Defining Ultralights

Currently, there are four HCPCS codes (K0001, K0002, K0003, K0004) for standard manual wheelchairs that don’t have substantial configurability or positioning features.

Also, there is just one HCPCS code — K0005 — for the industry’s most configurable type of manual wheelchair (see sidebar).

Ultralightweight chairs can be the most inclusive mobility solution for an incredibly wide range of users. K0005s cover a lot of literal and metaphorical ground, yet successfully justifying them can still be a challenge.

What the HCPCS Codes Say

Often, step one in justifying an ultralightweight chair is to differentiate it from codes K0001-K0004 relative to the client’s needs.

Tina Roesler, PT, MS, ABDA, International Business Development for Motion Composites, said of the differences among codes, “If you look at the definition of the [K0005] code, it is based on adjustability of the rear axle, availability of multiple sizes, and the specific weight of the frame. Manufacturers of K0005s are focused on design and function: How can they help optimize performance in [a consumer’s] day-to-day life? When you look at K0004, and/or K0001/K0002, you will find less adjustability, more standard features, fewer performance options, and more focus on price rather than performance.”

Lauren Rosen, PT, MPT, MSMS, ATP/SMS, Program Coordinator at the Motion Analysis Center, St. Joseph’s Children’s Hospital of Tampa (Fla.), uses the word design when working with ultralight chairs versus standard chairs. “In general, they’re like night and day,” she said. “I can pick every aspect of the chair when I design a K0005, because I can set the exact width and the exact depth that works for you. With K0004s, I frequently have a 16×16″, or an 18×18″. There’s not the customizability to the seat sizing. But the biggest thing that I deal with, both in pediatrics and adults, is the axle adjustability.”

K0005s, Rosen noted, “have the ability to move forward, backward, up and down in their adjustability, so I can dial in exactly where somebody needs their axle to be. A K0004 may have a little bit of ability to move the axle up and down, but it doesn’t have that forward-rear adjustability at all. For a lot of my clients, that would put the wheel way too far back and make the chair way too hard to propel with the wheel in that position.”

While complex rehab’s understanding of optimal propulsion has evolved, the codes have not, Roesler said. “The definition of these codes is outdated. Technology has evolved, but you could argue that the codes and definitions have remained stagnant. Innovation in materials and design has made the current coding system obsolete, as well as the funding levels.”

Configurability & the K0005

Due to the complexity of the typical K0005 user, the ultralight’s ability to adapt is key.

“K0005 chairs should be considered the most configurable manual chairs available,” Roesler said. “Configuration plays a critical role because it allows us to fit the chair to the user, rather than fit the user to the chair.

“Configurability is important, and should not be confused with adjustability. A highly configurable chair may be fixed or adjustable, depending on the needs of the client. It implies that the clinician/supplier will be able to dial in the chair to meet the specific requirements of the user. You will tend to have a wider ranges of sizes, a selection of high-performance options, more adjustment (more options, and smaller increments), fewer compatibility issues with aftermarket seating, and the ability to set the rear wheel position to optimize propulsion efficiency.”

Roesler added, “Some will argue that there is little difference between K0004 and K0005, but the incremental adjustments and ability to get an exact fit can be critical to the user’s long-term function and quality of life.”

Rosen knows the difference that robust configurability can make. She referenced creating a new chair for a long-time K0005 user with a C6 spinal cord injury.

“We weren’t making a bunch of big changes,” she said. “We were giving him a rigid back, and I tweaked a couple of things with his center of gravity, just so he’d be more comfortable.”

Rosen did not expect a huge difference: “I thought he would be able to propel a little bit easier. His real goal was to have a good wheelchair with a solid back.” What both Rosen and her client considered a small change actually had a big impact: “It turns out he could push so well with the center of gravity adjusted that he could get across grass. That had never been a goal of his, but he realized he was propelling so well that he tried it.”

His new ability alarmed his neighbors. “They’d never seen him roll on grass,” Rosen said. “They were panicking and coming over to help, and he said, ‘No, I got this. I can do this now because of this new wheelchair.’ Later, he said he didn’t think of this as a goal because he could never accomplish it before. If you’ve never known what you could do, then you don’t know you’re missing.”

K0005s for Full-Time Users

For consumers with significant mobility-related disabilities, the high level of configurability in a K0005 can be the difference between being independently active and being dependent.

“K0004-classified wheelchairs today — at least those available through third-party reimbursement — offer minimal or no adjustability, or configurability,” said Rita Stanley, VP of Government Relations for Sunrise Medical. “These wheelchairs lack the ability to position the rear wheel, which is critical for full-time manual wheelchair users.”

“From an energy conservation standpoint,” Roesler said, “the evidence is very clear that the ability to optimally configure rear wheel position will maximize propulsion efficiency — decreasing energy cost of propelling the chair, and lowering the risk of repetitive strain. The definition of K0005 also dictates this, and a K0005 chair tends to have smaller increments (sometimes infinite options) for both vertical and horizontal wheel position.”
Time and time again in clinic, Rosen said she has noticed what can happen when children are in chairs that are not optimally configured.

“I see a lot of clients for the first time who are teenagers with spina bifida,” she said. “They’re in pretty heavy chairs that are K0005s, but were not adjusted for mobility and function. They were really adjusted more for stability, and that limited the kids’ ability to do stuff. And a lot of them have come to my office significantly overweight.

“I feel like it’s because their chairs made them want to be inactive. Moving across the room was work, and going anywhere was work. So if my daily life is work, when I have free time and my choice is to sit on the couch and eat Cheetos or go chase my friends around, I’m going to pick the couch and the Cheetos because that’s easier.”

