Paying for Power

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November 2004

By David W. Clifton, PT

Several demographic trends have placed physical and occupational therapists in the position of managing patients who may be candidates for power operated vehicles (POVs). There are generally two categories of POVs: power wheelchairs and scooters. The former are generally more associated with indoor use, while the latter are often associated with outdoor mobility needs. America's aging population, chronic illness, injury prevalence, and availability of funding are contributing factors to the escalating use of assistive or rehabilitation technology. Ill-informed patients, unscrupulous durable medical equipment (DME) manufacturers and distributors, and uninformed physicians also share culpability for spiraling costs. The POV Medicare benefit has grown faster than any other benefit since 1994.¹ In 1999, 55,000 motorized wheelchairs were prescribed and funded at a rate of $289 million. By 2002, there were 159,000 prescriptions. This benefit alone eclipsed $1.2 billion in 2003. The K-0011 or POV code is the fourth ranked among the top 200 procedure codes in terms of expenditures during calendar year 2002.² These data spawned a number of tenacious accountability initiatives.

Fraudulent claims have become a major focus of Medicare across treatment settings and services. For instance, Operation Wheeler Dealer (OWD) is the federal program directed at curbing unnecessary and unreasonable POV prescriptions. This initiative in its first year recovered $84 million in fraudulent claims for power mobility products nationwide. OWD efforts are focused on 20 states due to a disproportionate rise in both prescription prevalence and cost. Results of investigations include: claims denial, fines, imprisonment, and eviction from the Medicare program.

REHAB TECHNOLOGY PRESCRIPTION
POVs fall within the universe described as rehabilitation technology (RT). RT is the application of science, engineering, and human factors design in the development of solutions that address functional limitations. More than 13 million persons or 5.3% of the United States population use some form of assistive technology (AT).³ Many of these persons use mobility-related AT including power operated vehicles. However, evidence suggests that some persons do not meet the medical necessity criteria for these devices, while others who do meet the requirements do not have access to the technology.

There is a paucity of systematic algorithms for successful technology prescription. Some contend that patients, physicians, and rehabilitation professionals often commit to the outright purchase of a technology without first securing additional data through independent assessment or trial periods.³ This can be problematic because Medicare requires that alternative sources of mobility (wheelchairs) be tried before prescription of a POV. Unfortunately, providers may rely principally on manufacturers' literature when making technology selections. These materials, it can be argued, have inherent bias.

Although virtually all PTs and OTs are functional experts and many are seating specialists, the Medicare program empowers physicians as the gatekeepers for AT or RT prescription. It is physicians who complete a Certificate of Medical Necessity or CMN, a Medicare requirement. However, the CMN may be insufficient in providing all of the details vital to successful RT prescription. Medicare now requires that a specialist from one of the following areas be responsible for POV prescriptions: physical medicine and rehabilitation or physiatrist, orthopedic surgeon, neurologist, and rheumatologist. Although these professionals may have more background and knowledge concerning neuromuscular problems than an average family physician, the process is suboptimal. Without the involvement of a PT, OT, or seating specialist in the prescription process, there still remains a void in terms of functionally based assessment. Physicians focus on medical diagnoses within a medical model, whereas therapists operate from a functionally based paradigm that highly prizes a therapy or functional diagnosis. Although therapist opinions are not completely discounted in the Medicare process, their role is clearly more diminished than it need or should be relative to RT prescriptions. Additional clinical documentation may be necessary for the identification of POV candidates and to match the candidate to the appropriate technology.

MEDICARE COVERAGE CRITERIA
DME Regional Carriers or DMERCs implement Medicare coverage policies specific to POVs and other DME products. General Medicare coverage criteria require the following: (1) an eligible beneficiary; (2) evidence that a product or service is reasonable and necessary for the diagnosis or treatment of an illness or injury; (3) adherence to all other statutory and regulatory requirements, (4) a written, signed, and dated physician order; and (5) completion of a CMN.

