Funding Justification: Ruling Out Manual Mobility

keyboardA generic rule of complex rehab technology procurement is the need to “rule out” less complex equipment. When opting for power mobility for a client with a lower-cervical spinal cord injury, that means explaining why a less expensive, self-propelled manual wheelchair won’t work.

Curtis Merring, OTR/L, MOT, clinical education manager for Permobil, evaluated many clients for mobility while he was a director of rehabilitative services. And he thinks the ruling-out process is valuable for an additional reason. “It’s so important not to just disqualify that chair for the sake of reimbursement, but also to show the [client]: This is the right device for you, medically. So just like that decision, power vs. manual, you want to show the person where they are going to get their best function. So not only should you be doing it for reimbursement, but you’re really doing it for the client. That should be driving it ultimately.”

The Justification Process

“I never do an evaluation where I can’t have the person trial it,” Merring said, “and I think this is one of the biggest errors in our field right now.” He pointed out that some “ruling out” decisions are based on conversations, rather than on the results of actually trying the equipment.

“They don’t sit in the chair, don’t drive the chair, don’t propel the chair, don’t go outside in the chair,” he said. “The way I rule [a manual wheelchair] out is I have it in front of me, and I have a power chair in front of me, and I may have a power-assist, if I’m lucky that day to have it in my clinic — and we’ll go through all those options. A lot of these things won’t happen in a 90-minute session, so I open up a plan of care, which is a clinical term for basically a treatment plan, and whatever I don’t get done the first day, I will trial on the second, third or fourth day. We try manual; then I’ll get a power-assist and see if power-assist works. If the power-assist doesn’t work, we’re going to try the Group 3 or Group 4 chair.

“We trial, we have the person do it, and whatever they’re successful with, we deem medically necessary. I then write on it. My justification doesn’t come from speculation. My justification comes from trial and error.”

An LMN Sample

Merring showed the following “ruling out” example from a portion of a Letter of Medical Necessity (LMN) he wrote:

The patient presents with severe weakness in her B UEs [bilateral upper extremities], B LEs [bilateral lower extremities], and her postural musculature 2/2 [secondary to] her tetraplegia. Her weakness results in her being unable to walk independently even with the assistance of cane or walker.

She has been paralyzed to this extent for the past eight years, and she is not expected to make any significant gains in her mobility at this time or in the near future. The patient’s B UE and postural strength is so weak that she is unable to propel even an optimally configured manual wheelchair. The patient is unable to use a POV [power-operated vehicle] 2/2 limited B UE control, weak postural control and the safety issues that arise when transferring to and from a POV. Also, POVs do not fit within most homes, which would further limit this patient from completing her MRADLs [mobility-related activities of daily living]. The patient’s medical justification for a Group 3 power wheelchair with power tilt, recline, elevating legrest, seat elevator and standing functions rules out Group 1 and 2 power wheelchairs.

While assessment time is a valuable and often scarce clinic commodity, Merring believes a methodical approach is what works best.

“It’s something that I think time needs to be allotted for,” he said. “We like to try to make decisions quickly and move forward and get people things as fast as we can, but that’s where I think the clinician needs to come in, be the moderator and be objective and say: We’re not ready to make this decision yet. We’re going to hold off for one week. Even the patient might ask why. And the answer is ‘You’re basically going to be in a relationship with this device for five years. So we need to get as much data now in order to make our decisions and move forward from here.’

“Ultimately, the outcome is going to be better, and when my funding source asks, I can pick up the phone and say, ‘I was with Mr. X on this date, this is exactly what we did, and this is why this person has a medical necessity for what I’m suggesting.’”

This article originally appeared in the May 2017 issue of Mobility Management.

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