CustomSeating Is it really that complicated?

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MANUAL POWER ADULT PEDIATRICS SEATING GERIATRICS CONTROLS FUNDING

Custom SeatingIs it really that complicated?

Presented by:Steve Boucher OTR/L &

Angie Kiger, M.Ed., CTRS, ATPClinical Education Specialists, Sunrise Medical LLC

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CONFIDENTIAL AND PROPRIET ARYDuplication or Distribution Prohibited

7-20-2012

• Breaks and Lunch

• Handouts

• CEUs

– Discuss questions

Housekeeping

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• IACET CEU CREDIT

• Must be paid in full

• Must sign in at the registration table

• Must provide last 4 of your SSN

– If you didn’t provide it when you pre-registered, there will not bea certificate onsite

– You can still provide the last 4 of your SSN now on yourevaluation, certificate will be provided within 45 days

• Must complete the evaluation form and turn it in at theclose of the seminar

• It is a requirement that to receive CEU credit, you must

attend the full course

To Receive CEUs

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Course Objectives

Participants will be able to:

• Identify postural deviations and their relationship to function and skin

• Identify commonly seen symptoms and use assessmentskills to understandthe cause, therefore providing solutions rather than band aids.

• Recognize when off the shelf solutions are simply nota solution!

• Identify limitations in Range of Motion as an indicator of the need forCustom Seating

• Identify when custom shaping is appropriate as well as how to achieve thebestpossible outcomes.

• Identify 3 or more clinical indicators for the use of tilt in space technology

• Understand when tilt is for positioning and when its for Pressure reduction

• Understand the funding requirements for Custom Seating.• Learn how to appropriately justify the medical need of Custom Seating.

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The Road To Documentation

• As we follow today’s course, you will see how each partties to the documentation you create and how it will be

used for insurance coverage.

• Documentation plays a critical role within the evaluationprocess for these products.

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Critical Questions

• Who is the funding source?

• What other equipment does the patient have (had)?

– Everything related to seating & mobility

– When was it received?

• Why does it no longer meet their medical needs (otherneeds can also be included)?

• Who funded the equipment?

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The First Steps

Preparation…• Think about… Who will review the letter of justification?• What is this person’s medical background? Do they have an

understanding of the Durable Medical Equipment (DME) worldthat we live in every day?

• Remember… The reviewer(s) only knows your patient by whatis on paper. It is your job to “tell” the detailed story – this isespecially true when we talk about custom systems.

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Common Funding Sources

• State Medicaid Programs– These vary by state

– Become involved

– Work with your providers

• Private Insurance

• Medicare (Could include pediatrics. Also issues with previoususers, but now new to Medicare program)

• Others…?

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What’s Your Style?

• Make a game-plan to keep it simple.

• Does your eval document need to be “tweaked?”

• What about templates?

– Keep in mind, your clients are individuals

– Proof-read!

– Contradictions

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Things To Know

• Nothing is really paid based only on diagnosis

• Assume the reader knows nothing of the client, thepresenting condition, or the requested equipment.

• Establish a professional appearance with the report, but

keep it organized with a flow.

• Manufacturer order forms are good to use as a cheatsheet/guide. Prioritize information and keep the facts

simple and focused.

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Helpful Hints

• Add pictures if value can be added

• The letter should be clear, easy to read and to the point

• Stick to the facts and keep it simple!

• Clarity is critical

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Today, Think About…

• Basic Demographics to include primary & secondarydiagnosis, history of condition, prognosis, etc.

• Description of equipment currently being used.

• How client currently presents in their existing equipment

and out of their equipment

• What postures relative to sitting are tolerant of correction

• What's the skin risk analysis and why

• What's the functional analysis

• Key component: Mat evaluation

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What If It’s A Replacement?

• For many funding sources… Largest denial cross-country: Same/similar

• Documentation is key!

• “Life of equipment” - 5 years plus….

• Change of condition - what is needed? This is whereeval’s are crucial.

• No automatics

• So… what do you do? What do you need?

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Clinical Best Practices

• Are there any related to seating?

• What would they be?

