Justify It! K0005 Manual Chairs

Therefore, the seating & mobility team has to do more than just think about a K0005 in terms of clinical need. The team also needs to document that need well enough to satisfy the funding source.

K0005 Clinical Considerations

What clinical issues might lead a clinician or ATP to consider assessing a client for an ultralight chair?

Tina Roesler, MSPT, ABDA, director of education and international sales for TiLite, notes the importance of getting a good client history and says key questions include, “Does the client have a history of upper-extremity pain or dysfunction? Is the client experiencing any pain with propulsion currently?”

Asked which mobility-related diagnoses might signal a need for an ultralight chair, Steve Boucher, OTR/L, ATP, clinical educator for Sunrise Medical, says, “Personally, I do not focus as much on diagnosis as I do on clinical presentation. However, individuals with paraplegia, higher-level quadriplegia, hemiplegia, multiple sclerosis, brain injury or those with developmental disorders such as cerebral palsy, spina bifida and muscular dystrophy can maximize their independence with the use of a K0005 mobility base.”

Roesler agrees that using diagnoses to choose a chair isn’t the best strategy: “Every client is different, and really, I don’t believe selection of an ultralight chair should be solely driven by diagnosis. The important piece is the client’s functional potential and the long-term goals that have been determined in therapy. If the client has the motivation and the functional capacity to self propel, an ultralight is appropriate.”

Justifying Those Clinical Needs

Once you’ve determined that the K0005 frame will meet your client’s needs, the second challenge begins: convincing your funding source.

Lois Brown, MPT, ATP/SMS, director of clinical operations & education for National Seating & Mobility, says it’s important from the start to establish how an ultralight — compared to a less-adjustable chair — will significantly improve the client’s ability to perform at least one mobility-related activity of daily living: toileting, bathing, feeding, dressing or grooming. Documentation needs to specifically involve performing an MRADL, rather than just the client’s ability or inability to get to the kitchen or bathroom.

So Brown says documentation could describe specific adjustments to the ultralight frame that would significantly impact MRADL performance, decrease pain using a pain scale rating, reduce the need for pain medication due to improved chair configuration, or enable full-day wheelchair use versus frequent rests. While the client may have sufficient strength and range of motion for manual wheelchair propulsion, Brown says clinicians should note cardiac or respiratory issues when the weight or configuration of an ultralight frame could make a diff erence versus less-adjustable frames.

“Ultralights are prescribed when end users are unable to or have increased difficulty propelling a lower-coded chair due to clinical deficiencies such as a compromised cardiopulmonary system, upper-extremity (UE) weakness, a decrease in UE range of motion, decreased endurance for propulsion, spasticity, pain with propulsion, and orthopedic deformities,” Boucher says. “In some situations, the client’s ability to transfer to and from their wheelchair requires a lower or higher seat-to-floor height that K0001-K0004 chairs cannot offer.”

Know Your Products

Being able to offer data about how a client could benefit from a K0005 — such as how he says his shoulder pain decreases from a score of 7 to 1 when propelling an ultralight — requires understanding how the ultralight differs from lower-coded chairs, particularly the highstrength, lightweight K0004 chair.

Key points to remember about the K0005:

Rear-axle adjustability:
This is the K0005’s ultimate distinction for clinicians and ATPs who need to dial in a chair to very exacting and unique specifications for complex rehab clients.

“The adjustable axle plate allows for center-of-gravity (horizontal shift ), seat-to-floor height (vertical shift ), camber, and lateral axle spacing (inward or outward) adjustments,” Boucher says. “These adjustments offer a tremendous benefit to our end users when implemented correctly.”

Brown points out that K0004 chairs have some ability to adjust, but at a price: “You can change a K0004 to have a lower rear seat-to-floor height than front, but you need to change the rear wheel and the casters to accomplish that, which aff ects the ability of the chair to roll efficiently. So when I want to achieve a lower rear seat-to-floor height than the front, that’s a critical feature of the K0005: I’m able to accomplish it without changing the roll of the chair.”

Seat back options: “There’s also seat-to-back angle adjustment and back height specificity,” Brown says. “If you use a K0004 and that back’s too high, it can push the shoulders forward, which changes the biomechanics of the upper body and also affects the client’s ability to efficiently propel and, again, complete their daily activities.”

Weight: This is probably the most popular factor among consumers, and it’s true: Ultralight frames can weigh far less than lower-coded ones. The key, however, is to underline the importance of that weight savings by tying them back to those MRADLs.