POV coverage criteria include more function-specific criteria. They exclude cardiologists who are critical in assessing cardiopulmonary limitations, contraindications, and precautions. Many persons cannot navigate manual wheelchairs due to cardiopulmonary or other non-neuromusculoskeletal conditions. Cardiologists are excluded as preferred physicians for POV prescription despite Medicare's own acknowledgement that cardiopulmonary disease can be a causative factor in upper extremity weakness. The clinical literature clearly establishes the fact that strenuous upper extremity use requires greater metabolic demands, can spike blood pressure, and can lead to symptoms in persons with cardiac compromise.^1,4-10 Persons with congestive heart failure, chronic obstructive pulmonary disease, coronary artery disease (COPD), insulin-dependent diabetes mellitus, end-stage renal failure, and peripheral vascular disease are common candidates for POVs, yet cardiologists, PTs, and OTs are not included in the prescription process.

The POV prescription requires a special CMN form, HCFA (CMS) # 850. The CMN requests specific information driven by Medicare's coverage criteria. However, a CMN alone may be insufficient for establishing the medical necessity and reasonableness of a service or product. Section B of the POV-based CMN form asks the following functionally based questions:

Does the patient require a POV to move around in their residence?
Have all types of manual wheelchairs (including lightweights) been considered and ruled out?
Does the patient require a POV only for movement outside their residence?
Is the physician signing this form a specialist in physical medicine, orthopedic surgery, neurology, or rheumatology?
Does the patient's physical condition prevent a visit to a specialist in physical medicine, orthopedic surgery, neurology, or rheumatology?

The CMN must be included with any request for Medicare reimbursement. It is important to note that the reverse side of the form, which contains the instructions for CMN completion, must also be provided to the Medicare intermediary. Both DME suppliers and rehabilitation providers make routine mistakes when considering an RT or AT prescription.³

MEDICARE POV COVERAGE CRITERIA
DMERCs make coverage determinations relative to POVs. DMERC medical policy specific to POV coverage criteria states that: the patient's or beneficiary's condition is such that without the use of a wheelchair the patient would otherwise be bed or chair confined; the patient's or beneficiary's condition is such that a wheelchair is medically necessary and the patient is unable to operate a wheelchair manually; and the patient or beneficiary is capable of safely operating the controls for the power wheelchair.

These three coverage criteria foster debate between DME suppliers and payers and between providers and payors. Each case must be evaluated on its own merits or lack thereof and coverage criteria cannot be universally applied across all claims. Each patient has their own story to tell; however, they often require a provider and/or DME supplier to tell it on their behalf. Rehabilitation providers may be ethically bound to serve in an advocacy role so that their patients can receive the assistive technology so vital to independent living. This role demands an intimate understanding of how payors arrive at noncoverage decisions. However, this is seldom an easy task, as the claims denial rationale is not always clear and, in fact, is routinely ambiguous. Medicare intermediaries are legendary for applying different interpretations or coverage decisions for similar cases.

Ironically, payors often demand evidence-based practice and RT prescription, yet the coverage process they engage in is often devoid of evidence relative to non-coverage decisions. Severe critics might even suggest that payors use an arbitrary or capricious approach in claims denial. Only 13% of Medicare's wheelchair claims (K-0011 chairs) meet the specific benefit criteria, while nearly 33% of claims for POVs do not meet requirements for any type of wheelchair.² These data beg a number of questions regarding the cause of so few cases meeting coverage criteria. Are the coverage criteria for POVs reasonable and evidence-based? Are suppliers overstating the medical necessity for POVs? What percentage of these cases represents "recreational scooters" (predominantly external environments) versus power wheelchairs (predominantly indoor use)? Do DMERCS take into consideration a patient's secondary diagnoses and comorbidities when making coverage decisions?

In December 2003, CMS released an article entitled "Power Wheelchairs and POVs-Policy Clarification and Medical Review Strategy." This article spawned an enormous backlash especially due to what many considered to be restrictive coverage criteria. For example, POV coverage is denied if a beneficiary "is able to walk either without any assistance or with the assistance of an ambulatory aid, the aid of a walker, cane, or brace they are not eligible for any mobility device."

