Msatc Wheeled Mobility 080509

AT FOR POINT A TO B WHEELED MOBILITY AS A TOOL TOWARD INDEPENDENCE Midnight Sun Assistive Technology Conference August 5, 2009 Presented by Lisa E. Maurer MS, PT, ATP

with Jerry Godden, CRTS, ATP Wayne Gould, CRTS, ATP

________________________________________________________________

SESSION OUTLINE __________________________________________________________________

INTRODUCTION OBJECTIVES HISTORY / DEFINITIONS SERVICE DELIVERY INFORMATION GATHERING THE EVALUATION EQUIPMENT OPTIONS EQUIPMENT TRIALS EQUIPMENT SPECIFICATION CASE STUDIES FUNDING AND DOCUMENTATION DELIVERY AND FOLLOW-UP REFERENCES RESOURCES APPENDICES

__________________________________________________________________

INTRODUCTIONS __________________________________________________________________

THE SPEAKERS Lisa Maurer MS, PT, ATP is the Program Coordinator at The Wheelchair and Seating Clinic at Providence. A physical therapist for 19 years, and a Certified Assistive Technology Practitioner since 1997, she has extensive experience in multi-disciplinary Assistive Technology services, specializing in seating and mobility.

Jerry Godden, ATP is a Rehabilitation Technology Supplier with Geneva Woods Home Medical Supply in Anchorage. An advocate for people with disabilityʼs since 1990, and a Certified Assistive Technology Practitioner since 2004, he 13 years of experience in custom rehab equipment.

Wayne Gould, CRTS, ATP is a Rehabilitation Technology Supplier and Rehab Manager at Frontier Medical in Anchorage. He been working with people with disabilities for 20 years, and has 10 years of experience in custom rehab equipment.

_________________________________________________________________

OBJECTIVES __________________________________________________________________

 Participants will understand the role of mobility products as assistive technology.  Participants will demonstrate knowledge of the referral process for obtaining recommendations for wheeled mobility products.  Participants will have an understanding of the evaluation process, funding coverage criteria, and documentation requirements for mobility products.  Participants will have an understanding of the various types of wheelchairs currently available.

_________________________________________________________________

HISTORY __________________________________________________________________

WHEELCHAIRS AS ASSISTIVE TECHNOLOGY? Excerpts from CMSʼs “Decision Memorandum for Mobility Assistive Equipment (CAG-00274N),” May 5, 2005: “The use of assistive technology to aid ambulation goes back into prehistoric times when the simplest crutches and canes to compensate for functional disabilities were fashioned from sticks. Since then, the evolution of mobility assistance equipment has become increasingly more technological - from King Phillip II of Spainʼs rolling chair with foot rests in 1595 to the paraplegic watchmaker Stephen Farflerʼs self propelled chair which he built for himself in 1655 at the age of 22 to the specialized power wheelchairs of today.” “For many beneficiaries, a device of some sort is compensation for (a) mobility deficit.”

_________________________________________________________________

DEFINITIONS __________________________________________________________________

Wikipedia: “Assistive technology (AT) is a generic term that includes assistive, adaptive, and rehabilitative devices for people with disabilities and includes the process used in selecting, locating, and using them… AT promotes greater independence by enabling people to perform tasks that they were formerly unable to accomplish, or had great difficulty accomplishing, by providing enhancements to or changed methods of interacting with the technology needed to accomplish such tasks.”

Durable Medical Equipment (DME): an assistive technology “product” •

Seating products that assist people to sit comfortably and safely (seating systems, cushions, therapeutic seats)

•

Standing products to support people with disabilities in the standing position while maintaining/improving their health (standing frame, standing wheelchair, active stander).

•

Walking products to aid people with disabilities who are able to walk or stand with assistance (canes, crutches, walkers, gait trainers).

•

Advanced technology walking products to aid people with disabilities, such as paraplegia or cerebral palsy, who would not at all able to walk or stand exoskeletons).

•

Wheeled mobility products that enable people with reduced mobility to move freely indoors and outdoors (wheelchairs/scooters)

•

Robot-aided rehabilitation is a sensory-motor rehabilitation technique based on the use of robots and mechatronic devices

CENTERS FOR MEDICARE AND MEDICAID SERVICES CHANGING DEFINITIONS… Excerpts from CMSʼs “Decision Memorandum for Mobility Assistive Equipment (CAG-00274N),” May 5, 2005: “Recent allegations of wheelchair fraud and abuse have focused considerable public interest on the provision of wheelchairs under the Medicare benefit. The agency has responded with a multifaceted plan to ensure the appropriate prescription of wheelchairs to beneficiaries who need them.” Mobility Assistive Equipment (MAE): described by CMS as: (equipment which is) “reasonable and necessary for beneficiaries who have a personal mobility deficit sufficient to impair their participation in mobility-related activities of daily living such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home.” Includes devices such as: • canes • crutches • mobile geriatric chairs • motorized wheelchairs • quad-canes • rolling chairs • safety rollers • walkers • manual wheelchairs • power operated wheelchairs • specially sized wheelchairs • power operated vehicles

_________________________________________________________________

SERVICE DELIVERY MODEL __________________________________________________________________

THE GOOD OLD DAYS THE HERE AND NOW “The demand in health care today is to do everything we used to do with the same amount of money or less, and with the same staff or less.” - Mark Schmeler, OTR/L, ATP 1999.

_________________________________________________________________

INFORMATION GATHERING __________________________________________________________________

REFERRAL AND INTAKE Wheelchair
and
Seating
Clinic
Referral
Form
(see
Appendix)

 Key Information: • Client
contact
info
 • Client
Date
of
Birth
 • Diagnoses
 • Funding
sources
 
 • Physician
contact
info
 Reason for Referral: • Why
is
evaluation
being
requested?
 • What
type
of
wheelchair
or
equipment
being
used?
 • In
what
condition
is
the
current
equipment?
 • Current
skin
breakdown?



Physician
Order
 Payor
Authorization
(VA,
TriWest)


PRE-SCREENING Clinical
review
 Enough information to schedule? Request for additional information/reports if needed Therapist
reports
 • •

School Private

Medical
reports
 Rehabilitation
Technology
Supplier
information
 • •

Past equipment Documentation on past attempts at obtaining equipment

Determination
of
services
 Seating/Mobility Evaluation Clients
typically
have
one
or
more
of
the
following
impairments:
 • • • • • • • • • • • •

Impaired mobility function Impaired postural control or alignment Inappropriate wheelchair or seating system Discomfort with prolonged sitting Endurance limitations affecting mobility and/or functional abilities Current skin breakdown History of compromised skin integrity Severe deformities Need for customized seating intervention Chronic or severe pain related to positioning/prolonged sitting Severe spasticity or postural instability which compromises safety and/or mobility function Medical issues necessitate Physical Medicine examination prior to evaluation of positioning and mobility needs.

General Therapy Evaluation/Treatment PT
Evaluation
is
a
component
of
the
Wheelchair
and
Seating
Evaluation.
 General
PT
or
OT
evaluation
may
be
useful
to
determine
need
for
further
services


Determination
of
services
(cont’d)
 Other Assistive Technology Services Augmentative
communication
 Environmental
control
 Computer
access
 Home
or
worksite
modification
 Job
accommodation
 Vision
or
hearing
aids
 Vehicle
modification
 Driving
Evaluation
 Comprehensive Assistive Technology Evaluation Client
has
needs
spanning
all
areas
of
assistive
technology,
or
his/her
needs
are
very
 complex,
requiring
the
involvement
of
specialists
in
several
disciplines.


Determination
of
team
members
 Family and caregivers are a given Role of therapists Physical
Therapist
 • • •

Evaluates physical performance and mobility function, balance, coordination, and posture Brings knowledge of anatomy, palpation of bony landmarks, lower extremity/pelvic/trunk range of motion/flexibility Division of labor: wheelchairs and accessories

Occupational
Therapist
 • • •

Evaluates functional, perceptual, and cognitive performance; sensorimotor impairments; and posture Brings knowledge of anatomy, upper extremity/hand range of motion/flexibility, fine motor function, access, and environmental accessibility Division of labor: cushions and backs

Assistive
Technology
Practitioner
 •

Clinician has RESNA required clinical experience and credentials, and has passed the RESNA national certification examination.

Determination
of
team
members
(cont’d)
 Role of supplier Works
with
the
evaluation
team
to
recommend
technology
options,
procures
the
 equipment
through
funding
source,
delivers
and
fits
equipment,
trains
client/family
in
 use,
maintains
and
repairs
equipment
 
 
Rehabilitation
Technology
Supplier
 •

NRRTS definition “… A SPECIALIST WHO PROVIDES ENABLING TECHNOLOGY IN THE AREAS OF WHEELED MOBILITY, SEATING AND ALTERNATIVE POSITIONING, AMBULATION ASSISTANCE, ENVIRONMENTAL CONTROL, AUGMENTED COMMUNICATION, AND/OR ACTIVITIES OF DAILY LIVING. “ “… EMPLOYED BY A COMPANY THAT SELLS DURABLE MEDICAL EQUIPMENT AND OFFERS CONSUMERS PRODUCT CHOICES, ALONG WITH PRICING AND FUNDING INFORMATION. “ “… MEETS BASIC STANDARDS OF ACCEPTABLE PRACTICE IN THE PROVISION OF EQUIPMENT, INCLUDING: ORDERING, ASSEMBLING, ADJUSTING, DELIVERING, AND PROVIDING ON-GOING SUPPORT AND SERVICE…”

•

Credentialing CRTS: CERTIFIED REHABILITATION TECHNOLOGY SUPPLIER Has met NARTS certification requirements for rehabilitation technology suppliers ATP: ASSISTIVE TECHNOLOGY PRACTITIONER Has RESNA required clinical experience and credentials, and has passed the RESNA national certification examination for assistive technology practitioners.