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How About…

• A thorough hands on evaluation must be conducted

– Identify flexible versus fixed postures

– Identify the symptoms versus causes

– Understand the level of risk for skin integrity issues

– Understand functional needs/limitations

• Translate clinical findings into product parameters

• Simulate the proposed solution prior to final prescription

• Client education on equipment use…

• Future financial planning – plan of care- repairs etc

• Knowing and understanding the funding of the product.

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Where Do We Stumble?

• Sometimes shortcuts are taken with the evaluation

• Sometimes trial is not possible

• Sometimes we battle with the conflict between therapeuticperfection – safety and function?

• We find out about the type of funding available after the eval and/orafter the equipment has been ordered.

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What Are The Goals?

PositioningPositioning

SeatingToleranceOr Comf ort

SeatingToleranceOr Comf ort

AestheticsAesthetics

AcceptanceAcceptance

Access toVocation

Access toVocation

Function/Mobility

Function/Mobility

SkinIntegrity

SkinIntegrity

Change inSize

Change inSize

ManageTone

ManageTone

StabilityStability

Seating &Mobility

Seating &Mobility

Reimbursable Non-Reimbursable

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Band-Aids

• Do we put band aids on the symptoms or actually dealwith the cause?

– Are we sure we catch ourselves doing this?

– I have to constantly ask myself this question…

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Seating Symptoms vs. Causes

• Sliding?

• Scissored legs?

• Trunk falling forward?

• Body extending like a banana from seat?

• Feet falling off the footplates?

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The Client Who Slides Constantly

• Do You Know Any?

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Did You Think Of These…

• Wedge cushion

• Medial thigh support (Pommel)

• Pelvic positioning strap (Seat belt)

• Elevating legrests

• Dicem

ARE WE CRAZY??!!

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What Did We Search For?

• Band-Aids for the Symptoms, or…

• Solutions for the Causes?

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Advise From Sharon

• Have we identified the cause of the problem or only thesymptom?

• Always ask ourselves – does the posture have flexible

and or fixed components?

• Lets look briefly at some of the more common posturesas they relate to seating.

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Postural Analysis

Posterior Pelv ic Tilt

New pressure pointsat sacrum and spine

Accompanied byincreasedkyphosis

Ischials travelforwards

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Full C-Curve

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Posterior Pelvic Tilt

• Extreme posterior pelvic rotation

– Ribs nearly touch the pelvis

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Could It Be a Technology Induced Posture?

What does this girls sitting footprint look like do you think?

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Respecting Client Shapes & Angles

• Core stability

• Optimizing distal function

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Anterior Pelvic Tilt

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Pelvic Obliquity

Right Obliquity

Compensating

Scoliosis

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Pelvic Rotation & Obliquity

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Skin Risk Assessment

• If the client is

– High Risk

– Moderate risk , or

– Low risk for skin breakdown

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Wheelchair Positioning for Managing Tissue Loads

• Obtain specific body measurements for optimal selectionof seating system dimensions

• Measure the effects of posture and deformity oninterface pressure distribution

• Prescribe power weight shifting systems for individualswho cannot perform an effective manual weight shift

• Use clinical judgment as well as objective data indetermining the compatibility of the individuals shapewith the seating system

• As you assess, keep in mind what documentation will beneeded for funding of what you decide to order for yourclient.

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Principles of Pressure Reduction “In Chair”

• Consider method of load redistribution– Pressure = Force (body weight)

Area (wt-bearing area)• How much positioning is needed?

– Postures needing accommodation or correction• How much stability is needed for function?

– Consider lateral and forward

• Consider Materials – Mechanisms and Forces• Consider moisture accumulation and temperature elevation at

support surface-skin interface• Avoid uninterrupted sitting – employ a power weight shift system

when manual pressure relief is not possible• Use written plan or protocol• Remember – things change – plan a follow up on equipment

performance

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Sitting: Dynamic or Static

• Is sitting a dynamic or a static activity?

– How much work is it to sit?

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Thinking About Sitting Footprint

• Where are all the loading surfaces?

• How can we maximize the footprint?

• What is the optimal footprint?

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Bodies Vary: Load & Shape

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Footprint in 45 Degrees Tilt

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Backrest Not Taking Load

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Increased Loading on Backrest

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Footplates Too High: Thighs Not Loaded

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Footplates Too Low

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Considerations For Tone Management

• High Tone

– CONSIDER THE TRIGGERS

– CONSIDER THE INHIBITORS

• What can the seating and mobility system do in reality toeffect the inhibitors?