MEDICAL VERSUS FUNCTIONAL MODEL
Physicians continue to play a dominant role in prescribing RT, including POVs. However, physicians operate from a medical model of care based on "medical" diagnoses. Their role could be augmented by PTs and OTs who operate from a function-based paradigm. Medicare has partially attempted to address the disconnect between these models by now requiring that specialist physicians complete POV CMNs. These specialists include: orthopedic surgeons, physical medicine and rehabilitation or physiatrists, neurologists, and rheumatologists.

Though perhaps a step in the right direction, this model falls short of what is necessary to assure appropriate RT selection. A coalition of power wheelchair companies agrees with the use of PTs and OTs in the prescription process. The Restore Access to Mobility Partnership (RAMP) has promulgated a 10-point plan that addresses the need to curtail Medicare fraud while assuring access to POVs for those persons with disabilities who meet the medical necessity requirements. Point five of their plan asserts that completion of a CMN involves a collaboration between physicians and therapists to more accurately identify functional limitations and document them accordingly.

CUMULATIVE TRAUMA DISORDERS
Simply because a patient can do something does not mean that they should. Medicare requires that alternative means of mobility be ruled out before prescribing a POV. However, it could be professionally irresponsible for a therapist to place at-risk patients in manual wheelchairs even if they can successfully pass a trial test.

Self-propulsion of manual wheelchairs has been shown to be associated with cumulative trauma disorders (CTDs).^11,12 Therefore, before prescribing a device one must examine the potential risk of CTDs, especially in those who are predisposed. Persons who engage in repetitive activities, assume nonphysiologic positions, and have pre-existing conditions, eg, vascular, orthopedic, or neurological conditions, are at risk of developing CTDs. The most prevalent CTD associated with manual wheelchair use involves the shoulder. Cooper et al found a repetitive strain disorder prevalence for manual wheelchair users of between 31% and 73%. They conclude that the risk of developing upper-limb pain increases as a function of time spent propelling a wheelchair. Carpal tunnel syndrome and rotator cuff strain represent two of the more common disorders associated with this activity. Elbow disorders occur in 16% of the population followed by wrist (13%) and hand pain (11%). These are significant prevalence rates. These results were confirmed by van der Woude et al during ergonomic analysis of wheelchair propulsion. These researchers examined the effect of lever, crank, hubcrank, and handrim propulsion of manual wheelchair users.¹³

The act of self-propelling a manual wheelchair can be extremely demanding from a metabolic standpoint for those with compromised cardiac or pulmonary systems. Many beneficiaries who are prescribed POVs have conditions that place them at risk when engaging in stressful activities. For instance, 75% of all strokes and 50% of all myocardial infarctions are associated with diabetes mellitus (DM).⁴ Patients with DM may therefore be at great risk if placed in manual wheelchairs versus POVs. A history of myocardial infarction, obesity, cerebral vascular accidents with hemiplegia, COPD, coronary artery disease, end-stage renal disease, and emphysema is often the rule and not the exception when dealing with an elder population.

Persons with chronic disabilities often have deficient peripheral and central hemodynamic responses due to inactivity of the skeletal muscle pumps. In so-called normals, intensity of exercise increases oxygen consumption linearly. Unfortunately, in persons with heart disease, maximum oxygen consumption is commonly 30% to 50% below their age and gender matched counterparts without heart disease.¹

The clinical literature indicates that between 25% and 30% of persons 65 or older will fall one or more times as a result of medical conditions.¹⁴ A history of prior falls has been shown to be highly predictive of future falls within the elderly population.^15-18 Therapists and physicians must take into account these and other data when making determinations about which patients should receive assistive ambulatory devices and which should receive mobility devices. Medicare POV coverage criteria markedly exaggerate the merits of ambulation especially when rejecting POVs based on ambulation status. There is ambulation, functional ambulation, and safe ambulation. These three are mutually exclusive concepts. The Medicare notion that a beneficiary's ability to take "a step" makes them an ambulator is a preposterous assumption.¹⁹ What a patient can do is not necessarily good for them and may place them at risk for greater disability and perhaps death. A full 25% of elder persons who fall with resultant hip fracture die within 6 months even with the provision of optimal care.²⁰

SUMMARY
POVs may be the most appropriate choice for persons who are at risk of catastrophic injury, disability, or death should they be placed in a compromised position relative to their medical conditions. There is no panacea for successfully securing Medicare reimbursement particularly in light of coverage variations between DMERCs/intermediaries and the shifting sands of coverage policy. However, the guidelines outlined here may assist therapists who wish to serve as patient advocates in establishing the medical necessity of RT prescriptions.

