It’s all about access, engineering … and physics.
The spring 2024 coding and funding decision by the Centers for Medicare & Medicaid Services (CMS) for power seat elevation was a textbook case of good news and bad news.
The good news: CMS, citing how seat elevation can support and facilitate transfers and reaching tasks, affirmed the medical necessity of seat elevation for Medicare power wheelchair beneficiaries.
But the bad news: The initial allowable was $2,000.34 for HCPCS code E2298. (In June 2024, CMS revised the allowable to $2,013.96.)
And E2298 was the only HCPCS code created. Despite Complex Rehab Technology (CRT) industry testimony that a second bariatric code and accompanying allowable were needed to ensure access to the technology, CMS contended the one code and allowable were entirely sufficient.
Design differences in bariatric seating, mobility
Just as designing pediatric wheelchairs isn’t as simple as shrinking an adult-sized wheelchair, successfully designing a heavy-duty wheelchair and seating system is much more complicated than making those systems wider, deeper and able to support more weight.
When engineering a bariatric power wheelchair and seating, “the user weight can be the least of our concerns,” said Brad Peterson, VP of sales USA at Amylior. “You can make something to support a [heavy-duty] weight; it can be big and robust. However, the bigger challenge can be safely accommodating their shape and the distribution of the weight, which can be widely variable from person to person. All the while, we must also take into consideration maneuverability, environmental access, transfer, stability, performance and comfort just as we do systems for more standard weights. Yes, everything needs to be bigger and stronger but in a smaller, lower and more stable package! It can be quite a balancing act.”
“There are differences in the design, materials used and engineering to provide support and durability for higher weight capacities,” said Leslie Wade, MOT, OTR/L, ATP, regional clinical education manager, Permobil. “Generally, heavy-duty power chairs feature larger batteries, more powerful motors, and advanced suspension to provide a smoother ride. The goal is to design power chairs that are safe and functional for our users with higher weight capacities.”
Asked also if manufacturers need to consider additional factors when designing bariatric seat elevation equipment, Jeff Rogers, director of power product management for Sunrise Medical, said, “I think there are two parts to this question. One: How do you first get 450 lbs. up that high — because that’s what the weight capacity is. Second: Once that weight is elevated, what do you do with it? From a QUICKIE standpoint, we don’t have a heavy-duty elevation [system] at this time because there are challenges with this. Could we develop one? Yes. Would it be really expensive right now? Yes. That’s been why we don’t have one currently in the market: The challenge is managing that weight. Getting it elevated is one thing, but managing the stability of the base is another. Because the physics are: If I put 450 lbs. up 12 inches in the air, there is a little thing called momentum which is much different than it is when the seat is in the home position.”
Rogers compared the low profile of a sports car, whose weight is low to the ground, versus a higher-profile SUV. “Which one is going to be more susceptible to tipping over?” Rogers asked. “A large SUV. Even though it may be bigger, heavier, and have a wider stance, when you put that much weight that high in the air, you’re going to have challenges.”
Rogers said that fact is one of multiple challenges to designing a functional, safe seat elevation system. “That’s one thing that we have to overcome,” he said. “To say it’s going to be the same as building a standard-capacity [system] — that’s not the case. We’re now forced with trying to figure out a way to build this technology at the same price, which is just not going to happen. Because not only does the seating system have to change, but the base will likely change as well to accommodate the weight being higher than a traditional HD base.”
The complexity of seat elevation
While CMS representatives seem to believe that seat elevation is substantially less complex than power tilt or recline, Peterson disagreed.
“Of course, you need a system that has a stronger actuator (motor) for heavy-duty weights. That’s the most basic thing because you’re lifting up to 150 lbs. more weight between the standard weight and the heavy-duty weight chair. So there is more weight, and oftentimes a lot more asymmetrical loads that are biased to the front.
“That puts different loads on the lifting actuators from a durability and stability standpoint. And we have to make sure it still supports tilt, recline, power elevating legs and back-mounted accessories such as backpacks, ventilators, oxygen, etc. These add weight but also greater asymmetrical and cantilevered loads, all supported by the power seat elevation system.”
“When designing heavy-duty power wheelchairs, stability is critical, especially when using power seat functions, such as seat elevate,” Wade said. “Heavier weight can potentially affect the stability of the power wheelchair. When there is a heavier load — e.g., 350 lbs. — positioned in seat elevate, the center of gravity is raised more than compared to a lighter weight (e.g., 175 lbs).
“To make the base more stable, manufacturers may design their power wheelchairs with wider bases, enhanced anti-tip mechanisms, as well as lower centers of gravity. Manufacturers may also limit the wheelchairs’ movement when the seat is elevated to prevent instability and risk of tipping.”
Rogers said that in addition to elevating the bariatric consumer, manufacturers need to ensure that the power chair remains safe to drive and can navigate varied terrain while in a raised position.
