Transcript The FUNDamentals of DME Equipment:

The FUNDamentals of
DME Equipment:
A Guide for Selection, Acquisition, and Delivery of Complex
Rehab Technology
Beth Beach MS, OTR/L, ATP
Tony Leo MOT/L, ATP
AEL/NRTTS
What is Durable Medical
Equipment (DME)?
Durable Medical Equipment must meet the following
criteria (Medicare.gov 2014):
1. Is durable or long-lasting
2. Is used for a medical reason
3. Is not usually useful to someone who isn’t sick, injured
or disabled
4. Is used in the home
What is complex rehab
technology (CRT)?
“Complex Rehab Technology products and services include
medically necessary, individually-configured manual and
power wheelchair systems, adaptive seating systems,
alternative positioning systems, and other mobility devices
that require evaluation, fitting, configuration, adjustment
or programming.” (NuMotion/NCART)
Who needs complex rehab
technology?
“Primary diagnoses that can require Complex Rehab
Technology include, but are not limited to, spinal cord
injury, traumatic brain injury, cerebral palsy, muscular
dystrophy, spina bifida, osteogenesis imperfecta,
arthrogryposis, amyotrophic lateral sclerosis (ALS),
multiple sclerosis, demyelinating diseases, myelopathy,
progressive muscular atrophy, anterior horn cell diseases,
post polio paralysis, cerebellar degeneration, dystonia,
Huntington’s chorea, spinocerebellar disease, amputation,
paralysis or paresis, or any other disability or disease that
may require the use of such individually configured
products and services.” (NuMotion/NCART)
General Funding Guidelines for CRT
 The client requires the equipment long-term
 The equipment will improve the client’s function
MRADLs) within the home and, if under 21, the school
environment
 Other less expensive/extensive equipment has been
considered but will not meet the client’s current and
anticipated needs (i.e. progressive disease)
Manual Wheelchair criteria
[Needs to meet criteria A, B, C, D, E, + F or G]
 A. Cannot participate in 1 or more mobility related activities of daily live (MRADL)
such as toileting, feeding, dressing, grooming, and bathing in customary locations
in the home
 B. Cannot be resolved with a cane or walker
 C. Patient’s home has adequate access and maneuverability
 D. Use of chair will improve MRADLs and patient will use on a regular basis
 E. Patient has not expressed unwillingness to use chair
 F. Patient has sufficient capabilities to self-propel the chair during a typical day
 G. Patient has caregiver who is willing to assist with chair
Source: OttoBock.com
Manual Wheelchair Criteria
Standard Hemi-Chair (K0002):
 Patient requires a lower seat height (17”-18”) because:

Short stature, OR

Need to place feet on ground for propulsion.
Lightweight Chair (K0003):

Patient cannot self-propel in a standard wheelchair
using arms and/or legs; AND

Patient can and does self-propel in a lightweight
wheelchair (min 2 hr/day).
Source: OttoBock.com
Manual Wheelchair criteria
High Strength Lightweight Chair (K0004):
 Patient’s ability to self-propel the wheelchair while engaging in frequent activities
 that cannot be performed in a standard or lightweight wheelchair; AND/OR
 Requires seat width, depth, height that cannot be accommodated in a standard,
lightweight, or hemi-wheelchair and spends at least 2 hours a day in the chair
Ultralight Wheelchair (K0005) payment determined on an
individual consideration basis
 Description of the K0005 features that are needed compared to the K0004 base.
Source: OttoBock.com
K0005- The Mystery Explained
Per Medicare criteria, a K0005 wheelchair is covered if 1
or 2 is met and 3 and 4 are met:
1. The beneficiary must be a full-time manual wheelchair
user OR
2. The beneficiary must require individualized fitting and
adjustments for one or more features such as, but not
limited to, axle configuration, wheelchair camber, or
seat/back angles which cannot be accommodated
through a lower level chair AND
K0005
3. The beneficiary must have a specialty evaluation
thatwas performed by a licensed/certified medical
professional (LCMP), such as a PT or OT or physician who
has specific training and experience in rehabilitation
wheelchair evaluations and that documents the medical
necessity for the wheelchair and its special features. The
LCMP must have no financial relationship with the supplier
AND
K0005
4. The wheelchair is provided by a Rehabilitative
Technology Supplier (RTS) that employs a RESNA certified
Assistive Technology Professional (ATP) who specializes in
wheelchairs and who has direct, in-person involvement in
the wheelchair selection for the patient.
Tilt in Space Wheelchairs
Tilt in Space coverage criteria
Needs to meet criteria A, B, C, D, E, + F or G]

