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ASSISTIVE TECHNOLOGY

1/26/2007 12:00:00 AM

Summary of January 23, 2007 Assistive Technology Committee meeting.

Subject: Summary of January 23, 2007 Assistive Technology Committee Meeting


 For further information, contact: Judi Gerson, Vice President, Policy & Program Services

CP of NYS Assistive Technology Committee

Summary of January 23, 2007 Meeting

Attending: Ashlye Cheely & Leigh Bagg (Center for Disability Services), Charlene Schatzel (CP of Ulster), Bonnie Cole & Carrie Shore (HCA), Steve Newman (Hudson Valley CP), Paca Lipovac, Gary Grimaldi, Paul DiGiovanni & Charmaine Gabbidon (Metro), Barbara Sipper & Randy Fischer (SDTC), Rosemarie Nuzzi (Nassau), Mary Beth Frey (NYC), Linda Bollinger (Suffolk), Judi Gerson ( CP of NYS – Affiliate Services)        

DME Prior Approval Issues

  • DME Work Group – The Work Group comprised of DOH staff, DME vendors, Rehab Agency providers and consumers continues to meet, although on a less frequent basis. CP of NYS is represented by Judi Gerson, Kathy Kelly and Carrie Shore.  Many of the high priority issues identified early on are still pending action and resolution. These include adjusting the MRA for certain equipment, clarifying the use of the miscellaneous code and ensuring access to the prior approval process for dual eligible consumers. Although the Medicaid / Medicare issue was recently identified as high priority for resolution, DOH has now indicated it can not be addressed due to a recently filed lawsuit. With the assistance of a work group subcommittee, DOH has published new Wheeled Mobility Seating & Positioning Guidelines which are available on the emedny website. Everyone is encouraged to review these guidelines as they contain a lot of useful information relative to the approval process. They can be accessed at http://www.emedny.org/ProviderManuals/DME/PDFS/DMEWheeledMobilityGuidelines.pdf. An accompanying format for the letter of justification is also being developed (see below).
  • Current Status of DME Prior Approval Requests - There continues to be significant concerns and problems relative to the approval process. Frequent “missing information” letters, down-coding of equipment, denials and /or inappropriate alternate recommendations by DOH reviewers are among the issues. Judi requested that examples of particularly egregious responses from DOH be forwarded to her (names and identifying information removed please) for use in ongoing advocacy efforts.
  • Standardized Format for Letter of Justification – The group reviewed and modified a draft version of a standardized format developed by a subcommittee of the DME Work Group. The revised format is attached and will now be shared again with the DME subcommittee and then to the full Work Group.
  • Rationales for lap trays, strollers and special hardware - The group also reviewed material submitted by CP of NYS committee members to clarify the medical necessity for various pieces of equipment which seem to be problematic. The revised document is attached (including a statement on transit tie-downs) and will be shared with the DME Work Group for discussion at the next meeting. 
  • Bathroom Equipment – there are significant concerns regarding the quality of bathroom equipment currently being approved / provided, especially for individuals with spasticity who require more durable equipment. Part of the problem is down-coding, the reimbursement level associated with the MRA and the significant increase in shipping costs which are not being reimbursed to the vendor.

Billing Strategies for Computer Access Evaluations – The Center for Disability Services will be opening a new Assistive Technology Center in Clifton Park. Discussion of potential funding sources for computer evaluations included the county for Early Intervention and Preschool, School Districts, VESID for employment or college-related evaluations and Medicaid.

Billable Services to Residents of ICFs – Questions were raised about new procedures which limit clinic billings for residents of ICFs. A recent memo from OMRDD clarified that ongoing therapy services are now included in the ICF rate and implied that the only exceptions which could be billed by a clinic were for short-term services associated with “illness, injury or “post-hospitalization”.  We have received preliminary advice from OMRDD that billing for evaluations for DME and Assistive Technology should be permitted. We will confirm the outcome of further discussions. Please note: it is important for any billed services to be coded properly so they are identified with one-time or time-limited specialty services associated with wheelchair or other DME or AT. 

New Medicare Requirement for RESNA-Certified ATP or Board-Certified Physiatrist – Following is an excerpt from CMS Local Coverage Determination L23613 on Power Mobility Devices: “For claims with dates of service on or after April 1, 2008, the specialty evaluation required for patients receiving a Group 2 single power option or multiple power option PWC, any Group 3 or Group 4 PWC, or a push rim activated power assist device for a manual wheelchair must be performed by a RESNA-certified Assistive Technology Practitioner (ATP) specializing in wheelchairs or a physician who is board-certified in Physical Medicine and Rehabilitation. The ATP or physician may not have any financial relationship with the supplier. In addition, the wheelchair must be provided by a supplier that employs a RESNA-certified Assistive Technology Supplier (ATS) specializing in wheelchairs who is directly involved in the wheelchair selection for the patient.”