Determination
of
team
members
(cont’d)
 Durable
Medical
Equipment
Dealer/Supplier/Vendor
 • • •




Essentially performs the same functions as the RTS, but is not certified, and not bound to the standards of the CRTS Scope of practice and level of experience varies greatly Choose wisely based upon reputation, credentials, demonstrated knowledge, and past experience.

Rehabilitation
Technology
Supplier
Selection
Criteria
 •

•

• • • • •

•

• • • •

Client is first priority Responsive to clients Timely Available in emergency situations Willingness to be a “team player”ʼ Responsive to therapists and other team members Timely Available as necessary Relationships with a variety of manufacturers Wide range of technologies and services Availability of equipment for trials prior to procurement High value placed on informing and educating clients Knowledge of service provision Procurement Coverage criteria Required documentation Payor specific processes and procedures Handling of denials and appeals Repair and servicing Warranty servicing and repair Willingness to consider servicing equipment provided by other dealers Qualified and competent staff Trained regarding specific technologies Attendance of manufacturersʼ technical schools Regular continuing education/equipment inservices Attendance of trade shows RTS Certification Membership in NRRTS, NAMES, RESNA Adherence to NRRTS and NAMES Standards of Practice Joint Commission accreditation Receptive to new ideas and techniques

Other team members 
 Physician
(MD)
 • •

Determines diagnoses and prognosis, writes orders for the evaluation, certifies medical necessity of equipment by signing required documentation Physiatrist and Orthopaedic Surgeons are often more involved in the evaluation process, and are often team members in some settings

Speech‐Language
Pathologist
 • •

•

Evaluates cognitive and language abilities, and oral motor function (speech, swallowing, drooling) Typically involved if seating/positioning affects swallowing, communication, or augmentative communication use, or if cognitive factors have a significant affect on mobility function Division of labor: mounting of AAC device, access of AAC device, integration of AAC device with wheelchair where appropriate.

School
Therapists,
Teachers
 • •

May provide valuable information relating to positioning and mobility function within the educational setting; may identify accessibility and transportation concerns/requirements. Equipment may affect current treatment, treatment plan, and goals.

Private
Therapists
 •

Client may be receiving general therapy services elsewhere, but therapists may not be able to complete seating/mobility evaluation. Incorporate their input, and prevent duplication of services or conflict of therapeutic goals. Many payors will not cover both services, but in some case will recognize the role of PT and OT in seating/mobility as a separate specialized service.

Other team members (contʼd) 
 Rehabilitation
Engineer
 •

Modifies equipment to meet the clientʼs specific needs, designs and fabricates customized equipment when commercially available products are inappropriate.

Nurse
 • •

Caregiver Specialist in wound management (enterostomal nurse)

Orthotist/Prosthetist
 •

Typically involved when seating intervention consists of an actual orthosis or prothesis (i.e. polypropylene TLSO, bilateral hip disarticulation or hemipelvectomy prosthesis)

Case
Manager
 Payor
 Employer
 Other
Support
Systems


VERIFICATION OF BENEFITS 
 PT/OT
coverage
 If
currently
receiving
general
therapy
services
by
another
provider,
ensure
coverage
for
 PT/OT
for
seating/mobility
as
a
specialized
service
(vs.
duplication
of
services)


Coverage
for
extended
evaluation/extended
evaluation
rates
 May
request
information
on
content
of
evaluation,
length
of
time
required



Requirement
for
use
of
specific
RTS/Dealer
 Some
payors
have
participating
RTS/Dealers
that
they
will
use
exclusively
 Some
state
agencies
may
require
several
bids
before
processing
through
one
RTS/Dealer;
 some
RTS/Dealers
may
not
wish
to
be
involved
if
they
will
not
“get
the
sale.”


VERIFICATION OF BENEFITS (CONTʼD) 
 Coverage
of
durable
medical
equipment
 RTS/Dealer will handle funding issues, but therapists must have general knowledge to plan for the evaluation, select equipment, and complete documentation. Funding source should not determine the equipment evaluated or drive the selection process, but must be taken into consideration. Payor for equipment may be different from payor for services Covered items Allowables,
caps
 Percentages
 Amount
of
client
responsibility
may
limit
options


Some clients may not wish to be evaluated if they are responsible for a large portion of the cost. Medical necessity vs. educational, vocational or other restriction on environment Appropriate
for
use
in
home
environment
 Use
outside
of
payor‐covered
environment
(i.e.
school,
workplace)


SCHEDULING Location
 Notification
of
team
members
 Client/family Therapists RTS/Dealer

Transportation
to
appointment
 Coordination
of
equipment
 Specific cushions, backs, wheelchairs needed

REQUEST FOR CURRENT PHYSICIAN ORDERS “Physical
Therapy
Evaluation
for
Seating/Mobility”


_________________________________________________________________

THE EVALUATION __________________________________________________________________

REVIEW OF INFORMATION Pertinent
demographic
information
 Diagnoses Primary
 •

Primary diagnosis relating to present concerns (e.g. cerebral palsy with spastic quadriplegia and scoliosis)

Secondary
 •

Additional pertinent diagnoses

• • • •

Hemiplegia, etc. Abnormal posture Abnormal involuntary movement Gait abnormality

• • •

Uncontrolled seizures Orthostatic hypotension Open skin areas

Functional
or
treatment
diagnoses



Specific
dates
of
onset

 Prognosis
 Progress
 Contraindications/precautions
affecting
equipment
use


Pertinent
demographic
information
(cont’d)
 Pertinent medical/surgical history Past
hospitalizations
 History
of
skin
breakdown
 Relevant
surgeries
 • • •

Orthopaedic Skin flaps Bone shavings

Pertinent medications Current or past services Date
last
seen
by
MD
 Current
therapy
and
emphasis
 Referral source Reason for referral Height, weight

Subjective
information
 Client, caregiver, referral source goals General
Expectations
 • • • •

What type of equipment does the client want? What does the client want to be able to do? What are the clientʼs priorities? What are the clientʼs expectations of this evaluation?

Functional
goals
 Vocational
goals
 Recreational/lifestyle/personal
goals
 Current problems Level
of
satisfaction
with
equipment
 Likes/dislikes
 Broken
parts
 Functional
implications/deficiencies
related
to
current
equipment
 Service
history
 Pain/discomfort Functional
implications
 Relation
to
equipment
 Past equipment experiences Successes/failures
 Tolerance/willingness
to
change
 Past
experience
with
RTS/Dealer
 Recent changes in function Related
or
unrelated
to
equipment


Subjective
information
(cont’d)
 Environmental issues Home
environment
 •

•

General accessibility Levels of home Type of entrance/exit Layout Dimensions of smallest doorways, halls Does current wheelchair fit through all doorways? Location (i.e. rural, suburban)

Work,
school,
other
environments
 • •

General accessibility Requirements

Caregiver

 • • •

Role Availability Abilities

Transportation
 • • • •

Type of vehicle Method of loading of wheelchair Driver vs. passenger Type of tie-down system

Subjective
information
(cont’d)
 Psychosocial issues Lifestyle
 • • •

Passive Active, involved Risk taker

Activity
level
 • • • • • •

Daily routine Amount of time up in wheelchair during day Work School Day program Recreation/leisure

Motivation
 Support
system
 Cultural
influences
 Family
dynamics/involvement


PHYSICAL EXAMINATION Strength/Motor
Control
 Gross motor control – manual muscle testing Fine motor control Quality of movement Coordination Reaction time, ability to initiate or stop movement Tone/spasticity Reflex activity Movement patterns Volitional
 Involuntary
 Functional use of extremities Effect
on
mobility,
posture


Range
of
Motion/Flexibility


Tolerance of corrective forces/pressure Effect on mobility, posture

Endurance
 Cardiopulmonary Shortness
of
breath
 • •

At rest With activity (i.e. after propelling wheelchair 20 ft.)