• What might it be doing to motivate the triggers?

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Examples of High Tone

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Facilitate Functional Tone

• We need tone!

• Identify triggers and inhibitors

• Reduce as many triggers as possible in the seatingmobility system

• Provide a safe environment with surfaces that the childcan get back to

• Respect that sometimes static solutions are not ideal for

dynamic postures

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Remember…

• Seating DOES NOT

– Sprinkle magic

– Administer drugs

– Do surgery

x x x

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Considerations For Tone Management

• Low Tone

– What the biggest challenge?

• Is it the HEAD?

• The bowling ball on the noodle idea?

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Low Tone

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Where Do We Begin

Off The Shelf

Custom Shaping

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Seating – Hierarchy - Complexity

• Consider a product ladder

– What changes from bottom to top?

– Keep this in mind when it comes todocumentation for proper reimbursement.

Basic off the shelf seating – non customizable

Off the shelf seating – customizable

Custom made seating – linear, contoured,molded

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Seat Cushions

• When is a solution NOT enough

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When Is This NOT Enough?

Off the shelf: Pre-contoured, non customizable

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Off the shelf: Pre-contoured, customizable

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Off the shelf: Modified

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Addition or subtraction of components

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• Controlling the volume and location of a fluid

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Funding of Seat & Back Cushions

• The Categories:

– General Use Seat or Back Cushion

– Skin Protection Seat Cushion

– Positioning Seat or Back Cushion

– Skin Protection & Positioning

• For Medicare funding and many others, all seat & backcushions must be officially code verified by PDAC (a

Medicare contractor). This coding process requirestesting of all products.

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General Use Seat & Back Cushions

• Covered if a patient has (and qualifies for) a mwc orpwc with a sling/solid seat.

– Will not be funded if the clients wc has a Captains Seat.

• Always good to add why standard upholstery will notmeet the medical needs… should be a no-brainer.

• No specific dx requirements.

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Skin Protection Seat Cushion

• The patient must have (and qualify for) a mwc or pwcwith a sling/solid seat; AND

• The patient has either of the following:– Current Pressure Ulcer or past history of a pressure ulcer on the

area of contact with the seating surface; OR– Absent or impaired sensation in the area of contact with the

seating surface or inability to carry out a functional weight shiftdue to a specific dx.

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Positioning Seat or Back Cushions

• The patient must have (and qualify for) a mwc or pwcwith a sling/solid seat/back; AND

• The patient has significant postural asymmetries that are

due to one of the specific dx.

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Combination Seat Cushions:Skin Protection & Positioning

• Covered for clients who meet the criteria for both a skinprotection seat cushion & positioning seat cushion.

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Miscellaneous Seating Items

• No separate payment for a solid insert (E0992) - aseparate rigid piece of wood or plastic which is inserted

in the cover of a cushion. If used, must bill with A9900.

• A solid support base (E2231), which is attached withhardware to the seat frame in place of a seat sling can

be billed on mwc’s only.

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Back Supports

• Off the shelf

• Custom

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Level of Support in“Off The Shelf” Back Support Solutions

Lower Thoracic

Mid Thoracic

Upper Thoracic

Shoulder

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Angle Adjustment

• Whatdegree of adjustment is available?• What is the resulting seat depth loss?

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• How much is provided?

• Where is it located?

• Built in or attached?

• Fixed or swing away?

• What is covered and what documentation is needed?

• What are the considerations?– Function – enhanced or compromised?– Width impact?

– Propelling impact?

– Static solution to dynamic challenge???

Lateral Support

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Lateral Contour Location - Is It Where You Need It?

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Shape

• Can clients posturalneeds be corrected

and or accommodatedwith simple on the spotshaping components?

• If not – then this maysend us in the direction

of more customizedshaping

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Spine Shaping Components

• As thisexample of a“C” shapedposturedemonstratesthe footprintincreasesdramaticallywhen Spine-align shapingcomponentsare used.

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Spine Shaping Components

• In this example,a different set ofcomponents areused to match adifferent spinalposture.

• If this is notenough – mayneed toconsider a morecustomizedback support

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What Is It?

• Custom Shaped/Molded Seating

– Any type of seat and/or back cushion that is manufactured toclosely match the shape of a specific individual by actuallycapturing that person’s shape in some way.