Attachments can be obtained by contacting the Affiliate Services Office at (518) 436-0178.

[TEXT FROM DRAFT JUSTIFICATION LETTER]

NOTES FROM GUIDELINES

·        All services must be supported by the original, signed written order from a qualified licensed practitioner.  In the event an order has been telephoned or faxed to the vendor, it is the vendor’s responsibility to obtain the signed fiscal order from the ordering practitioner within 30 calendar days.  A written, faxed or telephone order must be received prior to delivery of the service.

·        The fiscal order must be specific to the item being requested.  Generic orders such as “wheelchair” or “wheelchair repairs” are not acceptable.  The order must clearly and specifically state the type of item being requested or the specific repairs being requested.

·        The minimum information required on a fiscal order is:

·        Name, address and telephone number of the ordering practitioner;

·        Name and Medicaid identification number of the recipient;

·        Date ordered;

·        Original signature of the ordering practitioner; and

·        Name of the item, quantity ordered, size, catalog number as necessary and directions for use

·        The order and supporting documentation must be kept on file by both the vendor and ordering physician, and made available to the Department upon request for audit purposes.

·        It is expected that the recipient’s medical records will reflect the need for the item provided.  The recipient’s medical record may include, but is not limited to, the physician’s office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals (physical/occupational/speech therapists) and test reports.  This documentation must be available to the Department upon request.

·        When requesting a custom fabricated cushion the request must also include the manufacturer/fabricator name and model name/number of the product (if applicable), or if not, a detailed description regarding the dimensions and construction of the product that is being requested.

·        The product name/number that is listed must exactly match the complete product name/number that is listed in the Product Classification List on the SADMERC web site.

·        Refer to the DME Provider Manual and Appendix III of this document for more information on documentation requirements.

*Need to clarify certification (order?) type and date*

Order date:    __/__/____

Name and Address of Vendor:


The minimum supporting documentation and questions to be addressed for wheeled mobility and/or seating and positioning components are as follows:

Date of Evaluation:

Basic Recipient Information

      Recipient’s Name:                                                          Gender: ___male___female

      Medicaid #:                                  Other Insurance:

      DOB: __/__/____                       Age: ___ years                      Phone Number:

      Diagnosis:

Referral Source / Reason for Referral (optional)

Background / Experience of Evaluator/ Writer / Relationship to Recipient (optional)

Requested Equipment:

     

      List all components

      Estimated length of need for equipment in # of months: ___ months or ___ lifetime

Place of Residence:

     

      Recipient’s living arrangement: ___home alone

                                                            ___ home with caregiver

                                                            ___ supported living facility

                                                            ___ institutional

                                                            ___ home with support from home health or waiver

                                                            ___ foster care home

                                                            ___ other

                                                            OR

Describe the customary environment and caregiver supports (e.g., skilled nursing facility, OMRDD-certified residence, private home, home health or waiver services)

Add: include also supports at school, work or other community / day activities.

Relevant Medical History/ Prognosis:

      Is there a history of decubitus/skin breakdown?                      Yes___ No___

      If yes, explain.

     

      Is there absent or impaired sensation in the area of contact with the seating surface?

                                                                                                            Yes___ No___

      Can the recipient carry out a functional weight shift?  Yes___ No___

     

      Does the recipient have significant postural asymmetries? Yes___ No___

     

      If yes, describe in detail:

(recommend use of diagrams / chart formats from pages 6-7 of Rehab Institute of Chicago’s equipment evaluation / justification form)

      Describe other physical limitations or concerns (i.e., respiratory):

      Describe any recent or expected changes in medical, physical, or functional status:

      If surgery is anticipated, indicate:          the CPT procedure code(s) ______

                                                                        and ICD-9 Diagnosis code(s) _________

                                                                        or ICD-10-PCS code________

                                                                        and expected surgery date __/__/____

      Additional Narrative: (optional)

Recipient Measurements

      height: ___inches

      weight: ____pounds

? add other measurements here (trunk, head, chest, shoulders, pelvis, thighs, legs, calf, foot, etc. in chart format?  (see sample next page or use page 4 of Rehab Institute of Chicago’s form)


Required Measurements:                                                        Foot Length    

Height: _______                                                                                             Left:          H._______

Weight: _______                                                                                             Right:     H*.______

Head/Trunk Length: A._______                                                              Shoulder to Fingertip

Head Width:               B._______                                                                   Left:        I._______

Trunk Width:             C._______                                                                   Right:      I*.______