• •

At rest With activity

•

May change with provision of postural support

Labored
breathing
 Vital
capacity


Endurance
(cont’d)
 Muscular Ability
to
generate
and
sustain
force
 Ability
to
perform
repetitive
contractions
 Tolerance
of
sustained
activity
 •

Wheelchair propulsion

General
activity
tolerance



 Sensation
 
 Pressure
relief
 Technique Standing
 Constant
shifting/changing
of
position
 Wheelchair
push‐ups
 Manual
tilt/recline
 Power
tilt/recline
 Frequency Effectiveness

Current
skin
breakdown
 Location Typically
over
bony
prominences
 Occasionally
over
soft
tissue
 Severity Measurements Drainage Current management Type
of
dressing
 Frequency
changed
 Potential causes Extrinsic
factors
 • • • •

External pressure Shearing forces Heat Moisture

Intrinsic
factors
 • • • • •

Immobility Lack of sensation Poor nutrition Decreased tissue elasticity/resiliency with age Skin changes due to previous breakdown

Pain

 Location Severity Length of time present Possible causes Functional implications

Balance/Postural
Control
 Head control Ability
to
achieve
and
maintain
midline
position
 Influence
of
tone,
reflexes
 Trunk control Sitting
with/without
external
support
 Ability
to
assume
and
maintain
erect
posture
 Influences
of
tone,
reflexes
 Standing with/without external support Static sitting and standing balance Dynamic sitting and standing balance Functional implications

Activities
of
Daily
Living

 Transfers Feeding Bathing Communication Dressing Hygiene Bowel/bladder Household/community activities Aides/caregivers Employment/educational activities Assistance
provided
 Time
available
 Implications of positioning, mobility

Vision
 Acuity Neglect Blurred vision Forward gaze Depth perception Field losses Scanning Perceptual deficits

Cognition
 Ability to follow directions (simple vs. complex) Attention span Judgment Distractibility Understanding of cause/effect Neglect Effect on use of equipment

Communication
 Ability to communicate functionally Effect of positioning on communication/interaction Management of secretions Use of augmentative communication device Transport/mounting
considerations
 Integration
considerations


EVALUATION OF CURRENT EQUIPMENT Seating
System
(cushion,
back,
other
supports)
 Manufacturer, model Age Dimensions Condition Repair history Estimated cost of repairs Estimated remaining life expectancy Comfort Effect on positioning/pressure distribution Pressure mapping Acceptability to use Appropriateness

Wheelchair
 Manufacturer, model Age Dimensions Components Seat
and
back
upholstery
 Armrests
 Legrests
 Footplates
 Wheels/casters
 Tires
 Condition Estimated cost of repairs Estimated remaining life expectancy Comfort • •

Effect on positioning/pressure distribution Effect on mobility function

Acceptability to user Appropriateness Fit
 Function
 Accessibility


SEATING/POSITIONING ASSESSMENT Basic
Principles
 Review of normal postural alignment Pelvis
neutral
(or
slightly
anterior)
and
symmetrical
 Trunk
erect
with
slight
lumbar
and
cervical
lordosis,
slight
thoracic
kyphosis
 Thighs
and
legs
separated
 Knees
and
ankles
flexed
to
90
degrees,
with
feet
resting
on
floor
or
support
surface
 Head
upright
and
in
midline
 Shoulders
and
arms
relaxed
and
supported


Characteristics
of
normal
posture
 Provides
stable
base
of
support;
stability
precedes
mobility

 Active
and
dynamic
 • • • •

“Dynamic posture is crucial for function in or out of a chair.” “Mobility is superimposed on an active, responsive base.” “Quality of posture determines motor skill capability.” “Motor function is the interplay between posture and movement.” – Ball 1996

Allows
horizontal
gaze
and
optimal
visual
field
 Allows
optimal
arm
and
hand
function
 Pelvic
position
largely
determines
posture


Examination
of
resting
posture
in
Wheelchair/Seating
System
 Note position of Pelvis
 Trunk/spine
 Head/neck
 Hips/legs
 Knees
 Ankles/Feet
 Shoulders
 Arms
 Observe and palpate symmetry of bony landmarks Shoulders
 Ability to self-correct or move into neutral alignment Postural changes with volitional/non-volitional movement


 Examination
in
supine
 Pelvic mobility Lower extremity flexibility Range of motion Spinal flexibility

Examination
in
sitting
at
edge
of
mat
 Sitting balance/trunk control How
much
effort
is
required
to
maintain
this
neutral
posture
with
the
influence
of
 gravity?
 Posture Note
posture
under
the
influence
of
gravity
as
compared
to
that
observed
when
sitting
 in
current
seating
system
 • • • • • • • •

Pelvis Trunk/spine Head/neck Hips/legs Knees Ankles/Feet Shoulders Arms

• •

Location of needed corrective support was indicated during supine assessment. May require additional support, or support in other areas when influenced by gravity. May require change in orientation (i.e. tilt-in-space)

Note
postural
changes
with
volitional/non‐volitional
movement

 Observe
and
palpate
symmetry
of
bony
landmarks

 Re‐evaluate
flexibility
of
deviations
observed
in
supine
 Provide
support
to
correct
flexible
deviations,
accommodate
fixed
deformities,
and
 allow
individual
to
maintain
neutral
posture.


•

Begin
thinking
of
what
type
of
supports
may
be
necessary
to
replicate
the
supportive
 force.


MOBILITY ASSESSMENT Primary
means
of
mobility
 Ambulation Manual wheelchair Power wheelchair Scooter Other Dependently
carried
 Crawling,
creeping


Ambulation
 Level of independence Type of assistive device used Distance Efficiency/energy expenditure Safety Need
to
hold
on
to
walls,
furniture
 Frequency
and
severity
of
falls
 Functional for home or other environments Impact on “Mobility Related Activities of Daily Living”

Manual
wheelchair

 Level of independence Propulsion technique Arms
 Legs
 One
arm
 Arm/leg
combination
 Distance Efficiency/energy expenditure Postural changes during propulsion Obstacle management Performance/safety on varied terrain Flat,
level
surfaces
 Carpet
 Ramps/inclines
 Grass
 Gravel
 Maneuvering/managing wheelchair during transfers

Manual
wheelchair
(cont’d)
 Advanced skills Loading
wheelchair
into
vehicle
 Curbs
 Ramps
 Stairs
 Falling
 Righting
the
wheelchair
 Cushion
adjustment
 Narrowing
the
wheelchair
 Wheelies
 Glides
in
a
wheelie
 Turning
on
a
dime
 Impact on “Mobility Related Activities of Daily Living”

Power
wheelchair

 Level of independence Access point Hand
 Head
 Chin/mouth
 Other
body
part
 Input device Hand
control/joystick
 Head
control
 Chin
control
 Pneumatic/sip&puff
 Switches
 Distance Efficiency Postural changes during operation Obstacle management Performance/safety on varied terrain Flat,
level
surfaces
 Carpet
 Ramps/inclines
 Grass
 Gravel
 Maneuvering/managing wheelchair during transfers

Scooter/Power
Operated
Vehicle
 Level of independence Type of control Distance Efficiency Postural changes during operation Obstacle management Performance/safety on varied terrain Flat,
level
surfaces
 Carpet
 Ramps/inclines
 Grass
 Gravel
 Maneuvering/managing scooter/seat during transfers

_________________________________________________________________

EQUIPMENT OPTIONS __________________________________________________________________

SEATING INTERVENTION Forms
of
postural
support
 Spinal fixation (i.e. Harrington rods) Intimate support (i.e. body jacket, corset) Adaptive seating

Goals
of
adaptive
seating
 • •

• • • • • • • • • • • •

Support neutral posture or posture required for function. - J. Zollars “Provide sufficient external support to restore normal sitting posture without restricting function, and to maximize pressure distribution to prevent tissue trauma.” - J. Minkel Obtain optimal postural alignment. – M. Ball Provide postural support for symmetrical biomechanical alignment Correct or accommodate postural deformities Inhibit abnormal tone and reflexes to prevent abnormal postural alignment and deformities Improve safety Improve respiratory function Provide pressure relief or reduction to prevent compromise of skin integrity Equalize pressure distribution Increase sitting tolerance to level sufficient for requirements of daily activities Improve interaction with other individuals and the environment Improve function in ADL, self-care, mobility, and communication Improve comfort

Classification
of
Support
Surfaces
 Primary Cushion/seat
 Back
 Secondary Headrest
 Footrest
 Armrest
 Pelvic/thigh
supports
 Trunk
supports
 Shoulder
supports


TYPES OF PRIMARY SUPPORT SURFACES (CUSHIONS/BACKS) Fluid/Flotation
 Air Contains
one
or
multiple
air
bladders
or
cells
 Advantages
 • • • •

Excellent pressure relief Lightweight Easy to clean Air may flow between cells

• • •

High maintenance Poor durability May make transfers difficult

Disadvantages


Water Sealed
cushion
with
water‐based
fluid
inside
 Not
a
frequently
used
type
of
cushion
 Advantages
 • • •

Good pressure relief Reduces shearing Dissipates heat well

• •

Heavy Assumes ambient temperature CAN FREEZE CAN GET VERY HOT May make transfers difficult

Disadvantages


•

Fluid/Flotation
Cushions/Backs
(cont’d)
 Viscous fluid Gels
or
fluids
contained
in
oversized
flexible
membranes
 Typically
used
in
combination
with
some
type
of
foam
base/shell
 Advantages
 • • • • •

Good pressure relief Reduces shearing Easy to clean Dissipates heat well Maintains fairly stable temperature

Disadvantages
 • • •

Heavy Can be uncomfortable if sensation is intact May make transfers difficult

Elastomer gel Firm
gel
contained
in
flexible
membranes
(similar
to
Jello)
 Typically
used
in
combination
with
some
type
of
foam
base/shell
 Advantages
 • • •

Dissipates heat well Maintains fairly stable temperature Reduces shearing

Disadvantages
 • •

Poor durability Difficulty attaching to foam surface

Polyfoams
 Planar Flat
surface,
typically
plywood
covered
with
foam
and
upholstery.

 Advantages
 • • • • • • • • •

Adjustable (i.e. for growth) Modular components Available from many manufacturers Offers minimal support Accommodates a wide variety of postures Lightweight “Inexpensive” Easiest to maintain Least interference with transfers

Disadvantages
 • • • •

No pressure relieving properties Often result in localized pressure over bony prominences, with greater risk of shearing forces developing under weighted areas Least surface contact Provide least support for maintaining neutral posture

Typical
applications
 • • • • •

Good pelvic and trunk control Frequent changes in position Pediatric clients Progressive disabilities Short periods of sitting

Polyfoams
(cont’d)
 Contoured Commercially
fabricated
contoured
surface
of
pre‐determined
size
and
shape
based
 upon
anthropomorphic
data.

