Clinician's corner: Explore payment options for elevation
In my travels and discussions with clinicians and providers I am hearing a disturbing myth that “nobody” pays for a power seat elevation system. This could not be further from the truth.
E2300—“Wheelchair accessory, power seat elevation system, any type”—was added to the HCPCS code set on Jan. 1, 2004, and is listed as valid for DMERC submission. Unfortunately, Medicare policy states that a power seat elevation feature is non-covered because it is not primarily medical in nature.
But just because traditional Medicare does not view this as a reasonable and necessary option, the truth is any payer with a prior approval or predetermination process will consider it for coverage and reimbursement. But it must be submitted for them to do so.
When power seat elevators first came on the market, they were not the most user-friendly feature. The fact that the user had to stop, creep up the elevated position and then proceed with driving at 1.2 mph, which is far below average walking speed, did not provide much incentive to show a consumer this feature, let alone seek funding for it. However, with the launch of highly functional power adjustable seat height systems that double the usefulness of the power wheelchair being prescribed, it is time we show this option to consumers, document the medical benefits derived from adjusting the height of the seat along the continuum and submit it for reimbursement.
If you are recommending a power wheelchair, ask yourself these five questions:
• Does the consumer have difficulty or need assistance to transfer to/from the power wheelchair to a surface (bed, toilet, shower chair, car/van seat, etc.) that is higher than the power wheelchair seat?
• Does the consumer have difficulty or require assistance to reach high enough to safely access areas of the home, school, work or community to perform/participate in tasks?
• Does the consumer experience pain or difficulty sitting in his chair or communicating his care needs when looking up from a low, fixed seat height?
• Does the consumer have difficulty seeing where he is going, moving through crowds or crossing the street from a low, fixed seat height?
• Would the addition of a feature that elevates up to 10 inches in 16 seconds, while operating the power wheelchair at up to 3.5 mph be of benefit to the consumer in carrying out his daily routine?
If the answer to any of these questions is yes, it behooves the clinician and provider to evaluate and document what the consumer cannot do at a low, fixed-seat height, as compared to what he can do at an adjusted height for the activity he is performing or participating in. For example, the beds in my house range from 23 inches to 29 inches high. If a user with a power wheelchair at a fixed height of 21 inches requires assistance to transfer to his bed (measure the height), but can do it independently or safer and with less assistance elevated to a height equal to or slightly higher than his bed, the need for seat elevation related to transfers has been
The medical need for food and water is well established. In my kitchen:
• The stove is 36 inches high with the controls on top
• The light and vent controls are 55 inches high and set back 10 inches from the edge of the counter
• The microwave controls are 60 inches high and set back the same distance
• The faucet handle is 41 inches high but is 21 inches from the edge of the counter
• The top shelf of the refrigerator/freezer is 55 inches high
From a power wheelchair at a fixed height of 21 inches, a user would have to perform an over shoulder reach numerous times a day (easily counted and documented) for his nutritional health. If he requires assistance to get something to eat or drink at a fixed-seat height, but can do it independently or with less assistance from an adjusted seat height (measured and documented), the need-related performance or participation in a critical MRADL has been established.
While a power adjustable seat height feature is not necessary for all power wheelchair users, it may limit the need for attendant care, allow consumers to live in the least restrictive environment possible and save payers money in the long run. In fact, in the first 120 days since iLevel has launched, we have validated that 65% of the systems were paid for by state Medicaid programs, commercial payers, vocational rehab services, workers’ compensation, Medicaid and Medicare Advantage plans, and the Veterans Affairs. We also know that if you do not submit it for review and consideration because you think nobody pays for it, you are correct, “nobody” will pay for it if you do not provide them with an opportunity to do so.
Julie Piriano, PT, ATP/SMS is director of rehab industry affairs for Quantum Rehab. She serves on the RESNA board of directors and the DME MAC Advisory Councils, and is involved with AAHomecare, NCART, IAMES and MAMES. She can be reached at 1-800-800-8586 or firstname.lastname@example.org.