We spend a great deal of time and effort performing and documenting seating and mobility evaluations so that our clients can get what they need to function every day. Did you know that 30-35% of these evaluations/recommendations result in pends or denials? Pends mean that the funder needs more information before a decision. Denials mean just that. Statistically, this is found most often with clients who have Medicare and commercial insurers who follow Medicare policy.
All of this means that our clients either don’t get their much-needed complex equipment, or they have to wait a long time to get it. Either situation is unacceptable. So how can we mitigate that? During evaluations, time is at a premium, and sometimes things can be overlooked.
The thing is, we spend time and attention with this either on the front end, during eval and documentation, or on the back end, once the request is pended or worse, denied.
We must know how to
rule out lesser equipment: why lesser/ less expensive equipment will not work for your client. We need to answer the question: “Why does your client need higher-level equipment that costs more?”.
In doing that, we also have to know how to
rule in the equipment that your client needs. This involves the clinician matching their client’s needs to equipment components and is best done in partnership with their ATP/ supplier. The clinician is the expert on identifying and communicating the client’s physical and functional needs; the ATP/supplier’s expertise is taking those goals and matching them to equipment.
Identified “pinch points” based on data, where there is often not clear documentation are identified as:
- Understanding how to follow the clinical algorithm—adapted from CMS website. This begins with- can they walk to accomplish MRADL’s safely and in a timely manner. Period. This is the very foundation of ruling out lesser costly items.
All statements and discoveries from the evaluation must be backed up with either objective evidence or clinical observation.
- Lower end manual wheelchair vs K0005. It is necessary to understand how a K0005, ultralight manual wheelchair configuration affects the client’s function to understand why your client needs certain features, such as the adjustable axle.
- Tilt only vs tilt + recline. Why is tilt needed for your client? Why do you need to add recline to the tilt? Pressure relief, mitigation of spasticity, intermittent catheterization. Tilt and recline need to be justified independently of each other.
- Group 2 vs Group 3 multi power. Why will the Group 2 not meet your client’s needs? Clinical observations/interviews, details from the home assessment, and or objective measures are needed to rule in the Group 3 multi-power wheelchair.
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