Typically
a
combination
of
molded
plastic
shell
and
 contoured
foam,
occasionally
with
pressure
relieving
gel
or
air
inserts.


 Advantages
 • • • • • •

Pre-contoured for a generic body type Offers moderate support Greater pressure distribution Reduces risk of peak pressures under weighted soft tissues More forgiving than an intimately contoured surface Some adjustability

Disadvantages
 • • • • • •

Offers minimal postural accommodation Not contoured to an individualʼs shape May have to add accessories to achieve adequate support May restrict postural adjustments Components typically require constant monitoring to insure proper placement May require some maintenance

Typical
Applications
 • • • •

Fair trunk control and balance Specific body types and postural deformities compatible with specific products Need for pressure reduction or equalized pressure distribution Need for portability

Polyfoams
(cont’d)
 Molded Contoured
surface
created
to
fit
the
exact
contours
of
a
single
user.
 Advantages
 • • • • •

Offers maximum support Best pressure distribution Best accommodation of deformities Individualized shape Least peak pressures and shear

Disadvantages
 • • • • • •

Requires skilled clinician and supplier Reduced air flow between support surface and skin Total support may prevent development or improvement of postural control Restriction of movement prevents postural adjustments and weight shifting Minimal adjustability Labor intensive and costly

Typical
Applications
 • •

Poor trunk control and balance Severe fixed deformities

Oscillating
 Contain air cells that alternately inflate and deflate, or alternately change mechanical pressure. Advantages Excellent
pressure
reduction,
possibly
promoting
healing
of
open
areas
while
allowing
 for
limited
sitting
time.
 Disadvantages Very
costly


TYPES OF SECONDARY SUPPORT SURFACES (ACCESSORIES) Pelvic
and
thigh
control
components
 Medial thigh supports Lateral thigh supports Lateral pelvic supports Anterior pelvic supports ASIS
pads/bar
pelvic
positioner
 Pelvic
belt
 Safety
belt


Trunk
control
components
 Lateral thoracic supports Posterior lumbar supports Sacral supports Anterior trunk support

Shoulder
control
components
 Posterior shoulder supports Anterior shoulder supports Superior shoulder supports

Head/neck
control
components
 Posterior neck support Posterior head support Lateral head support Anterior head support Circumferential head/neck support (i.e. cervical collar)

Upper
extremity
control
components
 Arm support Arm trough Tray Provides
support
to
the
arms
and
upper
extremities;
can
be
used
to
assist
upper
trunk
 or
arm
positioning.


Lower
extremity
control
components
 Posterior calf support Calf
strap
 Calf
pad
 Foot support Foot
platform
–
one
piece
 Footplates
–
individual
 • •

Fixed angle Angle adjustable

Foot
positioner
 • • • •

Heel loops Ankle straps Toe straps Shoe holders

Anterior knee support Anterior leg support

DYNAMIC PRESSURE RELIEVING SEATING SYSTEMS Tilt‐in‐space
 Seat-back angle is maintained as the seating system rotates around a fixed or sliding pivot point. Typically tilt in a posterior direction to re-distribute and relieve pressure. May also be used to provide rest from the upright position, and gravity assisted positioning to improve posture and head control. • • • • •




Manual Power Posterior tilt Anterior tilt Lateral tilt

Recline
 Seat-back angle to increase as the backposts are reclined. Typically used for accommodation of severe hip extension contractures, orthostatic hypotension, and pressure re-distribution for prevention of skin breakdown. May result in tendency to slide forward in the seat. May cause shearing at the sacrum and low back. • • •

Manual Power Low Shear


 Standers
 Manual or power systems which move from the seated to standing positions. Typically used for environmental access and pressure relief.

MOBILITY INTERVENTION Goals
of
Wheeled
Mobility
 • • • • • • • •

Provide a means of independent mobility Maximize performance of activities of daily living Allow access to all terrain and environments encountered during the course of the day Provide support of neutral posture Provide orientation in space required for optimal posture and function Provide a base for the adaptive seating system Provide a means of pressure relief Accommodate changes in size and weight

TYPES OF MOBILITY BASES Dependent
mobility
bases
 Strollers Typically
used
for
dependent
community
mobility
for
children

 Some
models
have
higher
weight
limits
suitable
for
small
adults


 Variety
of
seating
options
 Transport wheelchairs Lightweight
chair
with
small
wheels
used
for
dependent
transportation
over
level
 surfaces


 Very
few
options


Manual
wheelchairs
 Standard Medicare
classification
(K0001)
 Traditional
wheelchair
with
no
adjustability
and
very
few
options


 Very
heavy,
requiring
good
strength
and
sitting
balance
to
operate
effectively

 Very
durable
 Few
options
 Standard hemi Medicare
classification
(K0002)
 Traditional
wheelchair
with
a
lower
seat
height
 Allows
for
propulsion
with
feet
 Few
options
 Lightweight Medicare
classification
(K0003)
 Similar
in
appearance
to
traditional
wheelchair,
but
slightly
lighter
weight


 May
have
some
axle
adjustability.


 Beneficial
for
individuals
with
slight
upper
extremity
weakness

 Few
options
 High-strength lightweight Medicare
classification
(K0004)
 Lightweight
wheelchair
of
durable
construction
 Limited
axle
adjustability;
may
have
1
or
2
positions,
or
some
horizontal
or
vertical
 adjustability
 Variety
of
components
available
as
options
 Most
models
have
hemi
option
 Some
models
offer
one‐arm
drive
mechanism


Manual
wheelchairs
(cont’d)
 Ultra-lightweight Medicare
classification
(K0005)
 Greatest
degree
of
adjustability
maximize
user
efficiency
and
function
 Axle
adjustability
allows
center
of
gravity
of
the
user
to
be
changed
in
relation
to
the
 wheel
base
 Previously
used
by
high
functioning
users
 Frequently
used
by
individuals
with
severe
weakness,
fatigue,
or
complex
positioning
 requirements
due
to
ability
to
maximize
efficiency
 
 Folding
frames
 • • • • • •

Traditional cross-brace frame Offers greatest ease of folding Greater shock absorbancy Can be narrowed to get through doorways Can be grown by replacing cross tubes and upholstery Less efficient propulsion

• • • • • •

One-piece frame, typically with horizontal cross bars Offers greater durability Lighter weight Offers more efficient ride Less shock absorbancy May be difficult for some individuals to “fold”

Rigid


Heavy-duty Medicare
classification
(K0006)
 Traditional
wheelchair
with
no
or
limited
adjustability
 Durable
construction
for
users
weighing
more
than
250#

 Very
few
options
 Very
heavy
 Extra Heavy-duty Medicare
classification
(K0007)
 Traditional
wheelchair
with
no
or
limited
adjustability
 Durable
construction
for
users
weighing
more
than
300#
Very
few
options
 Very
heavy
 Custom Medicare
definition
(K0008)
 • • •

Uniquely constructed or modified for the specific beneficiary Feature needed not available on an already manufactured base Must be customization of the frame, not components

Other/miscellaneous wheelchair base Medicare
definition
(K0009)
 •

Includes pediatric wheelchair bases and other bases

Dynamic
pressure
relieving
bases
 •

Manual tilt SEAT-BACK ANGLE MAINTAINED AS SEATING SYSTEM ROTATES AROUND A FIXED OR SLIDING PIVOT POINT

•

•

MAINTAINS SITTING POSTURE WHILE ORIENTATION TO GRAVITY IS CHANGED TYPICALLY REQUIRES A LONGER, HEAVY BASE DIFFICULT TO PROPEL Manual recline SEAT-BACK ANGLE INCREASES AS THE BACKPOSTS ARE RECLINED TYPICALLY REQUIRES A LONGER, HEAVIER BASE DIFFICULT TO PROPEL Standing wheelchairs MANUAL WHEELCHAIR WITH AN ADDED STANDING FEATURE ALLOWS INDIVIDUAL TO COME TO A STANDING POSITION FOR ADL’S

Wheelchair Componentry Seat
 •


 Back


• •

•

•




Upholstery NYLON NAUGAHYDE Solid Adjustable angle

Upholstery NYLON NAUGAHYDE ADJUSTABLE TENSION Can accommodate slight postural deviations Can be kept tight to prevent sling over time Back-posts STRAIGHT BACK-POSTS 8-10 DEGREE BEND ADJUSTABLE ANGLE PUSH HANDLES

Legrests
 •

•

•

• •

•

Select based upon functional need ALLOW FOR TRANSFERS ACCOMMODATE KNEE CONTRACTURES REDUCE EDEMA REDUCTION OF SPASTICITY/TONE Swing-away EASIEST TO REMOVE FOR TRANSFERS CAN BE REMOVED TO INCREASE ACCESSIBILITY MECHANISM MAY BE DIFFICULT TO MANEUVER, AND MAY WEAR-OUT WITH TIME Rigid/fixed GREATER DURABILITY MAY MAKE TRANSFERS DIFFICULT CANNOT REMOVE TO IMPROVE ACCESSIBILITY Semi-rigid SWING-AWAY LEGRESTS JOINED TOGETHER AT THE FOOTPLATE IMPROVES DURABILITY Elevating USEFUL IN CASES OF LIMITED ROM, EDEMA INCREASES OVERALL CHAIR LENGTH MAY COMPROMISE PELVIC POSITION BY STRETCHING HAMSTRINGS QUESTIONABLE BENEFIT FOR EDEMA REDUCTION INCREASES LENGTH OF CHAIR, DECREASES ACCESSIBILITY MECHANISM DIFFICULT TO OPERATE Articulating LEGRESTS EXTENDS AS IT ELEVATES, ALLOWING TRUE ELEVATION WITHOUT CAUSING THE KNEE TO FLEX