Because it’s so critical to efficient propulsion, Rosen said she is especially careful about axle position when designing ultralightweight chairs for kids. She also recommends that axle position is checked and adjusted when needed as kids get older, “to make sure we keep that axle in that functional position. I feel like the kids that I start in a [well-configured] wheelchair have always felt that it is not limiting. It’s freedom.”

Ultralights as Long-Term Interventions

Ultralightweight chairs are also specifically designed to be longterm mobility devices. The right K0005 with the optimal setup for its user has the potential to stave off future injuries.

“This is an area where a great deal of evidence exists,” Stanley said. “The weight of the wheelchair is important, especially related to shoulder injury. This isn’t limited to propulsion; transferring the wheelchair in and out of vehicles for transportation can cause extreme shoulder damage, resulting in pain, requiring therapy or surgery. The ability to configure and set up the wheelchair — only possible with K0005 technologies — doesn’t merely make a wheelchair easier to propel. It means that the user is not expending all of their energy in propelling their wheelchair, it reduces stress on the body and conserves energy for other routine activities and allows the person to remain functional in their wheelchair for longer periods throughout the day.”

Rosen pointed out that another design option exclusive to the K0005 makes propulsion more efficient: “You can’t get a rigid frame in a K0004. Everybody has a little bit of movement in a folding-frame chair that they don’t have in a rigid-framed chair. I don’t like to waste an ounce of energy.”

She acknowledged that some users insist on a folding-frame K0005, usually for transportation reasons. “But generally, I try to move you toward rigid if you are propelling.”

Over a wheelchair user’s lifetime, efficiency is critical. “It also means that the user has a higher likelihood of continuing to use a manual wheelchair as opposed to requiring a power wheelchair,” Stanley noted. “Rear wheel adjustment (horizontal and vertical), seat-to-floor height adjustment (to facilitate transfers, foot propulsion or combined foot- and upper-extremity propulsion), caster adjustment, seat-to-back angle for positioning, front frame angle options for proper foot placement or to accommodate limited range of motion: All of these adjustments, features and additional options that allow K0005 wheelchairs to be uniquely configured are critical for permanent and full-time users of manual wheelchair technology.”

The Ultralight as Self Expression

The ultralightweight chair also is adaptable in a way that speaks right to the hearts of wheelchair users.

“This is one of the most important things!” Roesler said. “I have had many users choose a specific model of wheelchair based solely on the color options… we can’t downplay it! The chair becomes an extension of the user, and the more it seems to match their style and personality, the more likely they are to use and thrive with the equipment.”

Rosen cited research that demonstrated how important it is for users to like their chairs. “How people in wheelchairs feel about themselves, the more decisions they get to make on how the chair looks — those things are huge in getting out in the community and doing things,” she said. “With kids, the less medical the chair looks, the more likely that other kids are going to come up to them and want to be their friend. The ability to pick hot sparkle pink or electric plum because it’s your favorite color: That’s huge to people.

“When you have an outfit on that you like and you feel really good in, you have a better day. To be able to customize those chairs so you like your chair and you like how you look in your chair will make you want to get out and do more. It makes a difference in how you feel about yourself.”

Roesler would like to see more conversations with consumers about aesthetic options: “I think it is important to understand that not all options may be covered by normal funding. We need be more open to having the discussion about cost and price, and make the consumer part of the decision-making process. We often make financial assumptions about a user’s ability to pay for upgraded features (better tires, wheels, casters, etc.), and hence limit their access to choices. Not all funding sources are need based. Many clients on Medicare may have the finances and desire to upgrade, and most have the option to pay cash (or not use the insurance benefit).

“For some reason, the idea of asking a client to share in the cost of a product that will impact every aspect of their lives brings fear to the minds of many clinicians and suppliers. But with continued declines in funding, we do our clients a disservice if we do not present the options that can maximize their function and performance. We should not be scared of the conversation; I have found that many users welcome it and appreciate knowing what is available.”

Just the Right Fit, Today & Tomorrow

The beauty of the ultralightweight wheelchair is how well it can adapt to its user from the start, and going forward.

“Our bodies change over the years,” Rosen said. “I think people forget that people who use chairs age as well. Their bodies change, some of their morphology changes, and we need to adjust chairs to that. That’s the nice thing about a K0005: I can dial in and change [specifications] so I’m sure I get it exactly right for you. Even the best chair on the market is bad if it doesn’t fit you right and do what you need. I will never force somebody to change [their chair], but I always talk to them about how as we age, our needs change. You’re older, your body has changed.”

The K0005 is uniquely positioned to fit the human condition, whatever that means for any given client. It could be a C6 spinal cord injury client who needs a very carefully balanced chair: “You can’t necessarily put that axle as far forward as you want, because the chair’s too tippy for a quadriplegic,” Rosen said. “A lot of higher-level injuries need the wheels a little further back for some stability. I have to play with the axle position for every single person who comes into my office.”

Or it could just be someone looking to get through the day a little more smoothly. “We all know those days where we’re just getting through,” Rosen said. “If you set somebody up in a bad wheelchair, every day they’re just getting through. To me, our job as therapists and suppliers providing this equipment is making sure that our equipment makes these individuals see less and less of the limitations, and dream and want to be able to do anything. My kids [in clinic] hop in their chairs and go, and don’t even think twice about the fact that they’re in a wheelchair. It’s no big deal to them, because the wheelchair is so empowering.”