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Custom Seating: Diagnosis Codes

Code Descrption

138.0 Late effects of acute poliomyelitis

323.82 Other causes of myelitis

330.0 - 330.9 Leukodystrophy Unsp cerebral degen in childhood

331.0 Alzheimer ’s Disease

332.0 Paralysis Agitans

333.4 Huntington’s Chorea

333.6 Genetic Torsion Dystonia

333.71 Athetoid Cerebral Palsy

334.0 - 334.9 Fredreich’s Ataxia Spinocerebellar Disease Unsp.

335.0 - 335.21 Werdnig-Hoffman Disease Prog Muscular Atrophy

335.23 - 335.9 Pseudobulbar Palsy Anterior Horn Cell Disease Unsp

336.0 - 336.3

Syr ingomyelia & Syringobulbia – Myelopathy in Other Diseases

Classified Elsewhere

•Skin Protection dx

•Positioning dx (added to the Skin Protection dx, except pressure

ulcers)

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Code Desc rption

340.0 Multi ple Sc lerosi s

341.0 - 341.9Neuromy elitis Optica D emyelinating Disease of C entral NervousSys tem Uns pec if ied

342.00 - 342.92

Falc c id Hemiplegia & Hemi par esis Af fect ing Unsp. S ide – Unsp

Hemiplegia & Hemiparesis Affec ting Non-Dominant Side

343.0 - 343.9 Congeni tal Di plegi a Infanti le C erebral Palsy Uns p

344.00 - 344.1 Quadriplegia Unspec if ied - Paraplegia

344.30 - 344.32

Monoplegia or Lower Limb Affecti ng Unsp Si de – Monoplegia of Lwr

Limb Affecti ng Non-Dominant

359.0 Congenital Hereditary Musc ular Dy strophy

359.1 Hereditar y Progressi ve Mus cular Dys trophy

438.20 - 438.22

Hemiplegia affec ting Unsp Side – H emiplegia Affec ting Non- Dominant

Side

•Skin Protect ion dx

•Posi tioning dx (added to the Skin Protection dx, exc ept pressure

ulc ers)

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Code Descrption

438. 40 - 438.42Monoplegia of Lower Limb Affecting Unsp Side – Monoplegia of LwrLimb Affecting Non-Dominant

707. 03 - 707.05

Pressure Ulcer, Lower Back – Pressure Ulcer, Buttock (Skin

Protection or Combination Seat Cushions Only)

741. 00 - 741.93

Spina Bifida Unsp Region w/ Hydrocephalus – Spina Bifida LumbarRegion w/out Hydrocephalus

756.51 Osteogenesis Imperfecta

897.2 - 897.7

Traumatic Amputation of Leg(s) (Complete) (Par tial) Unilateral at orAbove Knee w/out Complication – Traumatic Amputation of Leg(s)

(Complete) (Partial) Bilateral (Any Level) Complicated


•Posi tioning dx (added to the Skin Protection dx, except pressure

ulcers)

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Custom Fabrication

• Seating to accommodateunique postures

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Custom Fabrication

• Seating to accommodate unique postures

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Custom Fabrication

• Molded seating to accommodate unique postures

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Molded Seating

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Custom Shaped, Molded Seating

• This type of seating tends to be for clients who areunable to attain a stable, comfortable position in off-the-

shelf adjustable seating

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• Meant to accommodate any posture!

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• Spreads the load over alarger area

– Interface Pressures in seatingare relative to area.

– In two people with the sameweight, the person with thelarger bum will have a lowerInterface Pressure.

– These two individuals mayactually have the sameInterface Pressure!

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• Categories

1. Simulation and casting

2. Simulation and digitizing

3. Cushion molding directly on client

4. One use shippable simulator

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Before You Start Molding

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Perform Full Mat Evaluation

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Clothing Can Complicate

• Try to have client wear clothingthat doesn’t complicate the

molding process

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Protect The Client

• Take all Necessary Precautions to Protect Your Client

Heavily Padded SimulatorFrame

Extra People to Help Hold ClientSecurely and in optimal alignment

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Remove Jewelry

• Remove All Jewelry,Watches And Any Other

Sharp Objects From YouAnd Your Client!