Trunk Width:                                                                                             Seat to Elbow:

       Without Braces            D._______                                                                

                                                                                                                          Left:       J.________

       With Braces                 D*.________

                                                                                                                          Right:     J*._______

Pelvic Width:

       Without Braces            E.________

        With Braces                E*._______

Thigh Length:

         Left                            F.________

         Right                         F*._______

Calf Length

        Left                                 G._______

          Right                           G*._______

Optional Measurements:                                            Additional Notes:     

Width across Shoulders: ___________________                ______________________________

Depth of Head: __________________________                   ______________________________

Head Circumference: ______________________               ______________________________

Seat Belt Girth: __________________________                 ______________________________

Thigh Height:         L:______    R: _______                           _______________________________

Functional Status / Limitations

                 

      What is the level of the recipient’s independence in mobility?

            ___independent

            ___requires caregiver assistance for long distances and/or uneven terrain

            ___ requires mobility device for long distances and/or uneven terrain

            ___ always requires mobility device

      If wheelchair dependent, how many hours per day are spent in the wheelchair? ____

      Indicate recipient’s transfer capabilities:          ___ maximum assistance

                                                                                    ___ moderate assistance

                                                                                    ___ minimum assistance

                                                                                    ___ independent

      How is the recipient fed?           ___ enteral

                                                            ___ parenteral

                                                            ___ oral

     

      Are seating modifications required to facilitate feeding capabilities? Yes___No___

      If yes, explain:

      Indicate the recipient’s ADL capabilities:        ___ maximum assistance

                                                                                    ___ moderate assistance

                                                                                    ___ minimum assistance

                                                                                    ___ independent

      Describe activities, other than ADL, performed while in wheelchair:

                                                     

                                                                              OR

(Include description of use of WC / seating system at home, school, work or other environments?)

      For mobility, add: describe current level of ambulatory function & mobility needs:

     

     

     

      Additional Narrative (optional):


Current Equipment

      Does the recipient currently have a mobility / seating system?         Yes___ No___

           

If yes, describe the recipient’s current mobility / seating system (e.g., make, model, serial number) including the mobility base, the age and condition of the system.

      Describe why the current mobility / seating system is not meeting the recipient’s needs:

      ___ damaged

      ___ age of system

      ___ growth change

      ___ change in recipient’s medical or functional status

      ___ other

      Required explanation, including rationale for replacement instead of repair / modification:

Justification for Requested Equipment

      What type of equipment is being requested?___ custom fitted

                                                                                    ___ custom made

                                                                                    ___ prefabricated

What medical needs are or will be met by the use of the mobility/ seating system? (check all that apply)

      ___ postural deformities

      ___ contractures

      ___ tonal abnormalities

      ___ functional impairment

      ___ muscle weakness

      ___ pressure points

      ___ difficulties with seating balance

      ___ other, please specify

      Optional additional explanation:

Does the recipient require a seating system beyond the standard sling provided with a wheelchair?                                                           Yes ___No___

      Has a basic positioning cushion been ruled out?       Yes___No___

If custom, explain why a prefabricated seating system is not sufficient to meet the recipient’s seating and positioning needs:

      If a custom fitted seating system is required, what components are needed?

      ___ headrest

      ___ laterals

      ___ hip guides

      ___ wedge

      ___ other: specify

      ___ none

      Describe recipient’s need:

      If a custom made seating system is required, what type is required?

      ___ vendor carved

      ___ bead seat

      ___ custom molded

      ___ other, specify

                                                            AND / OR

Additional optional information: For each component of this mobility / seating system, explain why the component was selected, what it will  accomplish and its medical necessity in relation to the recipient. Also include alternatives considered or attempted and why these alternatives do not meet the medical need

(recommend use of Rehab Institute of Chicago’s form pages 8 -13)

      Describe the growth potential of the requested equipment in number of years.

      ___years or ___lifetime

Describe anticipated modifications or changes to the equipment within the next three years, if applicable:

      Will the seating system be used on a new or existing chair?             ___new ___existing

      Can this system be integrated into a new wheelchair?                      Yes___No___

     

      Can this system be integrated into an existing wheelchair?  Yes___No___

Has the recipient been evaluated by a physical therapist or occupational therapist for the need of the mobility / seating system?                                                                                                                                                                                                                Yes___No___

If yes, do the results of the evaluation support the need and use of the mobility / seating system?