•




•

Tapered INCREASED ACCESSIBILITY IMPROVED LEG ALIGNMENT DECREASED CALF SPACE Hanger angle

Footplates
 • • • • • •

Composite or Aluminum Flip-up Extended Platform Angle adjustable Tubular High-mount

•

Selection based upon how used by individual STABILIZATION OF TRUNK STABILIZING POINT FOR PUSHING UP TO STAND OR FOR PRESSURE RELIEF ATTACHMENT POINT FOR TRAY Fixed Height Adjustable height Removable vs. Flip-back Tubular/swing-away Desk length vs. full length


 Armrests


Axle


• • • • • • • • • • •




•

Non-adjustable/single position Semi-adjustable Adjustable/multi-position Amputee/extended Quick release ALLOWS REMOVAL OF REAR WHEELS REQUIRES GOOD HAND FUNCTION Quad release ALLOWS PERSON WITH LIMITED HAND FUNCTION TO REMOVE REAR WHEELS MAY ACCIDENTALLY DISENGAGE One-arm drive

Wheels


Tires


• • •

Spoke Mag Composite

• •

Diameter and composition affect rolling resistance Solid/polyurethane GOOD FOR INDOOR USE NO MAINTENANCE DURABLE ROUGH RIDE OUTDOORS HEAVY HIGH OR LOW PROFILE High profile offers some traction Pneumatic LESS ROLLING RESISTANCE GOOD ON ROUGH TERRAIN GOOD TRACTION LIGHTWEIGHT AIR PRESSURE MUST BE MAINTAINED FOR PERFORMANCE Airless/foam inserts MAKES PNEUMATIC TIRES FLAT-FREE ADDS WEIGHT Kevlar REINFORCED, PUNCTURE RESISTANT TIRE Knobby ALL TERRAIN TIRE WITH SIGNIFICANT TREAD INCREASED TRACTION PUNCTURE RESISTANT High-pressure HIGH PERFORMANCE LIGHTWEIGHT REQUIRES PRESTA VALVE (SMALL BICYCLE-TYPE VALVE)

•

• • •

•


 Hand‐rims
 • • • •

Anodized aluminum/chrome Plastic coated Molded Projections

• • • • •

Push-to-lock Pull-to-lock Scissor High-mount Low-mount

Wheel
locks


Casters
 • •

•

•

Small front wheels attached to fork, swivels about stem bolt Large casters (6-8”) LEAST ROLLING RESISTANCE IMPROVED MANEUVERABILITY OVER UNEVEN TERRAIN INCREASED CLEARANCE BETWEEN FOOTPLATE AND GROUND CAN BE USED TO ACHIEVE POSTERIOR TILT-IN-SPACE Small casters (3-5”) MORE RESPONSIVE TO QUICK TURNS AID IN CURB MANEUVERABILITY INCREASED CLEARANCE BETWEEN FOOTPLATE AND CASTER LESS SHIMMY (SIDE-TO-SIDE FLUTTER AT HIGH SPEEDS) GREATER ROLLING RESISTANCE DECREASED ABILITY TO ROLL OVER OBSTACLES Solid NO MAINTENANCE LEAST ROLLING RESISTANCE

Casters
(cont’d)
 •

• • • • •

Pneumatic MOST SHOCK ABSORPTION OFFER SMOOTHER RIDE EASE OF MANEUVERING OVER UNEVEN SURFACES Semi-pneumatic NO MAINTENANCE COMPROMISE BETWEEN ABOVE Caster stem bolt LONG STEM BOLT IMPROVES CLEARANCE BETWEEN FOOTPLATE AND FLOOR INCREASES TILT WITHOUT CHANGING CASTER Caster fork LONGER FORK INCREASES TILT WITHOUT CHANGING CASTER DECREASES CLEARANCE BETWEEN HEEL AND CASTER Quick release casters USEFUL FOR THOSE WHO EXCHANGE FRONT CASTERS FOR DIFFERENT ACTIVITIES Caster pin locks PROVIDE ADDITIONAL STABILITY OF WHEELCHAIR DURING TRANSFERS DIFFICULT TO MANAGE

Accessories
 •

Anti-tippers MAY INTERFERE WITH NEGOTIATION OF ROUGH TERRAIN; DECREASES GROUND CLEARANCE

•

•

•

REAR FRONT Brake extensions BRAKE IS EASIER TO REACH AND ENGAGE USEFUL FOR HEMIPLEGICS DECREASE BRAKE DURABILITY MAY INTERFERE WITH TRANSFERS AND PROPULSION Grade aids PREVENTS WHEELCHAIR FROM ROLLING BACKWARD WHEN ASCENDING INCLINES MUST BE USED ON TIRE WITH TREADS (I.E. PNEUMATIC) DIFFICULT TO PROPEL WHEN ENGAGED MAY ENGAGE INADVERTENTLY MAY PREVENT RECOVERY FROM BACKWARD FALL POOR DURABILITY Clothing guards PREVENT HIPS AND THIGHS FROM RUBBING TIRES CAN BE USED TO CENTER CUSHION OR PERSON IN SEAT RIGID Must remove for lateral transfers Limit use of larger cushion if increased width needed CLOTH Does not need to be removed for transfers Allows for use of wider cushion if necessary Needs to be tightened Allows for slipping of cushion

Accessories
(cont’d)
 •

•

Spoke guards PROTECTS FINGERS FROM INJURY PREVENTS DAMAGE TO SPOKES MAY NEED TO REMOVE IN ORDER TO TIE-DOWN IN VEHICLE MAY RATTLE IF NOT TIGHT Leg straps/heel loops MAINTAIN FOOT POSITION MAY BE USEFUL DURING TRANSFERS BETWEEN CHAIR AND FLOOR MAY MAKE TRANSFERS DIFFICULT

TYPES OF MOBILITY BASES (CONTʼD) 
 Scooters/Power
Operated
Vehicles


 Typically steered with a tiller Speed is controlled by thumb lever Typically used for community mobility by individuals with limited ambulatory function Three-wheeled Narrow
base
of
support
 High
center
of
gravity
 Unstable
 Requires
good
trunk
control
and
good
upper
extremity
function
 Large
turning
radius
 Four-wheeled More
stable
 Requires
good
trunk
control
and
good
upper
extremity
function
 Large turning radius

Power
Wheelchairs
(PWC)
 Group 1 PWC; K0813 – K0816 • • • • • • • • • • • •

Standard integrated or remote proportional joystick Non-expandable controller Incapable of upgrade to expandable controller Incapable of upgrade to alternative control devices May have crossbrace construction Accommodates non-powered options and seating systems (e.g., recline-only backs, manually elevating legrests) (except captains chairs) Length - less than or equal to 40 inches Width - less than or equal to 24 inches Minimum Top End Speed - 3 MPH Minimum Range - 5 miles Minimum Obstacle Climb - 20 mm Dynamic Stability Incline - 6 degrees

Power
Wheelchairs
(cont’d)
 All Group 2 PWC; K0820 – K0843 • • • • • • • • • • •

Standard integrated or remote proportional joystick May have crossbrace construction Accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports) (except captains chairs) Length - less than or equal to 48 inches Width - less than or equal to 34 inches Minimum Top End Speed - 3 MPH Minimum Range - 7 miles Minimum Obstacle Climb - 40 mm Dynamic Stability Incline - 6 degrees

Group 2 No Power Options PWC; K0820 – K0829 • • • • •




Non-expandable controller Incapable upgrade to expandable controller Incapable of upgrade to alternative control devices Incapable of accommodating a power tilt, recline, seat elevation, standing system Accommodates non-powered options and seating systems (e.g., recline-only backs, manually elevating legrests) (except captains chairs)

Power
Wheelchairs
(cont’d)
 
 All Group 3 PWC; K0848 – K0864 • • • • • •

Standard integrated or remote proportional joystick Non-expandable controller Capable of upgrade to expandable controller Capable of upgrade to alternative control devices May not have crossbrace construction Accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports) (except captains chairs)

All Group 3 PWC; K0848 – K0864 (2) • • • • • • • •





Additional requirements: Drive wheel suspension to reduce vibration Length - less than or equal to 48 inches Width - less than or equal to 34 inches Minimum Top End Speed - 4.5 MPH Minimum Range - 12 miles Minimum Obstacle Climb - 60 mm Dynamic Stability Incline - 7.5 degrees

Power
Wheelchairs
(cont’d)
 Group 4 PWCs K0868 – K0886 • • •

Have added capabilities not needed for home use If provided and coverage guidelines met for Group 2 or 3, allowance based on least costly alternative medically appropriate PWC If billed with KX modifier, allowance based on comparable group 3 PWC

Group 5 PWC; K0890 – K0891 • • • • • • • • • •

Standard integrated or remote proportional joystick Non-expandable controller Capable of upgrade to expandable controller Capable of upgrade to alternative control devices Seat Width: minimum of 5 one-inch options Seat Depth: minimum of 3 one-inch options Seat Height: adjustment requirements-≥ 3 inches Back Height: adjustment requirements minimum of 3 options Seat to Back Angle: range of adjustment-minimum of 12 degrees Accommodates non-powered options and seating systems

Power
Wheelchairs
(cont’d)
 Group 5 PWC; K0890 – K0891 (2) • • • • • • • • • • • •

