ATP Series

The Complexity of E1161

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Of all the complex rehab HCPCS codes, E1161 — Manual adult size wheelchair, includes tilt in space — is usually not the most exciting. E1161 chairs aren’t raced by Paralympians. They aren’t made of titanium and carbon fiber, and they don’t boast state-of-the-art electronics and Bluetooth compatibility.

For a diverse patient population, however, E1161 wheelchairs provide positioning support and improve sitting tolerance so users can more independently perform mobility-related activities of daily living (MRADLs). When family members need to help, E1161 chairs can make caregiving tasks much easier and safer for everyone. And the tilt ranges in some E1161 chairs can perform weight shifting for pressure relief.

The E1161 code comprises a range of wheelchairs with a range of capabilities, which results in a user population that’s extremely diverse… and makes this code and its justification quite complicated.

The E1161 User Demographic

The E1161 code is so complex that basic questions about typical users get complicated in a hurry.

Think about a “typical” user of a K0005 ultralightweight, self-propelled manual wheelchair, and you’ll likely think of spinal cord injuries, paraplegia or lower-level quadriplegia, relatively good upper-body and upper-extremity strength and function. But who is the “typical” user of an E1161 wheelchair?

Michael Owen, Product Specialist for Freedom Designs and Invacare Corp., said, “Any clinical situation where there is dependent ranging of motion or dependent location in space can benefit from an E1161 coded tilt-in-space manual wheelchair. Diagnoses range from TBI [traumatic brain injury] to SCI [spinal cord injury] to motor-neural conditions. Patients with ALS, muscular dystrophy, cerebral palsy, CVA [cerebrovascular accident, aka, stroke] can all find benefits from weight shift in space.”

John Frank, Product Manager for Tilt at Ki Mobility, suggested that understanding the patient population that could benefit from E1161 chairs requires first understanding how different the designs of various E1161 chairs can be.

“Recognize that there are a few different design types of manual tilt-in-space wheelchairs on the market,” he said. “Among the designs, a couple of them provide tilt ranges from 45° to 60°. These include rotational tilt and mid-seat frame pivot designs. The most commonly used is the rotational tilt, which rotates through an arced path. There are also front seat frame pivot tilt chairs, often referred to as ‘knee tilt,’ which have their axis of rotation at the front of the seat frame. By virtue of their axis of rotation at the front of the seat frame, they tend to be more limited, having a 20° to 30° range of tilt available.”

The user’s needs and goals are critical in determining which type of E1161 chair is best for a particular individual.

“The intended use or function of the chair can influence which style of tilt in space chair is selected,” said Curt Prewitt, MS, PT, ATP, Director of Education, Ki Mobility. “For example, the full tilt-in-space provides the greatest range of tilt angles. Due to its ability to significantly change the loading on the tissue, it is commonly used for individuals who are considered high risk for pressure injury. These full-tilt chairs are also often used to address more complex postural needs as well, such as significant deformities, asymmetries and tonal issues.”

By comparison, “knee-tilt” chairs have less range available, Frank said: “With a pivot point at the front of the seat, the rear of the seat drops down to change seat angle, maintaining the front seat-to-floor height (STFH).” Prewitt added, “This combination of low STFH and varying tilt angles is appropriate for individuals who would benefit from a change of position to promote independence with MRADLs, such as foot propulsion or hemi-propulsion (foot and hand), transfers and transitions and functional reach.”

Linda Bollinger, PT, DPT, Clinical Education Manager for Sunrise Medical, said she considers ranges of tilt when recommending one type of E1161 chair over another. “A manual wheelchair that is coded as E1161 must have the ability to tilt the frame of the wheelchair greater than or equal to 20° from the horizontal while maintaining the same seat to back angle,” she said. “If a wheelchair does not tilt the full 20° from horizontal, it cannot be classified as an E1161 manual tilt-in-space wheelchair. Based on this definition, when recommending a wheelchair with tilt, I make a distinction between minimal tilting wheelchairs (less than 20°) and full tilting wheelchairs (greater than 20°). The clinical benefits of tilting the body from the horizontal include pressure relief, managing spasticity, managing edema, physiological effects, postural control and improving function. A full-tilt wheelchair is indicated for individuals who use a wheelchair full time and require positional changes, but are unable to weight shift independently.”