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Midline Adjustment is Often The Goal

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Can We Mix?

• You Can Mix Molded Components With Off The ShelfProducts

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Consider The Mobility Base

• Lets review some principles and thoughts on Tilt

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Definitions

• Tilt: cause to lean, incline, slope or slant (refers to an object). Moveinto or assume a sloping position or direction (dictionary.com)

• Tilt-in-Space: “changes an individual’s orientation in space, relativeto the ground while maintaining the seat-to-back, and seat-to-leg-restangles” (RESNA position paper)

• Can be manual or power operated

• Has your documentation ruled out whyoff the shelf seating systems do notmeet your client’s medical needs?”

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Benefits of Tilt-In-Space

• Allows for gravity-assisted positioning

• Can be positioned and re-positioned throughout the dayat varying degrees of tilt

• Maintains seat-to-back angle

• useful with contoured seat backs to maintain contact

with back support ( Shear forces)

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Shear Forces

cl

Reference point on client

Reference point on chair

Client slides down in chair= shear forces

Recline Tilt

Client relationship withseating systemremains constant

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Why Use Tilt-In-Space

• Functional Posture: may facilitate eating and digestion,ADL’s, respiratory function and therapeutic activities.

• Supportive Posture: repositions the body to the pull of

gravity.

• Pressure-redistribution Posture: Sufficient tilting,

redistributes loads, providing pressure redistribution.

Supportive PostureFunctional Posture Pressure-Relief Posture

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Coverage of Tilt-In-Space MWC

• Simply put… not very hard to get covered. You are onlyputting client’s in these wc’s that truly need them.

• Basics:

– Inability to independently weight shift

– Do not need to self-propel

– The clinical eval is key

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Conclusion and Summary

Consider the following:

• Pressure relief can be achieved through posturalchange, positioning and repositioning.

• Provides physiological benefits

• Functional improvement through increased participationin ADLs and environmental access

• Tilt may decrease pain, increase sitting tolerance andreduce fatigue

• Aligning Centre of Rotation and Centre of Gravitycreates stability, decreases wheelbase of the chair

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Getting a Custom Shaped System Funded

The Basics:

• Does it vary by funding source?

– What are your state Medicaid funding requirements?

• Is this only covered for specific diagnosis?

• Is a therapist eval required?

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Getting a Custom Shaped System Funded

• Think about a “ladder”

• Must justify why a pre-fabricated seat and/or back doesnot meet the end-users medical needs.

– Be specific to that client

• Realize that everything is rolled into a specific code formost funding sources.

– i.e. E2609 – Custom seat – all parts & pieces that relate to thecustom seat need to be included in the one code.

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The Complaints & The Rumors

• “Medicare won’t pay for it”

• “It’s non-covered”

• “It’s too complicated to bill”

• “Nobody get’s paid”

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The Basics

Let’s keep it simple…

• The codes

• What does the policy say?

• Who are the customers?

• What documentation are you

receiving?

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The Codes

• E2609 – Custom Fabricated, Wheelchair Seat Cushion,Any Size

• E2617 – Custom Fabricated Wheelchair Back Cushion,

Any Size, Including Any Type Mounting Hardware

• You can always verify through PDAC.

• If a product is not officially code verified by PDAC foreither of these codes, they cannot be billed using the

codes.

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What Does Policy Say?

• E2609, covered if:

– The patient meets all the criteria for a prefab skin protection seatcushion or positioning seat cushion; AND

– There is a comprehensive written evaluation by an “LCMP,”which clearlyexplains why a prefab seating system is notsufficient to meet the patient’s seating & positioning needs.

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What Does Policy Say?

• E2617, covered if:– The patientmeets all the criteria for a prefab positioning back cushion;

AND

– There is a comprehensive written evaluation by an “LCMP,” whichclearly explains why a prefab seating system is not sufficient to meetthe patient’s seating & positioning needs.

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What Does This Mean?

• Selecting the product may be the easy part, howeverATPs and prescribing clinic ians must understand the

policy.

• Prescribing clinicians must be able to document why the“out of the box” options would not meet that specific

clients’ needs. This should not be basic generalstatements.

• ATPs must be able to communicate with the prescribing

clinician if a client may not qualify.

• Internal staff must understand what they are reading.