Additional requirements: Accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports) Adjustability for growth (minimum of 3 inches for width, depth and back height adjustment) Special developmental capability (i.e., seat to floor, standing, etc.) Drive wheel suspension to reduce vibration Length - less than or equal to 48 inches Width - less than or equal to 34 inches Minimum Top End Speed - 4 MPH Minimum Range - 12 miles Minimum Obstacle Climb - 60 mm Dynamic Stability Incline - 9 degrees Crash testing - Passed

Power
Wheelchairs
(cont’d)
 Power seating options Dynamic
pressure
relieving
seating
system
 •

Power tilt SEAT-BACK ANGLE MAINTAINED AS SEATING SYSTEM ROTATES AROUND A FIXED OR SLIDING PIVOT POINT

•

•

•

•

MAINTAINS SITTING POSTURE WHILE ORIENTATION TO GRAVITY IS CHANGED TYPICALLY REQUIRES A LONGER, HEAVY BASE NEW FORWARD SLIDING SYSTEMS ALLOW USE OF SHORT BASE Power recline SEAT-BACK ANGLE INCREASES AS THE BACK-POSTS ARE RECLINED TYPICALLY REQUIRES A LONGER, HEAVIER BASE MAY INCLUDE SELF-ELEVATING LEGRESTS (AUTOMATICALLY ELEVATE AS BACK RECLINES) Power stand SEATING SYSTEM MOVES FROM SITTING TO STANDING ALLOWS INDIVIDUAL TO COME TO A STANDING POSITION FOR ADL’S MAY OR MAY NOT BE ABLE TO BE DRIVEN IN STANDING POSITION Power elevating seat SEATING SYSTEM IS RAISED OR LOWERED ALLOWS FUNCTIONAL HEIGHT FOR ADL’S, TRANSFERS, INTERACTION WITH OTHERS Power elevating legrests LEGRESTS ELEVATE EXCLUSIVE OF THE SEATING SYSTEM ALLOWS INDEPENDENT LOWER EXTREMITY ELEVATION FOR EDEMA REDUCTION OR POSITIONING

Power wheelchair components Input
devices
 • •

Allow user to input the speed, direction, and command to stop the wheelchair Proportional DIRECTION AND SPEED OF THE CHAIR ARE IN PROPORTION TO AMOUNT OF MOVEMENT AT THE INPUT DEVICE

•

JOYSTICK Hand control Chin control Head controlled joystick PEACHTREE HEAD CONTROL Digital SWITCHES ARE EITHER ON OR OFF NON-PROPORTIONAL BODY/CONTACT SWITCHES Switch activated by direct pressure Each switch controls a direction or function May be used at nearly any access point, in any combination PROXIMITY/NON-CONTACT SWITCHES Switch activated by movement toward or away from the switch Each switch controls a direction or function May be used at nearly any access point, in any combination PNEUMATIC (SIP&PUFF)

Motors
 • • •

Allow movement of the chair Belt or direct drive Mounted to front, mid, or rear wheels

Controller
 • •

Brain of the wheelchair Allows adjustment of parameters (how wheelchair responds to input from the user) MAXIMUM SPEED LOW SPEED ACCELERATION DECELERATION TURNING SPEED TREMOR DAMPENING Also called sensitivity Makes wheelchair more or less responsive to joystick movement Useful in cases of tremor or extraneous movement JOYSTICK THROW Amount of joystick movement necessary to obtain full speed and direction control Often reduced for users with limited ROM MOMENTARY CONTROL Chair operates as long as input is provided Chair stopped when no input LATCHED CONTROL Either on or off Chair operates continuously in response to single activation of switch Subsequent activation of switch stops movement

Batteries
 •

•

•

Sealed (gel cell) NO MAINTENANCE (OTHER THAN CHARGING) SAFEST ACCEPTED ON AIRPLANES AND PUBLIC TRANSPORTATION Lead acid (wet cell) FLUID LEVELS MUST BE REGULARLY MAINTAINED POTENTIALLY HAZARDOUS NOT ACCEPTED ON AIRPLANES OR PUBLIC TRANSPORTATION Capacity U1 Small capacity For indoor or short-term use 22/24NF Larger capacity For full-time use Necessary for powering of other systems (i.e. tilt, recline)

INTEGRATION ISSUES Tilt/recline
systems
 Compatibility with various manufacturers Variations in tilt systems Basic
tilt

 Center
of
gravity
tilt

 Forward
sliding/weight
shifting
tilt
 Additional seat height Attachment of after-market backs Pinch points Drive lock-out

Transportation
issues
 Tie-down system Lift/loading Transfers Driving

Alternative
methods
of
access
 Compatible electronics Sufficient access sites for all devices

Communication
devices/computer
access
 Compatible electronics Mounting of system to wheelchair Placement of cables Seat height

OTHER MOBILITY DEVICES Push‐rim
activated
power
assist
 Attach to manual wheelchair frames Motor turns rear wheels Allows use of wheelchair as manual or power Weight negatively affects use as manual wheelchair Easily removed to allow folding of wheelchair for transport

Beach
wheelchairs
 Hand‐cycles
 Sports
wheelchairs


_________________________________________________________________

TRIALS _________________________________________________________________

Start with least expensive mobility option that may meet their mobility and positioning needs • •

Wheelchair Wheelchair componentry

Add least expensive seating intervention that will provide amount of support deemed necessary from the mat assessment • •

Primary support surfaces Secondary support surfaces

Attempt to match the individualʼs dimensions as closely as possible Assess for each option evaluated: • • • • • •

Fit Comfort Positioning Mobility Transfers Functional abilities

_________________________________________________________________

TRIALS (contʼd) _________________________________________________________________

Determine effectiveness of least costly options, noting reasons why they did or not work Progress to other mobility and seating options, concluding when you have determined the least costly option that will meet the individualʼs mobility, positioning, comfort, and functional needs. If no objective or subjective difference between options, chose the least costly option.

_________________________________________________________________

EQUIPMENT SPECIFICATION _________________________________________________________________

While
positioned
in
the
least
costly,
most
appropriate
intervention,
verify
 the
individual’s
measurements
in
the
context
of
the
equipment
 Collaborate
with
the
client
and
RTS/dealer
to

 Determine appropriate equipment dimensions Complete wheelchair and seating system order forms Specify all components Specify type and size of primary support surfaces Specify type and size of secondary support surfaces Ensure clientʼs understanding of all options specified

Incorporate
info
from
Vendor
home
assessment


_________________________________________________________________

CASE STUDIES _________________________________________________________________

Manual
 C7
complete
tetraplegia
 5’0”
woman
with
hemiplegia
 Bilateral
LE
amputee
 Decreased
vision
 MS,
limited
ambulation,
impaired
coordination
 400
pounds
 Triplegia
(i.e.
only
left
arm
function)
 Profound
MR,
severe
scoliosis,
pelvic
obliquity
 Poor
judgment
 Inability
to
perform
pressure
reliefs
 Client
drives
own
car


_________________________________________________________________

CASE STUDIES _________________________________________________________________


 Power
 COPD,
oxygen
dependent
 Severe
trunk
and
UE
ataxia
 C4
complete
tetraplegia
 Extreme
startle
reflexes
 Impaired
vision
 400
pounds
 Inability
to
perform
pressure
reliefs
 Distractibility,
poor
judgment
 Rapidly
progressing
ALS
 Use
of
public
transportation
 Client
drives
own
van


_________________________________________________________________

FUNDING AND DOCUMENTATION _________________________________________________________________

THE OLD DAYS: Medically
Necessary
 Durable Medical Equipment is required for the treatment of the clientʼs documented medical condition

Prescribed
by
a
Physician
 Physician attests to the documented medical need of the covered device.

EVOLUTION OF MEDICARE COVERAGE Typically
covers
older
adults
or
people
with
long
term
disabilities
 Policies
largely
determine
industry‐wide
reimbursement
 Coverage
Considerations:
 Medicare is a defined benefit program. An item or service must fall within one or more benefit categories, and not otherwise be excluded by statute from coverage. Section 1861(n) of the Social Security Act lists items that are included as durable medical equipment (DME), including wheelchairs. MAE is covered under the benefit category of DME. DME is defined as equipment that 1)
can
withstand
repeated
use,

 2)
is
primarily
and
customarily
used
to
serve
a
medical
purpose,

 3)
generally
is
not
useful
to
an
individual
in
the
absence
of
an
illness
or
injury,
and

 4)
is
appropriate
for
use
in
the
home
(42
C.F.R.
§
414.202).

 CMS has several national coverage determinations (NCD) regarding various mobility assistive equipment.

Recent
Events
 Excerpted from May 5, 2005 CMS Decision Memo for Mobility Assistive Equipment (CAG-00274N) “On
December
15,
2004,
CMS
opened
an
NCD
on
mobility
assistive
equipment
to
 examine
and
set
the
clinical
criteria
for
the
provision
of
this
equipment.
 Recent
allegations
of
wheelchair
fraud
and
abuse
have
focused
considerable
public
 interest
on
the
provision
of
wheelchairs
under
the
Medicare
benefit.
The
agency
has
 responded
with
a
multifaceted
plan
to
ensure
the
appropriate
prescription
of
 wheelchairs
to
beneficiaries
who
need
them.
One
facet
of
this
plan
is
the
delineation
 of
suggested
clinical
conditions
of
wheelchair
coverage.”
 
 “Many
advocacy
groups
have
suggested
that
the
agency
adopt
a
function‐based
 interpretation
of
its
historical
“bed
or
chair
confined”
criterion
for
wheelchair
 coverage.”
 
