Page 12 - HME Business, Jan/Feb 2019

Julie Piriano, PT, ATP/SMS
Provider Strategy
Clinically Speaking: Group 2 vs. Group 3
Determining which type of power wheelchair is right for a client requires ‘knowing the code’ as well as understanding patient needs.
Selecting the clinically appropriate power wheelchair (PWC) base for an individual with a permanent need for mobility assistive equipment can be daunting, even for the most experienced clinicians. With 29 power wheelchairs showing as “active” on the Pricing, Data Analysis and Coding (PDAC) website in the Group 1 category, 366 available in the Group 2 cat- egory, 297 in the Group 3 category and 66 listed in the Group 4 category how does anyone narrow down the selection to the “right one?” The reality is, there are not 758 power wheelchairs that can meet the unique identified needs of an individual, there are a much smaller number once you “know the code.”
On Nov. 15, 2006 the Centers for Medicare and Medicaid Services (CMS) established new HCPCS codes for all powered mobility devices based on their specific features, functions and minimum performance criteria. In advance
of this change CMS sought advice from a Technical Expert Panel (TEP) comprised of industry leading engineers, technicians, specialists, corporate officers, and advocates in the development of the codes and testing standards to differentiate each category of chairs.
Connecting Devices to Need
We can use this information, derived from subject matter experts, to help nar- row down the selection process. For adult power wheelchairs the TEP recom- mended four power wheelchair categories, based on speed, range and terrain handling features so the first question is, what group will accommodate my patient’s daily routine in all settings of anticipated use?
1. Standard Use (Group 1) – A category of chairs designed primarily for intermittent use on flat, hard surfaces with minimal surface irregularity.
2. Standard Plus Use (Group 2) – A category of chairs designed primarily for regular use on flat hard surfaces with minimal to moderate surface irregularity.
3. General Use (Group 3) – A category of chairs designed for a mixture of continuous use on flat to rolling terrain, and hard surfaces with moderate surface irregularity.
4. High Activity Use (Group 4) – A category of chairs designed for frequent use on uneven terrain, hard and soft surfaces with moderate to extreme surface irregularity, or for speeds and ranges that exceed those of chairs designed for standard or general use.
Group 1 PWCs are ideally suited for beneficiary’s living in an independent or assisted living facility due to their limited performance characteristics. On the other end of the spectrum, CMS determined that Group 4 PWCs have performance characteristics that are not necessary for use in the home and will not consider them for coverage and reimbursement. However, many other third-party payers may provide funding for this level of PWC for the health, safety and well-being of the individual, especially when it allows them to live in the “least restrictive environment possible” (i.e., home and community).
Defining “Use”
This leaves us with Group 2 and Group 3, which takes us down to 663 PWCs. The second question is, what is the difference between “regular use” and con- tinuous use?” In its local coverage determination (LCD) for powered mobility
devices CMS implemented restrictions for reimbursement purposes between these two groups of PWCs, which we can use as a guideline when recommend- ing the right power wheelchair base, but it is just that — a guide. Per the LCD and individual must have a neurological condition, a myopathy or a congenital skeletal deformity to qualify for a Group 3 PWC.
Typically, individuals that fall into one of these three diagnostic categories will, in fact, use their chair all day, every day as their only way of moving about for the 12 to 18 hours they are up out of bed. However, there are many other individuals that do not have a diagnosis that fits in one of these catego- ries such as, but not limited to rheumatoid arthritis, multiple limb amputa- tions, etc. who may also use their PWC on a continuous basis as opposed to bouts of use.
Assisted vs. Unassisted Transfers
This brings us to our third question: can the individual transfer to and from the PWC independently and change their position in it of their own volition, or do they require assistance to transfer and the mechanical means to change their position in the chair throughout the day?
For individuals who must change their position by mechanical means the TEP recommended that power seat functions only be available on power wheelchair bases designed for “continuous or high activity use” as follows:
1. Specific Use (Single Power Option) – A category of chairs designed for a mixture of indoor and outdoor use on flat to rolling terrain, and hard surfaces with moderate surface irregularity and with the capability to accom- modate positioning and power modalities and accept one power option at a time on the base.
2. Specialized Use (Multiple Power Options) – A category of chairs designed for a mixture of indoor and outdoor use on flat to rolling terrain, and hard surfaces with moderate surface irregularity and with the capability to accommodate positioning and power modalities and accept more than one power option at a time on the base.
As we know, CMS did not take this advice from the TEP and included HCPCS codes for Group 2 PWCs with single and multiple power options in the code set. However, when we analyze the Medicare provision of single and multiple power option chairs from 2010 to 2017 we find that 86.5 percent of them were provided on a Group 3 base. Why is this the case when roughly 95 percent of the PWCs with no power options provided during that timeframe were coded in the Group 2 category? Is it because the clinical and provider community is unaware that there are Group 2 power wheelchairs with a power tilt option available? Is it because two of every three where a medical need for power seating is established include both power tilt and recline for a multitude of reasons, and there are no Group 2 PWCs with a combination power tilt/ recline available in the United States? Or, Is it because clinicians and providers are intuitively following the recommendations put forth by the TEP?
Clinically speaking, the vast majority of individuals with a permanent need for a power wheelchair that use it continuously for 12 to 18 hours per day and
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