“[K0004s] are supposed to be less than 34 lbs., but you can have a K0005 that weighs significantly less,” Brown points out. “Remember the weight of the total system you’re creating. If you start with 33 lbs. and you add a 5-lb. cushion and a 4-lb. back, then you have to look at the effect on the person’s propulsion abilities based on the total weight of the chair. If you start high, based on what you have to add, obviously propulsion efficiency is decreased, there’s more respiratory demand, there’s more fatigue, the whole system is heavier for pushing.”

“Advancements made with implementing 7000-series aluminum in K0005 frames have further provided benefit to end users, as these frames can reduce the weight of a wheelchair significantly,” Boucher says.

Precision configurability:
As mentioned, the K0005 isn’t the only type of manual chair capable of being adjusted. It stands alone, however, in its wide range of adjustability.

“Study after study shows the importance of made-to-measure chairs in relation to maximizing function and preventing upper-limb injuries,” Roesler says. “Ultralight chairs are more adjustable, lighter weight, and overall more efficient to propel. While Medicare focuses on the ability to change rear wheel position as a differentiating factor — it is much more than that. The ability to change rear-wheel position for optimal propulsion is extremely important, but the type and amount of adjustment is, too.”

Roesler explains that for complex rehab consumers, seemingly minute adjustments can make a huge functional difference. “For some people, proper configuration means moving the axle forward 1/2″.

While some lightweight chairs might offer one or two rear wheel positions, you really aren’t able to fine-tune or optimize for the individual.

You also tend to have more options available for critical components, such as rear wheels, handrims, front wheels, tires, and frame sizes and geometry. All of these options will help maximize someone’s functional potential.”

In other words, it’s not just an optimized configuration, but also improved ride that can make the K0005 a much better choice for the full-time self-propeller.

“Availability of suspension systems as an option on K0005 chairs can help maximize the client’s sitting tolerance and utilization of their chair throughout the day,” Boucher says, “when propulsion of a chair without suspension causes undesired tonal reflexes, an elevation in pain or discomfort, or increased fatigue from maintaining functional sitting postures.”

Knowing the differences between types of chairs is critical to the documentation process, Brown says, especially for Medicare: “You must document in the letter of medical necessity and rule out the lesser device and why it does not have the features that will meet your patient’s needs in order for them to complete MRADLs. This is a best practice to justify your recommendations, regardless of payor source.”

It’s also important to know the features and benefits of individual products within the K0005 HCPCS code, Brown says.

“Therapists need to understand the differentiating features between the levels of products and also between the products themselves so that they can work with the RTS and the ATP on product selection,” she says. “The story begins with the therapist’s responsibility to first identify what are the patient’s problems, what are some potential solutions, what are some of the key critical features that you need to make sure that equipment has in order to solve the patient’s problem?

“Then you go to actual product selection. You should be able to think through the different levels of features offered by a K0005 and match them to the person’s geometry and clinical factors, like respiratory and cardiac issues, effects on spasticity, and postural stability.”

Tools & Facts That Can Help

The justification for a K0005 initially sounds quite straightforward.

“If you simply review the evidence, it is clinically justified that any client who uses a manual wheelchair for independent manual mobility should be considered for an ultralight chair,” Roesler says. “The RESNA position paper on ultralight mobility also supports this.”

But from there, the process gets more complex — as does the need for the ATP and clinician to back up their professional opinions and choices with plenty of facts.

“Documentation should include the client’s functional potential, such as data related to wheelchair propulsion that can be gathered with tools like the SmartWheel and other clinical assessment tools,” Roesler notes. “If you have tried or are tracking multiple wheelchairs, be sure to include this in the justification and tell the funding body that you have tried other categories of equipment and why they don’t work.”

Prashant Srinivasan, described as the driver of sales for Out-Front’s SmartWheel, says, “Including actual data is important because it adds an extra dimension of evidence to back up the justification argument that’s being made. Justification arguments will always be stronger if they are backed up by both subjective statements and objective data.”

As an example of such data, Srinivasan adds, “The simplest example of performance data is how much force a person is exerting on the handrim to propel their wheelchair at a functional speed. Tools such as the SmartWheel provide that data in automated reports that are easy for clinicians to include in their justifications. It’s important to show with hard data that ultralightweight chairs really do reduce the amount of force that chair users need to exert to go about their activities of daily living.”