A. Cannot participate in 1 or more mobility related activities of daily live (MRADL) such as
toileting, feeding, dressing, grooming, and bathing in customary locations in the home

B. Cannot be resolved with a cane or walker

C. Patient’s home has adequate access and maneuverability

D. Use of chair will improve MRADLs and patient will use on a regular basis

E. Patient has not expressed unwillingness to use chair

F. Patient has sufficient capabilities to self-propel the chair during a typical day

G. Patient has caregiver who is willing to assist with chair
Source: OttoBock.com
Tilt in Space coverage criteria
 Client must have a specialty evaluation that was
performed by a licensed/certified medical professional
(LCMP), as previously noted.
 The wheelchair is provided by a Rehabilitative
Technology Supplier (RTS) that employs a RESNAcertified Assistive Technology Professional (ATP) who
specializes in wheelchairs and who has direct, in-person
involvement in the wheelchair selection for the patient.
Note: as of 4/1/14, tilt in space frames are rentals under Medicare
Power Mobility Device criteria
 Patient has mobility limitation that significantly impairs
mobility related activities of daily living abilities
 Prevents ability to accomplish
 Can't accomplish safely
 Can't accomplish in reasonable time
 Limitation not resolved by cane or walker
 Limitation not resolved by optimally configured manual
wheelchair
*wheelchairjunkie.com
POV vs. Power Wheelchair
In order to request a power wheelchair, a power operated
vehicle, or scooter must be ruled out as an option for the
client
 POV has a tiller for operation
 POV has captain’s type seating
 POV is usually longer than a power chair
 Transfers can be an issue with a POV
Power Chair Groups
Group 1 power chair
 Standard integrated or remote proportional control input
device- cannot be upgraded for specialty controls
 Non-expandable controller- cannot be upgraded
 Accommodates non-powered options (i.e. manual recline and
manual elevating legrests)
 These chairs are not considered complex rehab technology
and fall under competitive bidding for Medicare
Group 1 Power Wheelchair
Power Chair Groups
Group 2 power chair
 Standard integrated or remote proportional control input
device
 Accommodates seating and positioning components such as
specialty backs, cushions
 Can accommodate power functions such as power tilt and/or
recline
 These cannot be upgraded with specialty controls and power
functions are more limited- not CRT under Medicare
Group 2 Power Wheelchair
Power Chair Groups
Group 3 power chairs
 Standard integrated or remote proportional control input
device
 Accommodates seating and positioning components such as
specialty backs and cushions
 Can be upgraded with specialty controls
 Has options for multiple power functions
 This is the first category considered CRT under Medicare
Group 3 Power wheelchairs
 Mid-wheel
 Front wheel
 Rear wheel
Power Chair Groups
Group 4 power chairs
 Not covered under Medicare as they have essentially the same
options as group 3, just are more heavy duty and faster.
Group 5 power chairs
 These are pediatric power wheelchairs
Power Chair Groups
Group 4
Group 5
Seating
Skin Protection and/or Positioning Seat Cushions
•
•
•
Positioning Backs
Positioning Accessories
Custom Fabricated Seating
Must have a manual wheelchair or power
wheelchair with sling/solid seat and back
and meet MCR coverage criteria for the skin
protection and/or positioning seat or back.
Role of the therapist
 Evaluate patient and document need for complex rehab
technology in a letter of medical necessity
 Communicate with other team members- rehab
technology specialist (RTS), physician, treating
therapists, case managers, client and family
Role of the therapist
 50% of orders in the Medicare Demonstration Project are
denied.
 A majority of the denied prior authorizations relied on
Physician chart notes and did not include a therapy
evaluation.
 When the customer sees a therapist for a wheelchair
evaluation, the approval rate jumps to around 90%.
 When there is a comprehensive therapy evaluation, the
process moves faster and the customer is more likely to
get their chair approved without needing repeat visits.
Letter of Medical Necessity
 Introduces the client- age, sex, diagnosis, past medical
history
 Discusses what equipment the client has presently and
what the problems are with the equipment
 Standard therapy evaluation including strength, range of
motion, bed/floor mobility, sitting balance, head
control, tone, etc.
 States the equipment recommended and WHY each
component is necessary
Letter of Medical Necessity
 Clinician or the Clinic’s own form (meeting all coverage criteria) VOTA
2014\Medicare LMN Requirements.pdf
 Orion FMEVOTA 2014\Group 3 Power Multiple Seat functions - Copy.pdf
 Illinois Seating/Mobility Evaluation (12 Page Eval)VOTA 2014\Seating Eval Form
from Illinois Public Aid_019.pdf
 State Medicaid and other Payer Specific Wheelchair or Equipment Forms; as
required but must be approved for Medicare FundingVOTA 2014\handout- sample
CHKD LMN.doc
Role of the ATP/RTS
 The ATP can never complete any portion of the PT/OT
Evaluation prior to, or after the evaluation.
 The only exception is the demographics portion of the form,
which may be completed before the evaluation.
 The ATP must complete a separate Client Assessment for all
Medicare orders requiring ATP involvement per Medicare
policy.
 The Client Assessment must be completed, signed and dated
by the ATP, including credentials to prove involvement in the
mobility evaluation
Medicare Forms
 F2F
 Chart notes
 7 element prescription
Face to Face
•
History of the present condition(s) and past medical history that is
relevant to mobility needs.
•
Symptoms that limit ambulation
•
Diagnoses that are responsible for these symptoms
•
Other diagnoses that may relate to ambulatory problems
•
Medications or other treatments for these symptoms
•
Progression of ambulation difficulty over time
•
How far the patient can walk without stopping
•
Pace of ambulation
•
History of falls, including frequency, circumstances leading to falls, and
why lesser equipment would not be sufficient
•
What ambulatory assistance (cane, walker, MWC, caregiver, etc.) is
currently being used and why isn’t it sufficient?
Face to Face
•
What has changed to now require the use of a power mobility device?
•
Description of the home setting
•
The ability to perform MRADLs in the HOME
•
Physical Examination that is relevant to mobility needs.
•
Weight & Height - Medicare will deny even a standard PWC if the client
exceeds 95% of the weight capacity per Medicare guidelines.
•
Cardiopulmonary examination
•
Musculoskeletal examination including upper and lower extremity
strength and range of motion measurements
•
Neurological examination including gait, balance and coordination
Chart Notes
• The F2F must occur BEFORE the physician completes the 7 element
written order.
• Medicare requires the doctor’s findings to be documented in a detailed
narrative note in the same format as all other entries in the client’s file.
• The note needs to clearly indicate that the major reason for the visit
was a mobility examination.
• The history should paint a picture of the patient’s functional abilities
and limitations on a typical day. It should contain as much objective
data as possible.
7 Element Prescription
Must contain each of the following elements and must be COMPLETED BY THE PHYSICIAN
after conducting the F2F examination (can be on the same day, but never before):

