Clinician Talk

Ultra-light Done Right

Clinical considerations and documentation demands for ultra-lightweight wheelchairs.

• By Julie Piriano
• May 01, 2010

One of the positive outcomes for durable medical equipment that took effect on Jan. 1, 2009, is that manual wheelchairs, along with the options and accessories provided with them, received a 5 percent payment increase under the Medicare program. This has made the provision of ultra-lightweight manual wheelchairs much more attractive. While the coverage criteria and documentation requirements for ultra-lightweight wheelchairs have not changed since the implementation of the National Coverage Determination (NCD) for Mobility Assistive Equipment (MAE), the utilization of the K0005code has increased steadily since 2005.

How have some providers been able to make these products available to Medicare beneficiaries while others find that Medicare never pays for this HCPCS code for the typical Medicare beneficiary? The answer is in the word “typical.” The Medicare program was designed to provide medical benefits for individuals who are over 65 years of age and those with a permanent disability who receive Social Security Disability Insurance. It’s important to understand the clinical considerations and documentation requirements for an ultra-lightweight wheelchair to determine which seniors and persons with a disability will benefit most from this type of product. The need for an ultra-lightweight wheelchair must be verified through the ADMC process.

A Medicare beneficiary is currently not required to have a face-to-face examination with their physician or other medical professionals to procure an ultralightweight manual wheelchair. However, the medical record must support the medical necessity of the wheelchair and all separately billable components. A thorough evaluation by the physician, clinician and provider that addresses the individual’s diagnosis, prognosis, abilities and limitations and current and future needs should result in the proper documentation.

For all MAE, it must be documented that the patient has a mobility limitation that significantly impairs their ability to participate in one or more mobility-related activities of daily living (MRADLs) in the home. The documentation must also refl ect whether the individual can get to the customary location in the home where the activity takes place safely, independently and in a timely manner using their current method of mobility. If all three conditions are not met the individual has a mobility limitation and it needs to be documented as such.

For the provision of an ultra-lightweight wheelchair, documentation of the mobility limitation alone is insufficient. Coverage for this type of chair is determined by individual consideration, so a description of the patient’s routine activities and independence must be included. If we examine the MRADL of feeding, the “typical” Medicare beneficiary would be expected to get to the kitchen safely, independently and in a timely manner with the appropriate MAE in order to eat or be fed. The ultra-lightweight wheelchair user, on the other hand, might use their chair to go to the store, buy the groceries, bring them home, put them away, prepare the meal, eat the meal and clean up after the meal. Medicare does not have a set of criteria to gage an individual’s routine activities or activity level as sufficient or insufficient to warrant the provision of an ultra-lightweight wheelchair. They do expect the information to include whether or not the patient is fully independent in the use of the wheelchair. To obtain this information many providers have given their customers the opportunity to tell Medicare about their routine activities that occur on a daily, weekly and monthly basis.

Medicare expects the documentation to include a description of the features on a K0005 that are medically necessary as compared to a less costly K0004 base. While there may be many features that would benefit to the user, the ones that must be highlighted are the weight of the chair and the adjustable axle as these two variables significantly affect propulsion mechanics and efficiency. One way to quantify the effect of the weight of the chair on propulsion is to document the differences in heart rate, respiration rate, oxygen saturation and the length of time it takes to traverse a set distance between a K0004 and K0005 that are similarly configured and propelled at a self-chosen pace.

Documenting the quantitative differences in axle position is easier if you have access to a SmartWheel, but it can also be done with two tape lines, a watch with a second hand and the following chart:

	Distance	Time (sec.)	# of strokes	Notes (describe axle position)
K0004	100 ft.
K0005, axle in #0 position	100 ft.			No camber, no dump
K0005, axle in #1 position	100 ft.
K0005, axle in #2 position	100 ft.
K0005, axle in #3 position	100 ft.

It should be noted that the minor vertical and horizontal rear wheel attachment points on the frame of some K0004 chairs that allow different size wheels to be used on the base are not the same as a fully adjustable axle. An adjustable axel is one that allows the rear wheel position to be customized in the horizontal, vertical (dump) and rotational (camber) planes relative to the user’s position in the chair. Each of these parameters have an effect on start-up propulsion force, continued propulsion forces, propulsion efficiency and the repetitive motion necessary to self-propel. By documenting the increased timeliness and reduced number of strokes required to propel over a set distance, it can be deduced that an individual who uses their wheelchair all day, every day in the participation of their routine activities will be less likely to suffer from repetitive strain injuries.

Lastly, it is beneficial to evaluate, compare and document the individual’s ability to start up and propel a K0004 vs. K0005 wheelchair on a variety of surfaces other than the level tile fl oors commonly found in clinics and hospitals for a Medicare beneficiary who’s routine activities required them to selfpropel over low and high pile carpet, grass, gravel, concrete, pavers and ramps. Appropriate wheelchair prescription requires maximizing user function while justifying cost. Ultra-lightweight wheelchairs are not medically necessary for all Medicare beneficiaries but are essential for many to maintain mobility independence.

This article originally appeared in the May 2010 issue of HME Business.