuals with reduced trunk function, they have a difficult time sitting at 0° tilt. In a study by Sonenblum, Sprigle& Maurer (2009), it was found that on average, users navigated in 8° tilt throughout the day. In this scenario, the individual can get the chair to the 0° tilted position, but they may feel uncomfortable reaching forward to perform daily tasks. When given access to tilt and recline, this allows the user to achieve the 0° tilted position and then recline the chair an additional 5° to 10° for increased trunk stability while completing tabletop activities.”

Tilt and recline can also aid in the actual activity of eating, Piriano explains.

“For wheelchair users with dysphagia due to a neurological condition or myopathy, the ability to receive adequate nutrition and hydration, safely manage different food textures (pureed vs. minced, ground, chopped or regular), liquid consistencies (thin vs. thick) or their saliva while minimizing the risk for choking or aspiration is wholly dependent on their stability and position in space,” she says. “Diligent, individualized use of power recline in combination with tilt allows the pelvis to be positioned to support the desired position of the head/neck biomechanically and promote control of the jaw, tongue and mouth while utilizing gravity to assist in stabilizing the trunk and, when appropriate, help move the bolus of food from the front to the back of the mouth.”

Make Your Best Case to Payors

Given all the ways that tilt and recline can make clients more functional and even help to prevent the development of more debilitating and costly conditions such as pressure sores, why are funding sources sometimes reluctant to pay for it?

For example, Stephanie Tanguay, OTR, ATP, clinical education specialist for Motion Concepts, says she’s heard from providers in Michigan that the state’s Medicaid program is not paying for a tilt and recline combination.

“It seems that’s been going on for a good portion of this year,” she says. “It’s one or the other: Pick tilt or recline. If you are submitting for both, it’s a big red flag apparently to somebody.

“I don’t know what to blame that on. I don’t know if it’s just a Michigan thing with financial woes at the state level. But I always wonder if failure to recognize something that has been approved in the past is because they think we’ve been overprescribing.”

To counteract that possibility — that funding sources don’t want to pay because they don’t believe all clients need what’s being asked for — seating & mobility professionals need to provide top-notch justifications, Tanguay adds.

“I think more than ever before, clinicians really need to be moving toward being excellent documenters,” she says. “We need to prove that we’ve considered less costly alternatives, why they’re not adequate to meet each individual’s needs, what we’ve found that has worked and how we’ve figured out it will work. I think we just need to be better about our documentation on all levels in order to secure the equipment that the consumers need.”

Asked what information the team should include, Love says, “How [clients] complete bowel/bladder care, and how the wheelchair and power seat functions will assist with increasing independence in this task. Spasticity, upper- and lower-extremity manual muscle testing — and if they are able to complete pressure-relieving activities without the use of power seat functions. Range of motion and contractures. Don’t just document their neuromuscular status — really relate to the funding source how this piece of equipment will assist the person and why the alternative (tilt, in this case) will not do.”

Piriano recommends that justifications be specific to the client.

“The primary reason power seating functions are recommended for wheelchair users is due to their high risk for the development of a pressure ulcer secondary to their inability to carry out a functional weight shift ,” she says. “However, if a generalized statement to this effect is documented in the medical record without any evidence or explanation, it makes it virtually impossible for any funding source to understand why the beneficiary needs tilt or recline, let alone the combination of the two.

“If the individual is unable to transfer independently to/from the chair using any method; is unable to reach well outside their base of support to the right, left and forward in unsupported sitting; and cannot do a wheelchair pushup for more than one minute and preferably for three, this information needs to be documented in the medical record and communicated in the justification for the power seating system.”

Piriano adds that justifications shouldn’t just state the “what,” but also the “hows” and “whys.”

“Current research evidence shows that the best pressure relief is achieved by using 25 to 45° of tilt in combination with 110 to 150° of recline, and that 35° of tilt with 120° of recline for three minutes has a positive impact on enhancing skin reperfusion, but that does not inform a payor why the particular beneficiary needs it,” she says. “It is incumbent upon clinicians and supplier ATPs to capture and communicate the evidence to support ‘why’ it is necessary for the person being evaluated. Pressure mapping is an excellent way to provide quantitative evidence regarding pressure distribution over the seating surface in upright, tilt, recline and in combination to paint the picture of n=1, your patient.”

The same goes for justifications for other functions, such as respiration.

“It is not helpful to describe what tilt, recline or the combination of the two functions does; it is important to convey what the identified needs of the person are and how the technology solution meets those needs,” Piriano says. “Therefore, if it will be used to improve respiratory function, then quantitative measures for respiratory rate, oxygen saturation and pulmonary function tests taken in upright, tilt, recline and utilizing the combination of tilt and recline would be important.”

Is Tilt & Recline Always the Right Answer?

Of course, before the seating & mobility team members start making their case to payors, they need to make sure tilt and recline is the right answer for their particular client. That means neither underestimating nor overestimating what a client is capable of.

Love says, “Oftentimes I hear the complaint that clients cannot tell the difference between tilt and recline — and because of this, the person will be ‘safer’ in a tilt-only system. I feel this is doing our clients a disservice. This is an education point, just like many of the therapeutic modalities we deal with daily as therapists. It is important to know an individual’s technology threshold — how much technology can they tolerate in their daily lives.”

For clients with lower thresholds, Love says, “It is vital to modify the task to make it as simple as possible for the person to complete daily activities. Th is may include limiting the amount of recline available in the system, taking away recline from the joystick menu (and just leaving it in an external switchbox), or programming memory seat functions. I have even used electrical tape and color-coded buttons for different seat functions. Oftentimes in an inpatient setting, the differences between these seat functions can be lost on individuals who are overwhelmed and hearing hours of new information daily — ‘drinking from the firehose.’ If a therapist feels that recline is medically necessary but the individual is not quite ready yet, it can be limited initially and turned on during a subsequent session. After getting back home and establishing routines, clients discover the various functional benefits of each individual seat function with greater ease.”

As for payors who may still be reluctant to see the value in having both tilt and recline, Love adds, “Don’t be afraid of denials. You are the medical professional telling the insurance company what you believe will be medically necessary for your client. It is your job first and foremost to provide client-centered care. It is the insurance company’s job to make a profit. If you feel that your client needs something, write a justification for it. Because not asking tells the insurance companies that it is not actually needed. Also, contact your manufacturers — they are more than willing to help with Letters of Medical Necessity writing or appeal letters.”

This article originally appeared in the November 2014 issue of Mobility Management.

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