Anna Gonzalez, Product Specialist for Freedom Designs and Invacare Corp., said, “Tilt can give you the ability to get an ideal posture to facilitate normal respiration, digestion and have more impact on swallowing. Weight shifts [and] position changes reduce the risk of pressure injury by redistributing pressure from the pelvis to the trunk. Tilt in space can help to relieve pain and discomfort caused by scoliosis, common in many neuromuscular conditions. Tilting clients when they fatigue facilitates thoracic extension and a neutral pelvis. Tilt helps promote proper seating alignment and decreases potential for postural deformities.”

E1161 Advantages Over Standard Manual

In discussions of manual wheelchair provision, the E1161 wheelchair is often mentioned along with standard chairs that do not tilt and are caregiver propelled: in coding terms, a K0003 or K0004 chair, for instance. But what greater benefits does the E1161 provide over less functional chairs?

Bollinger listed several: “A tilt-in-space wheelchair provides changes in position for individuals who cannot weight shift independently. To be effective for pressure relief at the greater tuberosities, the tilt angle should be greater than 25°. Tilting an individual while maintaining their relative body angles provides the benefits of positioning changes without eliciting increases in spasticity, such as those caused when opening the hip angle when using recline.

“By positioning the individual in a tilted position, edematous legs can be elevated slightly above the level of the heart to help the extra fluid move back towards the heart for circulation to the rest of the body. This is often best achieved with elevating legrests and recline back. Additional physiological benefits of tilting an individual include respiration, digestion, hypotension, and autonomic dysreflexia.”

“The ability to achieve a variety of seat angles,” said Debbie Pucci, PT, MPT, Ki Mobility, “can contribute to a safe, more stable posture, reducing the risk of aspiration. It also allows for access to tables and other appliances, and positions for improved visual access to the environment for socialization. All of this can be provided while still providing beneficial changes related to tissue loading.”

“Over time,” Frank added, “tilt-in-space chairs have been highly adapted to the needs of the people who use them. This includes the addition of features such as recline options, dynamic backrests and legrests, contracture footrests, elevating legrests, etc., to meet postural support or medical needs of those people.”

“Sitting for long periods of time causes your spine to collapse,” Gonzalez added, “affecting your respiratory system along with organs. Expanding the trunk in a tilt-in-space improves breathing, blood circulation and organ function.

“If your body has some weakness from a neuromuscular disease, you probably experience fatigue. Gravity in a tilt-in-space really can work against our bodies. Tilt can assist our bodies in reducing the amount of effort it takes to remain upright in a wheelchair. Hygiene, range of motion, weight and pressure management can all be improved using a manual wheelchair that can adapt and change to meet a patient’s daily needs.”

Technological Differences

The E1161 code comprises a number of diverse wheelchair designs and capabilities.

“The Quickie IRIS has always been a robust and durable frame,” said Jesus Ibarra, Product Manager, Adult Manual, Sunrise Medical. “Sunrise recently upgraded the weight capacity on the IRIS to 300 lbs. on a standard frame and up to 400 lbs. on the heavy-duty frame. This allows more clients to fit into a lighter-weight and maneuverable tilt-in-space wheelchair.”

He added, “There are differences between tilt chairs that provide easier mobility and those with greater tilt ranges to maximize the benefits of pressure relief. The market is starting to see more manufacturers develop new posterior tilt technology devices that provide a limited tilt range, which includes only up to 20° of tilt and meets the code E1161. Each manufacturer may provide its own unique benefits for the clients, e.g., light weight, foldable frame, and low seat-to-floor heights. The challenge is to provide a product that supports the clients’ changing needs today, which might need minimal tilt range for some positioning, but long-term needs might require more tilt for pressure relief when a client diagnosis progresses. We are also starting to see more power add-on devices configured with E1161 chairs.”