 “Historically,
wheelchairs
have
been
“covered
if
[the]
patient's
condition
is
such
that
 without
the
use
of
a
wheelchair
he
would
otherwise
be
bed
or
chair
confined.
An
 individual
may
qualify
for
a
wheelchair
and
still
be
considered
bed
confined.
 Wheelchairs
(power
operated)
and
wheelchairs
with
other
special
features
are
covered
 if
[the]
patient's
condition
is
such
that
a
wheelchair
is
medically
necessary
and
the
 patient
is
unable
to
operate
the
wheelchair
manually.”
 


“In
June
of
2004,
CMS
formed
a
workgroup
(the
Interagency
Wheelchair
Work
Group‐ IWWG)
of
Federal
employees
to
review
its
current
policy
for
wheelchair
provision
and
 to
analyze
the
published
scientific
literature
on
the
use
of
wheelchairs.
The
IWWG
 made
several
recommendations
for
the
clinical
interpretation
of
CMS’
statutory,
 regulatory
and
clinical
guidelines,
including
the
adoption
of
a
function‐based
 determination
of
medical
necessity.
A
function‐based
determination
might
consider
 the
beneficiary’s
inability
to
safely
accomplish
activities
of
daily
living,
such
as
 toileting,
feeding,
dressing,
grooming,
and
bathing
with
and
without
the
use
of
 mobility
equipment,
such
as
a
wheelchair.“
 
 On
December
15,
2004,
CMS
initiated
the
national
coverage
determination
to
address
 the
appropriate
prescription
of
Mobility
Assistive
Equipment.
 “Consistent
with
IWWG
recommendations
and
our
internal
review,
CMS
chose
to
use
 activities
of
daily
living
such
as
toileting,
feeding,
dressing,
grooming,
and
bathing
as
 these
are
activities
necessary
to
serve
a
medical
purpose
in
the
home.
We
collectively
 named
these
mobility
related
activities
of
daily
living
(MRADLs).”
 


RESULTING RECOMMENDATIONS FOR ASSESSMENT/PRESCRIPTION Excerpted from May 5, 2005 CMS Decision Memo for Mobility Assistive Equipment (CAG-00274N)


 Appropriate
Prescription
of
Mobility
Equipment
 An assessment of the beneficiaryʼs physical, cognitive, and emotional limitations and abilities, willingness to use mobility assistive equipment on a routine basis, and the beneficiaryʼs typical home environment is recommended to determine the appropriate prescription of mobility equipment. In order to facilitate the application of the new functional criteria, the IWWG proposed the following suggestions for the provision of wheelchairs.

Provision
of
Mobility
Assistive
Equipment
Under
Medicare
Should
Include
 All
Five
Points
Below
 The beneficiaryʼs physical limitations (diminished strength, speed, endurance, range of motion, coordination, sensation, deformity) prevent the beneficiary from accomplishing mobility-related activities of daily living in the home. The beneficiaryʼs mental capabilities (cognition, orientation, communication, judgment, memory, comprehension, affect, and suitable behavior) are sufficient for safe and adequate performance of mobility-related activities of daily living with the use of mobility assistive equipment. The beneficiaryʼs physical capabilities (strength, speed, endurance, range of motion, coordination, sensation) are sufficient for safe and adequate performance of mobilityrelated activities of daily living with the use of a mobility assistive equipment. The characteristics of the beneficiaryʼs typical home environment in which the activities of daily living are encountered (surfaces, presence or absence of surface accommodations, obstacles, accessibility, changes in grade, and distances covered) are suitable for use of the appropriate equipment. The beneficiary demonstrates willingness to use the equipment routinely.

Clinical
Criteria
for
Wheelchair
Prescribing
 The beneficiary, the beneficiaryʼs family or other caregiver, or a clinician will usually initiate the discussion and consideration of wheelchair use. Sequential consideration of the questions below provides clinical guidance for the prescription of a device of appropriate type and complexity to restore the beneficiaryʼs ability to perform mobility-related activities of daily living. These questions correspond to the numbered decision points on the accompanying flow chart. 


Clinical Criteria Algorithm for Wheelchair Prescribing Request initiated for mobility device for willing patient Yes No

#1: Mobility limitation? Yes Yes

#2: Other limitations?

No

#3: Compensated?

Yes

No

No

#4: Capable of safe use?

Yes #5: Canes/walkers?

Yes

Yes

Safe?

Canes or walkers

No No Exit

No # 6: Environment ?

Yes Yes

#7: Self-propel? No

Safe?

Yes

Appropriate manual wheelchair configuration

No Yes

#8: POV?

Safe?

Yes

POV

No

No

#9: PWC appropriate?

Yes

Safe?

Yes

No No

Power wheelchair

Does
the
beneficiary
have
a
mobility
limitation
causing
an
inability
to
perform
one
or
 more
mobility‐related
activities
of
daily
living
in
the
home?
A
mobility
limitation
is
one
 that
 • •

•

Prevents the beneficiary from accomplishing the mobility-related activities of daily living entirely, or Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform mobility-related activities of daily living, or Prevents the beneficiary from completing the mobility-related activities of daily living within a reasonable time frame.

Are
there
other
conditions
that
limit
the
beneficiary’s
ability
to
perform
mobility‐ related
activities
of
daily
living
at
home?
 • •

•

Some examples are significant impairment of cognition or judgment and/or vision. For these beneficiaries, the provision of a wheelchair might not enable them to perform mobility-related activities of daily living if the comorbidity prevents effective use of the MAE or reasonable completion of the tasks even with a wheelchair. If these other limitations exist, can they be ameliorated or compensated sufficiently such that the additional provision of a mobility equipment will be reasonably expected to materially improve the beneficiaryʼs ability to perform mobility-related activities of daily living in the home?

Does
the
beneficiary
demonstrate
the
capability
and
the
willingness
to
consistently
 operate
the
device
safely?
 • • •

Safety considerations include personal risk to the beneficiary as well as risk to others. The determination of safety may need to occur several times during the process as the consideration focuses on a specific device. A history of unsafe behavior in other venues may be considered.

Can
the
functional
mobility
deficit
be
sufficiently
resolved
by
the
prescription
of
a
cane
 or
walker?
 • •

The cane or walker should be appropriately fitted to the beneficiary for this evaluation. Assess the beneficiaryʼs ability to safely use a cane or walker.

Does
the
beneficiary’s
typical
environment
support
the
use
of
wheelchairs
or
 scooters/POVs?
 • •

Determine whether the beneficiaryʼs environment will support the use of these mobility assistive equipment. Keep in mind such factors as temperature, physical layout, surfaces, and obstacles, which may render an item of mobility assistive equipment unusable in the beneficiaryʼs home.

Does
the
beneficiary
have
sufficient
upper
extremity
function
to
propel
a
manual
 wheelchair
in
the
home
through
the
course
of
the
performance
of
mobility‐related
 activities
of
daily
living
during
a
typical
day? •

• •

• •

The manual wheelchair should be optimally configured (seating options, wheelbase, device weight and other appropriate accessories) for this determination. Limitations of strength, endurance, range of motion, coordination and absence or deformity in one or both upper extremities are relevant. A beneficiary with sufficient upper extremity function may qualify for a manual wheelchair. The appropriate type of manual wheelchair, i.e. light weight, power assisted, etc. should be determined based on the beneficiaryʼs physical characteristics and anticipated intensity of use. The beneficiaryʼs home should provide adequate access, maneuvering space and surfaces for the operation of a manual wheelchair. Assess the beneficiaryʼs ability to safely use a manual wheelchair.

Does
the
beneficiary
have
sufficient
strength
and
postural
stability
to
operate
a
power‐ operated
vehicle
(POV/scooter)?
 •

• •

A POV is a 3 or 4-wheeled device with tiller steering and limited seat modification capabilities. The beneficiary must be able to maintain stability and position for adequate operation. The beneficiary's home should provide adequate access, maneuvering space and terrain for the operation of a POV. Assess the beneficiaryʼs ability to safely use a POV/scooter.

Are
the
additional
features
provided
by
a
power
wheelchair
needed
to
allow
the
 beneficiary
to
perform
one
or
more
mobility‐related
activities
of
daily
living?
 • •

These devices are typically controlled by a joystick or alternative input device, and can accommodate a variety of seating needs. The beneficiary's home should provide adequate access, maneuvering space and terrain for the operation of a power wheelchair.


