Page 14 - Mobility Management, October/November 2019

Funding Series
JUSTIFY IT: GROUP 2 VS. GROUP 3 POWER
congenital/skeletal deformity automatically qualifies a client for a for safe, timely and independent mobility.
Group 3 wheelchair. “Those medical conditions are not guaran- teed Group 3 because it’s not a specific list of diagnosis codes,” Stephenson said. “Conditions that are considered neurological in the medical realm don’t classify as neurological for Medicare for mobility purposes. Like diabetic neuropathy, for example: That’s a neurological condition, but it doesn’t qualify for power mobility. There is no official list. None of these conditions automatically qualify you; you still have to rule out a Group 2 chair. But you have that in your favor, that you have a condition that has been aligned with Group 3.”
Piriano explained, “According to the Medicare Local Coverage Determination (LCD) for Power Mobility Devices (PMDs), an indi- vidual must have a neurological condition, a myopathy or a congen- ital skeletal deformity to qualify for coverage and reimbursement of a Group 3 PWC [power wheelchair]. Typically, individuals that fall into one of these diagnostic categories will, in fact, use their chair all day, every day as their only way of moving about for the 12-18 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 categories — such as, but not limited to, rheumatoid arthritis, multiple limb amputations, etc. — who may also use their PWC on a continuous basis and require the performance of a Group 3 base
“In fact, many other third-party payors may provide funding for a Group 3 PWC for the health, safety and well-being of the indi- vidual, especially when it allows them to live in the ‘least-restric- tive environment possible (i.e., home and community).’”
GETTING CLINICIANS INVOLVED
Aside from added functionality and customization possibilities as you ascend the power chair ladder of HCPCS codes, more complex power chairs require the participation of professionals certified in complex rehab.
“Clinically speaking,” Piriano said, “the majority of individuals with a permanent need for a power wheelchair that use it for 12-18 hours per day require the performance characteristics and capa- bilities of the Group 3 base, regardless of diagnosis, to safely navi- gate all settings of actual and anticipated use. If there is a medical need for power tilt and/or power recline or the need for alternative drive controls, the provision of a Group 3 PWC becomes impera- tive, even though Group 2 chairs technically must have the capa- bility to support power seat functions, upgraded electronics and alternative drive controls, according to the policy article associ- ated with the PMD LCD.
“Group 2 PWCs with power seat functions and all Group 3 PWCs require a specialty evaluation by a licensed/certified medical professional, such as a PT [physical therapist] or OT [occupational therapist], who has knowledge and skills in wheelchair evaluations and does not have any financial relationship with the supplier. From the supplier perspective, there must be a W2-employed, RESNA-certified Assistive Technology Professional (ATP) directly involved in the evaluation and recommendation process for these same bases. Both of these two professionals are bound by a stan- dard of practice and code of ethics that mandates they do no harm. During the evaluation and technology assessment, it is imperative that the team consider the physical, functional and environmental needs of the individual. The question is, what group will accom- modate the consumer’s daily routine in all settings of anticipated use — and why?”
Mobility assessments can be quite different depending on whether the client is a Group 2 or a Group 3 power chair user.
“In most cases,” Rogers said, “Group 3 clients generally require more time during the evaluation process to ensure the product can be ordered to fit them properly, but also [to] ensure the product can work most appropriately for them. Group 2 tends to be less involved due to the fact that many of the patients have less-involved presen- tations and can be fitted in a fraction of the time.”
Choosing between a Group 2 and a Group 3 power chair can be tricky with some client presentations. Multiple sclerosis (MS), with its varying rates of progression and presentations that can change by the hour, is an example of a diagnosis in which the client’s seating and mobility needs can substantially fluctuate in a short period of time.
“If you put an MS client into a Group 2 chair today,” Stephenson said, “and they progress to where they need power tilt and recline,
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