“Improvements and refinements in rotational tilt-in-space technology have brought about a new generation of wheelchairs that are less disruptive and more intuitive for the user and safer and easier for a caregiver to operate,” said Karl Schultz, Associate Product Manager, Freedom Designs and Invacare Corp. “The use of higher-quality materials and manufacturing techniques is providing parts and components that operate and function with durability and precision.” Foster Davis, Rehab Sales Specialist for Invacare Corp., added, “The PRO-CG [E1161 chair] from Freedom combines light weight with 24" wheels, which can allow some patients to propel for vestibular training, spatial awareness, and less dependence on caregivers.”

“Knee-tilt style tilt-in-space wheelchairs have been around for a while,” said Frank, “but until the introduction of the Ki Mobility Liberty FT in 2018, there was no model available that was also lightweight and portable. This is the first chair of its kind to combine ease of transport with STFH options that facilitate foot or hemi-propulsion and the ability to change seat angle to optimize postural support and activity-specific positioning.

“One particular population that could benefit significantly from the features of the Liberty FT is individuals who have had a stroke. In the United States, the stroke population may be underserved in terms of the equipment they commonly receive. Often, individuals who’ve had a stroke are provided with standard manual wheelchairs that may be inadequate in providing postural support, especially with regards to independent mobility, or they are placed into manual tilt-in-space chairs in which they are completely dependent.”

But there are other options, Pucci said. “In many cases, these individuals are assumed to be incapable of any independent mobility and MRADLs, without even being given the chance to explore the possibility. Sometimes this may be a limitation of the individual’s diagnosis and impairments, but many times, it may be a limitation of the equipment they’ve been provided.”

Overcoming E1161 Challenges

Despite the many benefits to be had, accessibility to E1161 chairs can still be a challenge.

“Medicare and competitive bidding have set up a paradigm where people are afraid of trying to do anything to service that population [of users],” said Tom Whelan, VP of Product Development, Ki Mobility. “They’ve become so rote that everybody’s going to get a K0003 wheelchair — if you’re lucky, you might be able to bump them to K0004. Then there’s competitive bidding, and to get to an E1161, there are a couple more hurdles: Now an ATP has to be involved. And K0003s and K0004s don’t require ATPs.”

The added work and the uncertainty of success can make some providers hesitant to offer an E1161 chair instead of a standard manual one. But Whelan added, “That doesn’t mean we can’t create a different paradigm, and that’s what we’re trying to do with the Liberty FT. We know there is nothing in Medicare that prevents a better paradigm for stroke patients who really do need a better level of intervention to meet their needs. The Medicare system does allow a stroke patient who needs it to get an E1161. Their own policies allow and set up a clear path for access to E1161 technology.”

Pucci said, “I think the confusion about ruling out lower-level [wheelchairs] is within Medicare’s LCD. To get from a K0003 to a K0004, you have to address someone’s ability to independently propel the chair within their home environment. When you move to the E1161, you don’t have to necessarily address propulsion. What you have to address is the functionality of that chair that cannot be provided in an upright manual chair — so, the tilt function or the adjustable seat angle function. I think that creates confusion when people are trying to go through that justification process.

“As a clinician still working in a seating clinic, I let patients and families know: There are chairs that fall within this code that provide more options. I will educate them and show them.”

Rita Stanley, VP of Government Relations for Sunrise Medical, said access to E1161 chairs hinges on documentation: “Since the Medicare coverage policy only requires the beneficiary meet all the requirements for a manual wheelchair plus a specialty evaluation by a qualified OT/PT, etc., and be provided by a supplier with an ATP involved in the selection — the documentation is the key. It is important to detail what features the consumer requires that are not available on any lower-level device. So, in the case of tilt, the justification needs to provide objective details regarding why the person needs tilt… and of course, they need to justify the other components being requested as well.”

Michael Salvi, Director of Passive Manual Mobility & Seating for Invacare Corp., said the many benefits of today’s E1161 are worth pursuing. “The ease of tilt and maneuverability are critical. Tighter frames as a result of these technologies and our advancements in center-of-gravity tilt and manufacturing improvements really make a difference to the caregiver. Technology has truly benefited the caregiver as well as the end user.”

This article originally appeared in the April 2019 issue of Mobility Management.

In Support of Upper-Extremity Positioning