“Our number one job is to keep the individual safe,” he said. “So, when someone’s driving a power chair, we must try to predict what environments they’re going to put this chair into. We can say in the owner’s manual, ‘Don’t drive on a given slope.’ But we also know people don’t pull out a protractor and measure every angle they drive on. So we try to prepare for as much of the unknown as possible. With a combination of mechanical features, as well as electronic features that limit the drive of that chair in certain scenarios, we can give the best ride experience, regardless of where they are. The chairs are getting smarter and smarter.”
Seat elevation as an accessory
While power tilt and power recline are acknowledged by CMS to be seating systems, seat elevation is defined as an accessory.
Julie Piriano, PT, ATP/SMS, senior director of payer relations & regulatory affairs for the National Coalition for Assistive & Rehab Technology (NCART), was the industry’s primary presenter during November’s Healthcare Common Procedure Coding System Public Meeting, 2nd 2023 Biannual HCPCS Coding Cycle. (At that time, Piriano was employed by Pride Mobility Products/Quantum Rehab.)
Seat elevation, Piriano believes, is a hybrid technology: “The industry recognizes that CRT power seat elevation is an accessory to a CRT power wheelchair, as it is a component that cannot be used without the chair,” she pointed out.
“However, like power tilt and power recline, we also contend that CRT power seat elevation is a complete system that moves the chair frame relative to the base and compromises the stability of the chair much more than either of the other two power seating systems combined. There are additional mechanical and/or electrical safety mechanisms inherent in the design of a CRT power seat elevation system, and they require more rigorous stability testing protocols not required of an accessory that is an addition to a power seating system, such as power elevating legrests (ELRs) or a power center-mount foot platform.”
And seat elevation’s classification as solely an accessory causes complications for documentation for ELRs and power articulating footplates (AFPs), Piriano added.
“In addition, if CRT power seat elevation is not deemed a power seating system, then the addition of power ELRs or a power AFP is not covered or reimbursable for a beneficiary who needs leg elevation in conjunction with their CRT power seat elevation system, as these accessories can only be billed as an addition to a power seating system,” she explained.
Reimbursement, meanwhile, remains a work in progress for both heavy-duty seat elevation and standard-weight seat elevation, which received a paltry $13.62 increase in June.
“We have informally been meeting with CMS on this topic,” she said. “But then we submitted a new HCPCS code application to the alphanumeric coding workgroup, so that it goes back into the formal process and is added to their statement of work. So they have to address it. We had to do it in a way that said, ‘We are seeking a revision to the code.’
“And we gave them the new code description, which then allows them to make changes, because we weren’t asking for a new code. And we weren’t removing a code. The only other option was revision.”
A Threat to Consumer Access
Ultimately, the CRT industry’s concern is that the lack of a bariatric seat elevation code will prevent bariatric wheelchair riders from accessing crucial technology that can help with transfers and other activities of daily living.
“This is where we say, ‘Let’s use gravity,’” said Rogers about how seat elevation can help with transfers. “Anytime we can get your starting point higher than your finish point of your transfer, gravity is going to help you, and your caregiver doesn’t have to lift you up and over.
“I’ve seen plenty of moms trying to take care of a son or daughter who may be bariatric. They’re going to blow out their backs trying to lift this person daily. If I offer a device to assist them, I save the caregiver from possible injuries.”
And if seat elevation isn’t available to this population?
“Then we’re going to have people who will be sitting for longer than they should or will be stuck in a situation that they can’t get out of,” Rogers said. “Riders are stuck at home sometimes because they’re afraid to go anywhere because they can’t transfer. This most definitely impacts the quality of life of our riders, and they deserve better.”
Peterson pointed out that demand for bariatric CRT is only expected to grow, especially for larger weight capacities.
“There are also people who weigh more than 450 lbs.,” Peterson said. “If you look at the tilt code, the recline code, if you look at other mainstream chairs in the very heavy-duty code, they’re oftentimes tilt-only chairs, or they’re 25 degrees of tilt, nothing else. Because they’re not designed to be able to give the benefit of full tilt, full recline, full power legs, just because of [the clients’] size. Because there’s no extra funding. Suffice it to say that the needs of someone who weighs 585 lbs. are much different than someone who weighs 185 lbs.”
Because of current Medicare policy — and one allowable for seat elevation of all weight capacities — Peterson expects bariatric clients to be denied access.
“We’re one of the only ones who will do seat elevation for consumers over 400 lbs., but we limit it to 5 inches or 7 inches, just from the stability standpoint,” Peterson said regarding Amylior’s current offerings. “So right there, these people are not going to be able to get that funded because it doesn’t [elevate] 11 inches.”
Peterson recalled a CMS representative “saying that a lot of people have a hard time thinking about putting someone who weighs 300 lbs., 11 inches in the air and driving at 3.5 mph. So think of doing the same thing with someone who weights 485 or 500 lbs.
“We need to be able to engineer and design specifically to that weight and make the system itself specifically to what they need, and we can’t do that with a code that says, ‘Any type’ [of seat elevation].”
Editor’s Note: This story originally ran in the August 2024 ebook edition of Mobility Management. See the rest of this edition, or subscribe to receive future newsletters and ebook editions for free, sent straight to your email box. Subscribing to the newsletter also subscribes you to the ebooks.