If the seating & mobility team doesn’t have access to equipment such as the SmartWheel, Srinivasan says there are other ways to gather useful, objective data: “Even without high-tech tools, clinicians can use basic observational tools — for example, count the number of push strokes needed to cover a certain distance — that will provide data to support their claims. A lower number of push strokes to cover the same distance in a similar time is also an indication of less exertion with an ultralightweight chair.”

Funding sources also want to see data supporting the client’s ability to successfully use that ultralightweight chair in the first place.

“Does the beneficiary have sufficient upper-extremity function to propel a manual wheelchair?” Brown asks. “It’s imperative that [clinicians and ATPs] document limitations in strength, endurance, range of motion, and I mean the numerical strength testing and range of motion testing. Funders are wanting to see documented the objective measures taken. You have to give those objective measures to support your statements and professional opinion.”

Don’t forget to cover the environment in which the K0005 will be used. Brown points out that Medicare requires the beneficiary’s
home provide adequate access between rooms for the wheelchair to maneuver through.

“Detailing the end user’s living environment, transportation needs, and mobility-related daily activities are also a necessity to include in a justification letter,” Boucher says.

And give your client the chance to share their feelings and discoveries in their own words, too.

“An end user’s report that they have an easier time propelling the chair due to rear axle adjustments, or reporting less fatigue or pain while propelling can support your documentation,” Boucher says. “Activities such as successful transfers, transferring the chair in and out of a vehicle independently, or overcoming thresholds and obstacles with better success are also excellent details to document. If needed, take photos or videos and provide to your funding source.”

Putting It All Together

Once the seating & mobility team has gathered all this information, from the potential clinical benefits of using an ultralight chair to the subjective and objective data that supports that opinion, it’s time to put it all together into a claim that will tell your story.

As you bring the pieces together, Brown suggests starting at the start.

The original definition of assistive technology really came before the Medicare Modernization Act of 2003, before the Mobility Assistive Equipment guidelines, before we started to talk about MRADLs,” she says. “We used to talk about prescribing assistive technology as the most simple, least-costly alternative. As we evaluated the patient and found more limitations or more issues, then we would start looking toward the more complex, more expensive equipment. “Clinical problem-solving is something we all do, and as we adapt to the new funding rules, it’s more important than ever for us to be able to paint that picture for the payor source so they understand how we came to our equipment selection. The bottom line is even though you can state those outcome findings or objective measures, you must always tie it back to how it will affect the patient’s ability to perform their routine activities and their MRADLs.”

“The best form of documentation is a concise, detailed evaluation that explains how the features of a K0005 chair will increase your end user’s ability to complete functional daily living activities,” Boucher says. “Quantitative data such as range of motion, upper- and lowerextremity manual muscle tests, and seating mat evaluation results are critical to share with funding sources so they understand why you are prescribing an ultralightweight frame. Going through the process of ruling out that the end user is able to complete daily activities with the use of a walking device, and/or a lower coded chair, is the best start.”

To be sure, the seating & mobility team creates a lot of pieces of information during the assessment and equipment trials process, and the task of choosing what to include can be intimidating.

“The therapist and the ATP need to work together closely to make sure they include all the relevant information and documentation,” Roesler says. “Sometimes, less experienced therapists can get overwhelmed when participating in wheelchair selection, but the data needed for justification is usually the same data they are using to document daily client goals and gauge outcomes in rehab. They simply need to integrate it as part of equipment assessment. The ATP can help by providing examples of success and helping to narrow down choices once the clinical indications have been identified.”

Finally, don’t let the upcoming documentation process discourage you and your team from seeking the K0005 solution when you believe it’s warranted.

“We want the equipment to become an asset, not a liability,” Roesler says. “Many people are shortchanged, whether it be by diagnosis or perceived funding limitations, and it results in poor outcomes for the client long-term. For example, I have had many therapists tell me that clients with a stroke do not qualify for an ultralight wheelchair. The diagnosis does not, and should not, preclude us from considering an ultralight chair.”

Custom-configured ultralightweight chairs can open new doors of opportunity and ability for consumers — and that potential independence is worth fighting for.

“We need to look at each client individually,” Roesler says. “It might be oversimplifying it, but I truly believe we should not be asking, ‘When should we consider an ultralight,’ but ‘Why shouldn’t we?’ We should give every client the chance and opportunity to have the highest quality of life.”