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Diagnosis Codes: E2609

Code Descrption



330.0 - 330.9 Leukodystrophy Unsp cerebral degen in childhood331.0 Alzheimer’s Disease








336.0 - 336.3

Syringomyelia & Syringobulbia – Myelopathy in Other Diseases


ICD-9 Code

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Code Desc rption

340.0 Multiple Sclerosis

341.0 - 341.9

Neuromyelitis Optica Demyelinati ng Disease of Central Nervous

System Unspec if ied

342.00 - 342.92

Falccid Hemiplegia & Hemiparesis Affecting Unsp. Side – Unsp

Hemiplegia & Hemiparesis Affecting Non-Dominant Side

343.0 - 343.9 Congeni tal Diplegia Infantile Cerebral Palsy Unsp

344.00 - 344.1 Quadriplegia Unspec ified - Paraplegia

344.30 - 344.32

Monoplegia or Lower Limb Affect ing Unsp Side – Monoplegia of Lwr


359.0 Congenital Hereditary Muscular Dystrophy

359.1 Hereditary Progressive Muscular Dys trophy

438.20 - 438.22

Hemiplegia af fecting Unsp Side – Hemiplegia Affec ting Non-Dominant

Side



ulcers)

ICD- 9 Code

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Code Descrption

438.40 - 438.42Monoplegia of Lower Limb Affec ting Unsp Side – Monoplegia of LwrLimb Affecting Non-Dominant

707.03 - 707.05



741.00 - 741.93

Spina Bifida Unsp Region w/Hydrocephalus – Spina Bifida LumbarRegion w/out Hydrocephalus


897.2 - 897.7

Traumatic Amputation of Leg(s) (Complete) (Partial) Unilateral at orAbove Knee w/out Complication – Traumatic Amputation of Leg(s)


ICD-9 Code

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Code Descrption



330.0 - 330.9 Leukodystrophy Unsp cerebral degen in childhood331.0 Alzheimer’s Disease








336.0 - 336.3

Syringomyelia & Syringobulbia – Myelopathy in Other Diseases


ICD-9 Code

40

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Code Desc rption

340.0 Multiple Sclerosis

341.0 - 341.9

Neuromyelitis Optica Demyelinati ng Disease of Central Nervous

System Unspec if ied

342.00 - 342.92

Falccid Hemiplegia & Hemiparesis Affecting Unsp. Side – Unsp

Hemiplegia & Hemiparesis Affecting Non-Dominant Side

343.0 - 343.9 Congeni tal Diplegia Infantile Cerebral Palsy Unsp

344.00 - 344.1 Quadriplegia Unspec ified - Paraplegia

344.30 - 344.32

Monoplegia or Lower Limb Affect ing Unsp Side – Monoplegia of Lwr


359.0 Congenital Hereditary Muscular Dystrophy

359.1 Hereditary Progressive Muscular Dys trophy

438.20 - 438.22

Hemiplegia af fecting Unsp Side – Hemiplegia Affec ting Non-Dominant

Side



ulcers)

ICD-9 Code

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Code Descrption

438.40 - 438.42Monoplegia of Lower Limb Affec ting Unsp Side – Monoplegia of LwrLimb Affecting Non-Dominant

707.03 - 707.05



741.00 - 741.93

Spina Bifida Unsp Region w/Hydrocephalus – Spina Bifida LumbarRegion w/out Hydrocephalus


897.2 - 897.7

Traumatic Amputation of Leg(s) (Complete) (Partial) Unilateral at orAbove Knee w/out Complication – Traumatic Amputation of Leg(s)


ICD-9 Code

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If You Are Billing These Codes

• Both codes will be manually reviewed for both medicalneed and pricing.

• You must always include the manufacturer model

name/number

• Modifiers:

– NU – New Purchase

– KX – Criteria is met, including comprehensive eval in file, it isbeing used on a wheelchair, and…

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Coverage Criteria

• For E2609 (Seat)– There is a past history or or current pressure ulcer in the area of

contact with the seating surface: OR

– There is absent or impaired sensation in the area of contact withthe seating surface or an inability to carry out a functional weightshift due to one of dx listed as a covered dx for skin protectioncushions; OR

– The patient has significant postural asymmetries due to one ofthe dx listed as a covered dx for positioning cushions.