Beneficiary’s Name

Description of the Item
 (may be general – e.g. “power wheelchair”), or may be more specific

Date of the completion of the F2F examination

Pertinent diagnosis or conditions that relate to the power mobility device

Length of need

The treating physician’s signature

The date the treating physician signed the order
7 ELEMENT PRESCRIPTION
— The Numotion 7 Element Written
Order has been revised for easier use.
— Contains a more accurate statement
under element #2 to assist the
physician with understanding the face
to face completion date.
— The 7 Element Written Order is to be
completed entirely by the physician.
***graphic abbreviated for content only
— No fields can be completed by the
supplier or medical office staff.
40
Appeals
 Important to be sure that you review the insurance’s
coverage criteria for the equipment prior to filing an
appeal
 First appeal is usually written. Can be filed by the
patient, family or representative of the family. Must
have an authorized representative statement signed by
the patient/family to file the appeal
 If appeal is denied, the next step is usually a telephone
hearing
 Some insurances allow peer to peer reviews
Insurance Trends
 Denial of standers as “experimental and investigational”
 Denial of adaptive strollers for distances as
“convenience to the caregiver” or “restraint of the
individual”
 Denial of adaptive beds for safety purposes
 Denial of back up wheelchairs or strollers
 Denial of bath equipment for very small children and
teenagers/young adults “convenience items”
Alternate Funding Sources
 Virginia Birth Injury Fund
 Charities- both local and national
 EPSDT
 VOTA 2014\Handout- RESOURCES FOR FUNDING
ADAPTIVE EQUIPMENT (VA).doc
Questions???