                                                                                                                        Yes___No___

Give details of the results of trial of equipment or documentation that equipment can be appropriately used in the living environment (e.g., fitting through doorways, access to home, transportable, ability to safely operate):

Summary of recommendation (optional)

Therapist’s name and licensure (if evaluated by a therapist):

Therapist evaluation date:

Therapist’s phone number:

Therapist’s employer:

Signature of person completing form:

Fiscal order or (Signature of Physician)

Cerebral Palsy Associations of NYS

Statewide Assistive Technology / Durable Medical Equipment Committee

Rationale / Medical Justification for:  

  • Upper Extremity Support Systems (Lap Trays)
  • Strollers
  • Removable / Swing Away Hardware
  • Transit Tie-Downs

Upper Extremity Support Systems (Lap Trays)

The following reasons will indicate the need for an UESS, despite having a safety belt, pelvic strap, harness, tilt-in-space, etc., for those who are significantly involved with multiple disabilities:

·        The individual cannot maintain an upright head, neck, and trunk position due to poor static and dynamic sitting balance and decreased muscle strength and tone.

·        The individual cannot maintain upper extremities on an armpad, arm trough, armrest modification due to low muscle tone, decreased muscle strength, or spasticity.

·        There is a risk of shoulder subluxation, nerve impingement, compromised skin integrity, upper extremity edema due to the lack of support and the individual’s upper extremities positioned in a consistently dependent position.

·        Injury to the individual’s upper extremities against the armrests/armpads due to spasticity.

·        The individual has athetoid or shoulder retraction movement patterns and protraction blocks on an UESS are required for positioning and/or protection of upper extremities.

·        Additional padding may be recommended for individuals who have poor upper extremity skin integrity, skin breakdown, or bruising, and inner rim protection is needed for the individual’s trunk

In addition to positioning needs, laptrays may be considered medically necessary for:

  • independence for self-feeding, particularly when wheelchairs may not fit properly under standard tables in the home or community setting
  • communication or boards or pictures/ symbols which need to be mounted to the tray.

Strollers

Strollers may be indicated for:

  • children who can ambulate for short distances or only on certain easy-to-manage surfaces, but require wheeled mobility for longer distances or more difficult terrain, or who need a mobility device for safe transport to and from school, who can not ambulate to and from the bus or ascend / descend bus stairs.  A stroller with positioning capabilities may be less costly, less cumbersome and easier to manage than a wheelchair with comparable positioning capabilities.
  • non-ambulatory children who live in inaccessible housing without ramps or elevators or for whom transport of the wheeled mobility device is necessary in family cars 
  • small / young children who are still developing physically and may be able to ambulate in the future. Less costly wheelchairs often recommended by DOH (K0001-K0004) are not available in age-appropriate sizes and children are not properly positioned as they would be in a stroller.

Note: A Convaid Stroller is often recommended for the following primary reasons:

  • It has been crash-tested, can be tied down in a school bus,  and offers accessories to maximize postural alignment
  • In addition, it can be easily folded for transport and much lighter than a standard wheelchair

Swing Away / Removable Hardware

Swing away or removable hardware is often a necessity in order for individuals to independently transfer. However, it is also indicated to ensure the safety of individuals who require partial or total assistance in transferring in and out of the wheelchair in the following instances:

  • Removable/ swing away abductor - necessary to accommodate a safe and efficient assisted transfer when the individual must slide forward and come to stand for a stand-pivot transfer. Swing away may be preferable for individuals who can independently prepare for transferring or toileting prior to getting the necessary assistance.
  • Swing away laterals – for optimal positioning of the trunk following a transfer, since injury to the consumer or damage to the laterals can occur if the laterals are fixed.
  • In situations where a consumer requires total assistance, either with a two-person transfer or with a Hoyer lift, for example, being able to remove the abductor, flip down the headrest, and swing away the laterals makes that transfer significantly safer for the consumer and for the caregivers. By swinging away and removing those accessories, one creates a "clear path" for the transfer. The more direct and unencumbered the route from the wheelchair to the surface is, the closer the consumer can be kept to the caregiver during the transfer (providing a secure hold and better body mechanics) and the less the client has to be lifted vertically to clear laterals and an abductor. Just these two aspects improve the safety of the transfer for the consumer tremendously.
  • Caregiver safety is also crucial, as injury to the caregiver could cause the consumer to be dropped or otherwise injured during a transfer. Additionally, injury to the caregiver could affect the daily care needs of the consumer.

Transit Tie-Downs

  • Requests for Transit Tie-Downs are often denied with an indication that the tie-downs should be included in the price of the wheelchair. However, many wheelchairs, especially adult wheelchairs, do not come with the tie-downs included and must be purchased separately. In order to ensure the most appropriate wheelchair and optimal safety for transport, tie downs are a necessary add-on for chairs which do not otherwise include them. It is also important for the proper maintenance and longevity of the chair, because without the tie-downs, chairs must be secured by the frame or other inappropriate part and may cause damage requiring repairs.

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