 Specific
Documentation
Requirements
for
Each
Category
of
MAE
 
 See
Noridian
Documentation
checklists
(appendix)
 • • • • • •

Manual wheelchairs Power wheelchair: Group 1/Group 2, no power options Power wheelchair: Group 2 Single/Multiple power options Power wheelchair: Group 3 Single/Multiple power options Power wheelchair: Group 3 No power options POV and Push-rim Activated Power Assist Device


 See
Noridian
Power
Wheelchair
Documentation
Requirements
(appendix)
 


OTHER PAYORS Medicaid
 Coverage based upon income; low-income and disabled Medicaid requires pre-authorization on certain items; this provides client and dealer/supplier with verification of coverage prior to ordering DME must be medically necessary; intended for use in home environment Requires specific medical justification for different types of DME Payor of last resort; must go through other sources first Covers DME at allowable charge (payment made to supplier/dealer); opportunity for individual consideration Covers repairs Covers DME for people in skilled nursing facilities through MAP 122 process Coordinated
by
nursing
facility
social
worker
 Supplier/dealer
must
be
willing
to
accept
MAP
122
assignment
(small
monthly
 payments
over
an
extended
time
period)
 DME for people in intermediate care facility, personal care homes, and adult homes is handled through normal process DME is owned by the client

Commercial
Insurance
 Covers individuals under employersʼ group plan, responsible for paying their portion of the premium Also may be Medicare Supplemental plan Coverage handbook typically offers vague summary of items covered Most offer pre-authorization DME must be medically necessary Most require specific medical justification for DME, some require MD prescription or letter only May require use of a “participating” supplier/dealer Covers DME at certain percentage (i.e. 80%) of a “reasonable" allowable charge; often subject to a small cap The supplier/dealer will bill the remaining percentage of the balance (i.e. 20%) to the secondary insurance or to the client Some cover repairs Most do not cover DME for people in skilled nursing facilities DME for people in intermediate care facility, personal care homes, and adult homes is handled through normal process DME is owned by the client

Workers’
Compensation
 Covers individuals with work-related injuries Typically offers pre-authorization, but must be coordinated through case manager Equipment must be medically, vocationally, or functionally necessary (broad definition of what is acceptable) Most require some level of justification for equipment; some may required MD prescription for certain items May require use of a “participating” supplier/dealer Covers equipment at 100%, but may obtain bids from several suppliers/dealers Covers repairs Equipment is owned by client

Division
of
Vocational
Rehabilitation
 Covers individuals with an intent to return to work or school Typically offers pre-authorization, but must be coordinated through field counselor Equipment typically must be vocationally necessary, but often cover items medically or functionally necessary (broad definition of what is acceptable) Requires written justification of need for equipment May require use of a contract supplier/dealer Covers equipment at 100%, but must often obtain bids from several suppliers/dealers Covers repairs Equipment is owned by DVR

Other
Sources
 Department of Veterans Affairs Self-pay Public Schools Department of the Visually Handicapped Community Service Fund Community Service Board Philanthropic organizations Churches Private/community fund raising

DOCUMENTATION Equipment
Specifications/Quote
 Therapist
Evaluation
Report
/
Letter
of
Medical
Necessity
 Physician
Prescription
 Medicaid:

Certificate
of
Medical
Necessity

 Medicare:

(see
Noridian
checklists)
 7 point physician prescription Face-to-face examination by physician Physician chart notes




_________________________________________________________________

DELIVERY AND FOLLOW-UP _________________________________________________________________

FITTING Collaborate
with
the
RTS/dealer
to
ensure
that
all
equipment
is
as
 recommended
and
configured
appropriately
prior
to
scheduling
delivery
 Attach
primary
and,
if
possible,
secondary
support
surfaces
to
mobility
base
 prior
to
client
arrival


ADJUSTMENTS With
client
positioned
in
seating/mobility
system,
ensure
that
all
 equipment
is
adjusted
properly
 Cushion position Back position Armrest height Legrest position Secondary supports • • •

Headrest Lateral supports Pelvic positioning belts

Controls/switches

Securely
attach
all
equipment
once
final
position
is
achieved
 Reassess
seating/mobility
system
for:

 Fit Comfort Positioning Mobility Transfers Functional abilities

TRAINING Make
sure
client/family/caregiver
is
able
to
position
client
properly
in
 seating/mobility
system
 Make
sure
client/family/caregiver
is
able
to
disassemble/
reassemble
and
 adjust
all
necessary
parts
 Legrests Armrests Cushion Back Wheels On/off
 Air
pressure
 Folding/loading wheelchair for transport Charging wheelchair batteries

Recommend
therapy
program
for
additional
mobility
training
if
necessary


EDUCATION Warranty
information
 Care
of
equipment
 Repairs Cleaning

Contact
person
for
additional
questions/concerns
regarding
 seating/mobility
system
(usually
RTS/dealer)


FOLLOW-UP Encourage
coordination
of
equipment
issues
directly
with
RTS/dealer
 Provide
client
with
therapist
contact
information
should
any
issues
arise
 that
are
beyond
the
scope
of
the
RTS/dealer
 Phone
follow‐up
at
regular
intervals
is
strongly
encouraged


_________________________________________________________________

REFERENCES _________________________________________________________________

Ball, M. (1996) A Multidisciplinary Approach to Dynamic Seating of the Multiply Involved Client. Conference sponsored by Freedom Designs, Charlotte, NC. Center for Assistive Rehabilitation Technology Training and Evaluation (CARTE), Central Region Training Manual (1996). Virginia Department of Rehabilitative Servcies, Virginia Assistive Technology System, University of Virginia, Woodrow Wilson Rehabilitation Center. Engstrom, B. (1993) Ergonomics: Wheelchairs and Positioning. Posturalis, Hasselby, Sweden. Hoppenfeld, S. (1976) Physical Examination of the Spine and Extremities. AppetonCentury-Crofts, Norwalk, CT. Huss, D. et al (1994) Recreating the Wheel: Howʼs and Whyʼs of Wheelchairs and Seating for Neurologically Impaired Adults. Conference sponsored by Woodrow Wilson Rehabilitation Center, Department of Physical Therapy, Fishersville, VA. Kapandji, A. (1974) The Physiology of the Joints, Vol. 3: The Trunk and Vertebral Column. Churchill Livingstone, New York, NY.

Kreutz, D. (1998) Fundamentals in Assistive Technology, 2nd Edition: Module VIII Characteristics of Seating and Positioning Technologies. RESNA Press, Arlington, VA. Maurer, L.E., and Vanhoy, M. (1998) AHCA Assistive Technology Services Assistive Technology Training Program Manual, Module 1: Seating and Mobility. Ambulatory HealthCare Corporation of America, Fredericksburg, VA. Maurer, L.E., and Vanhoy, M. (1998) UVA-HealthSouth Seating and Mobility Training Curriculum Manual. University of Virginia-HealthSouth Rehabilitation Hospital, Charlottesville, VA. Medhat, M.A., and Hobson, D.A. (1992) Standardization of Terminology and Descriptive Methods for Specialized Seating: A Reference Manual. RESNA Press, Arlington, VA. Minkel, J.L. (1996) Sitting Solutions: Principles of Wheelchair Positioning and Mobility Devices. Conference sponsored by Therapeutic Service Systems, Baltimore, MD. Nixon, V. (1985) Spinal Cord Injury: A Guide to Functional Outcomes in Physical Therapy Management. Aspen Publishers, Inc., Rockville, MD. Schuch, J. and Sprigle, S. (1995) Wheelchair Seating and Positioning: Improving Your Services from Assessment Through Follow-Up. UVA Rehabilitation Engineering Workshop, University of Virginia , Charlottesville, VA. Zollars, J.A. (1996) Special Seating: An Illustrated Guide. Otto Bock Orthopedic Industry, Inc., Minneapolis, MN.

_________________________________________________________________

RESOURCES _________________________________________________________________

Centers for Medicare and Medicaid Services May
5,
2005
Decision
Memorandum
 www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=143
 Clinical Criteria for MAE Coverage www.cms.hhs.gov/CoverageGenInfo/Downloads/MAEAlgorithm.pdf
 NORIDIAN Administrative Services, LLC (Medicare Administrative Contractor, Jurisdiction D) Documentation
Checklists
 www.noridianmedicare.com/dme/coverage/
 NAMES

National Association of Medical Equipment Suppliers 625 Sister Ln., Suite 200 Alexandria, VA 32314 (703) 836-6263 An
organization
of
suppliers
of
various
types
of
medical
equipment.

Their
 “Re/habilitation”
Section
has
established
Standards
of
Practice
for
Rehabilitation
 Technology
Companies.

They
sponsor
and
participate
in
several
trade
shows.



NRRTS

National Registry of Rehabilitation Technology Suppliers 3223 South Loop 289, Suite 600 Lubbock, TX 79423 (800) 976-7787 An
organization
composed
of
Rehabilitation
Technology
Suppliers,
“dedicated
to
the
 provision
of
high
quality
rehabilitation
technology
services
to
people
with
disabilities.

 All
NRRTS’
members
meet
specific
professional
membership
requirements
and
agree
 to
adhere
to
the
NRRTS
Code
of
Ethics
and
Standards
of
Practice.”


RESNA

Rehabilitation Engineering and Assistive Technology Society of North America 1700 N. Moore St., Suite 1540 Arlington, VA 22209-1903 (703) 524-6686 http://www.resna.org/resna/reshome.htm An
interdisciplinary
association
of
professionals,
providers,
and
consumers
with
 interests
in
disability
and
assistive
and
rehabilitative
technology.

RESNA
promotes
 research,
development,
education,
advocacy,
and
provision
of
technology.



 _________________________________________________________________

APPENDICES _________________________________________________________________

Providence Alaska Medical Center, Wheelchair and Seating Clinic Referral Form

Noridian Documentation Checklists www.noridianmedicare.com/dme/coverage/docs/checklists/manual_wheelchairs.pdf
 
 www.noridianmedicare.com/dme/coverage/docs/checklists/group_1_pwc_and_group _2_pwc_no_power_options.pdf
 
 www.noridianmedicare.com/dme/coverage/docs/checklists/group_2_single_power_o ption_group_2_multiple_power_option.pdf
 
 www.noridianmedicare.com/dme/coverage/docs/checklists/group_3_single_and_mult iple_power_options.pdf
 
 www.noridianmedicare.com/dme/coverage/docs/checklists/group_3_power_mobility _device_no_power_options.pdf
 “Documentation Requirements for K0823 Power Wheelchair Claims.” Noridian, 2009.