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April, 2002
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Smart Fit

Educate staff, physicians, patients, and payors about proper wheelchair selection to reduce somE injuries.

Helen M. Farrell

The use of manual wheelchairs in the home has increased almost 70% in the last 20 years—from about 720,000 in 1980 to an estimated 2.2 million in the year 2000.1 Because many home wheelchair users are seniors, analysts anticipate that these numbers will continue to climb as people live longer.

From a business standpoint, this anticipated growth is good news for HME providers. However, as the number of end users increases and medical advances extend life expectancies, an unexpected development has been identified—some end users are actually being hurt by the very wheelchairs prescribed to allow them more active and independent lives.

More than half of today’s wheelchair users suffer chronic injuries from long-term wheelchair use, according to Michael Boninger, MD, medical director of the Pittsburgh Human Engineering and Research Laboratories. Researchers at the University of Pittsburgh estimate that more than 400,000 people in manual wheelchairs experience serious secondary injuries to their shoulders, wrists, backs, and other body areas.1

For the most part, the researchers note, the injuries are caused by a health care system that fails to keep pace with gains made by the disabled rights movement. But there are other factors that enter into the equation. Many physicians are not trained to prescribe the right chair for a particular illness, body type, and lifestyle. Medicare and private insurance companies routinely match patients to a product that, although less expensive on the front end, can ultimately cause serious health care problems resulting in extensive health care costs. Patients are rarely given adequate instruction on wheelchair fundamentals such as axle, seat cushion, and backrest adjustments, as well as wheel stroke techniques and obstacle navigation. Expectations for the physically challenged patient to thrive in mainstream life remain low.

This information, well documented by Bruce Taylor Seeman in the Newhouse News Service in July 2000,1 is alarming, but likely it comes as no surprise to established HME suppliers. They see the physical proof of these statistics being propelled through the doors of their facilities.

The examples are easy to come by. Consider the 30-year-old spina bifida patient, initially placed in a standard manual wheelchair with footrests, who has undergone a partial foot amputation as well as four skin flap surgeries, all as a result of an inappropriate wheelchair being dispensed. Think of the young, tall, thin cerebral palsy patient, seated in a standard-width wheelchair, who has developed fixed contractures to her arms and hands as a result of balancing herself in a poorly fit wheelchair. Or recall the 26-year-old patient—brain-injured as a result of a car accident at 17 and originally fit in a narrow manual wheelchair—who grew too tall and to heavy for his chair. Nine years later, the constant pressure exerted on his hips from a wheelchair that is too narrow has resulted in a fixed, outward rotation of both legs and repeated pressure sores.

As a result of the damages HME providers see almost daily—postural deformities, fixed contractures, pressure ulcers, respiratory dysfunction, etc—the patient loses the very independence and mobility the wheelchair was prescribed to achieve.

Step 1 Is Education
A comprehensive education program can help the caring HME supplier meet the challenges presented by the manual wheelchair patient. Primary education should begin in-house. Ensure that the staff assigned to fit manual wheelchair patients has been well trained and that the training process is ongoing. Make every effort to ensure the staff attends both new and continuing educational programs to help them stay up to date on medical issues and new products. These programs are frequently offered by manufacturers, state and national associations, and before and during trade shows. In addition, asking employees to obtain certification in wheelchair fitting speaks highly of an HME company’s commitment to meeting the needs of wheelchair patients.

Once you have considered the education of your staff, consider your referral sources. Physician education is an important part of the process. Recognize that, for the most part, physicians receive little or no training in the fitting and application of HME. Include the physician in the fitting process. When required by a complex seating patient case, enlist the aid of a physical therapist. Explain to the physician why you and the therapist are recommending the specific wheelchair, options, and/or accessories, as well as the ultimate goals you hope to achieve for the patient.

Often, physicians attribute physical problems created by a poorly fit wheelchair to the ageing or disease process. Educating physicians on how some of these problems are caused by inappropriate wheelchairs helps the physicians more readily recognize those patients at risk and intervene before damage occurs.

Finally, educating physicians on the reimbursement process and their role in reducing or eliminating out-of-pocket expenses for the patients can help both your company and your patients.

Once you have considered your staff and your referral sources, consider the education of the end user of the product. The patient and/or caregiver should receive extensive instruction on wheelchair use based on the patient’s individual needs. Incorporate self-propel methods, transfer techniques, obstacle navigation, etc, into the standard patient education process.

Under Medicare guidelines, a patient may qualify for a manual wheelchair base if, without the use of a wheelchair, he or she would be confined to a bed or chair. The Durable Medical Equipment Regional Carriers (DMERCs) carefully define a manual wheelchair base and the definitions range from a standard wheelchair (K0001) to an extra-heavy-duty wheelchair (K0007).

The DMERCs designate the K0009 code for any manual wheelchair base that may be required to meet the specialized needs of a patient that cannot be met with another manual wheelchair base. Using the K0009 code requires a statement documenting the medical necessity of the base dispensed as well as the reason why another base (K0001 to K0007) was unacceptable for this patient. In addition, you must include the brand name and model name/number on the claim.

Effective October 1, 2001, a request for Advance Determination of Medicare Coverage (ADMC) may be submitted for the K0005 (ultra-light-weight manual wheelchair base), and the K0009 (other manual wheelchair base) as well as related options and accessories. The use of the ADMC process allows the HME provider and patient to know, in advance, if it appears that medical necessity guidelines have been met. If the ADMC process determines that the manual wheelchair base is eligible for coverage, the corresponding options and accessories ordered by the physician will also be eligible for prior review under ADMC.

When billing the individualized options and/or accessories, select the correct code for the wheelchair base and then apply the appropriate codes for the options and accessories. To be reimbursed, the need for these options and accessories must be justified by a medical condition. For example, if the physician has ordered elevating legrests, question No. 3 on the manual wheelchair Certificate of Medical Necessity (CMN—DMERC 02.03B) must be answered “yes.” The CMN also should contain a corresponding diagnosis (ICD-9 code) that validates the medical condition that creates the need for elevated legrests. Remember, for every option or accessory added to the manual wheelchair base, there should be a corresponding diagnosis to justify the medical necessity.

When submitting a claim for a manual wheelchair base with options and accessories to a private payor source, follow the same documentation guidelines to expedite the payment process. Establish medical necessity for the base and for each option and accessory.

One advantage of the education process besides improving the lives of patients is that it may aid in the funding process. HME providers who deal with educated physicians and patients can call on them for support and additional documentation that may be required for reimbursement. Certainly, it will be easier to obtain the required medical information if the physician has a thorough understanding of the reason the item has been recommended for the patient and how it will meet the goals established for the patient.

Implementation of a comprehensive educational program, beginning with the supplier staff, will allow you to meet the challenges presented by manual wheelchair patients with specialized needs and to help the patients achieve independence and mobility—the ultimate goal.

Helen M. Farrell is a senior consultant with Jane’s Billing & Consultation Services Inc of Marietta, Ga. Contact JB&C at (678) 445-1221 or visit its Web site at www.jbcservices.com.

1. Seeman BT. Newhouse News Service. Health and Science Beat. Long-term Wheelchair Use Leads to Stress Injuries in People with Disabilities. Available at: www.newhouse.com/ archive/story1a072000.html. Accessed on February 22, 2002.


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