David W. Clifton, PT, is president of Dolphin & Associates, Media, Pa.

REFERENCES

Cooper RA, Quatrono LA, Axelson PW, et al. Research on physical activity and health among people with disabilities: a consensus statement. J Rehabil Res Devel. 1999;36:142-154.
Department of Health and Human Services, Office of Inspector General. A Comparison of Prices for Power Wheelchairs in the Medicare Program. OEI-03-03-00460, April 2004.
Zimmermann KP, Brown RD. Rehabil-itation technology prescriptions: determinants of failure and elements of success. Phys Med Rehabil. 1997;11:1-12.
Goodman C, Boissonnault W. Pathology: Implications for the Physical Therapist. Philadelphia: WB Saunders Co; 1998.
Criqui MH, Langer RD, Fronek A, et al. Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med. 1992;326:381-386.
O'Sullivan S, Schmitz T. Physical Rehabilitation: Assessment and Treatment. Philadelphia: FA Davis Co; 1994.
Weissland T, Pelayo P, Vanvelcenaher J, Marais G, Lavoie JM, Robin H. Physiological effects of variation in spontaneously chosen crank rate during incremental upper-body exercise. Eur J Appl Physiol Occup Physiol. 1997;76:428-433.
Vinet A, LeGallas D, Bernard PL, et al. Aerobic metabolism and cardioventilatory responses in paraplegic athletes during incremental wheelchair exercise. Eur J Appl Physiol Occup Physiol. 1997;76:455-461.
Salvi FJ, Hoffman MD, Sabharwal S, Clifford PS. Physiologic comparison of forward and reverse wheelchair propulsion. Arch Phys Med Rehabil. 1998;79:36-40.
Glaser RM, Sawka MN, Brune MF, Wilde SW. Physiological responses to maximal effort wheelchair and arm crank ergometry. J Appl Physiol. 1980;48:1060-1064.
Cooper RA, Robertson RN, Boninger ML, et al. Clinical workstation for reducing wheelchair propulsion injuries. Rehabilitation R&D Progress Reports 1995. 1996;33:303-304.
Cooper RA, Boninger ML, Shimada S, et al. Manual wheelchair user upper extremity pain. Rehabilitation R&D Progress Reports 1996. 1997;34:277-278.
Van der Woude LHV. Ergonomics of manual wheelchair propulsion. VA Rehabilitation Research and Design Progress Reports. 1997;34:309-310.
Tinetti ME, Ginter SF. Identifying mobility dysfunctions in elderly patients: standard neuromuscular examinations or direct assessment? JAMA. 1988;259:1190-1193.
Brians LK, Alexander K, Grota P, et al. The development of the risk tool for fall prevention. Rehab Nurs. 1991;16:67-69.
Schmid NA. Reducing patient falls: a research-based comprehensive fall prevention program. Mil Med. 1990;155:202-2077.
Lipsitz LA, Jonsson PV, Kelley MM, Koestner JS. Causes and correlates of recurrent falls in ambulatory frail elderly. J Gerontol. 1991;46:M114-M122.
Shumay-Cook A, Baldwin M, Polissar NL, et al. Predicting the probability for falls in community-dwelling older adults. Phys Ther. 1991;77:812-818.
Centers for Medicare and Medicaid Services, DMERC article. Policy Clarification RE Manual and POVs, Scooters. Washington, DC; December 9, 2003.
Dunn SA, Erickson DM, Marx SC, et al. Falls among enrollees in a Medicare HMO. Medical Journal of Allina. 1998;7(1):1-10.

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