• For E2617 (Back)– The patient has significant postural asymmetries due to one of

the dx listed as a covered dx for positioning cushions.

• Now, how do you prove it?

Don’t forget the

clinical eval

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How Many Line Items

• You don’t do the billing so why do you care?

– All parts & pieces must be rolled into the codes themselves(E2609, E2617), therefore no additional codes will be billed asthey relate to seating.

– What if a manufacturer invoice is requested?

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Sample Justifications

• All should be different

• Custom Shaped/Molded Seat with Mounting Hardware –A standard sling seat or a pre-fabricated seat cushionwill not meet Patricia’s positioning & pressure reductionneeds due to the severity of her spinal curvatures &pelvic deformities. The custom shaped/molded seatcushion will provide indiv idualized & full contact withPatricia’s body to promote midline orientation & provideadequate pressure reduction over areas of highpressure, most importantly reducing pressure at the righthip (Stage 3 pressure ulcer), which is necessary topromote healing of the pressure ulcer.

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Sample Justifications

• Reminder, all should be different

• Custom Shaped/Molded Back with Mounting Hardware (HCPCE2617)- A standard sling back or pre-fabricated back cushion willnot meet Patricia’s positioning and pressure reduction needs due tothe severity of her spinal curvatures and pelvic deformities. Thecustom shaped/molded back cushion will provide individualized andfull contact with Patricia’s body to promote midline orientation andwill retard progression of the existing curvatures/ deformities.A pre-fabricated product will not provide full contact to Patricia’sbody. Improper or ineffective postural support will only allow theadvancement or worsening of the existing deformities. Progressionof the spinal curvatures and deformities will eventually impair thepatient’s respiratory and digestive functions.

What’s missing from

both?

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Key Items

• Roll all into the one specific code (for seat and back).

• Thorough evaluation

• Documentation – Ruling out all lower level options

• Reading documentation prior to ordering.

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Case Studies: Meet Anne Marie

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Anne Marie’s Presentation

• 27 yr old young lady

• T12 incomplete SCI (Gunshot wound)

• SX 2007 pressure ulcer L IT

– Shaved Left ischium – 1” removed

– Pain in L thigh

– Has discoloration in an area under left trochanter

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Anne Marie’s Equipment Rx

• Has had Qti and J2DC cushion 16x18

• Now has Q7, J3 back and is looking to replace hercushion

• Has tried many cushions including Ride

• Has truck with Bruno power lift

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Anne Marie’s Existing Cushion

• J2 DC 16x18

• Fluid Supplement pads bilaterally placed over top of thefluid pad

• Has piece of foam (visco) taped under front right of fluidpad in well

• O/E – not bottoming out – pelvis and trochantersimmersed in fluid

• Hydrostatic loading ITs and trochanters with loadredirected to front under femurs

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Anne Marie’s Clinical Presentation

• Client presents with Left obliquity and compensatingscoliosis- convex to left – shoulders to right

• Flexible pelvis spine relationship – can achieve a neutral

pelvis and neutrally aligned spine with a build up tosubstitute for her shaved IT

• On palpation – very bony trochanters and sacrum

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Anne Marie’s Clinical Presentation

• Lower extremities and Upper Extremities

– WNL for sitting

• SKIN:

– High risk for recurrence due to past hx

– Redness under left trochanter

– Left IT – surgery site

– Right side OK

• Trunk: Collapses- trunk to left – head and shoulders to

right – Flexible – can achieve neutral alignment

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Anne Marie’s Anatomical Measurements

• Distance between ASIS = 8.5”

• Bitrochanteric lateral outside: 13.5”

• Hip width 15.5

• Anatomical seat depth: 20”

• Scapular height from PSIS = 11”

– From plinth = 16”

• PSIS height from plinth = 5”

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Anne Marie’s Desired Equipment Measurements

• Wheelchair 16x16

• Cushion 16 x 18 to facilitate transfers

• Back support: 16 width : 13 shell height

– Positioning components to support posterior lateral pelvis/trunk

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Mapping System

• Tekscan Conformat Clinical System

• System Equilibrated and Sensitivity adjusted according tomanufacturers instructions the day before session

• System calibrated in situ with clients actual weight prior to each trial.

• Scale as presented in each slide

• Each slide is a average of 5 minutes of registrations at 1 secondintervals

• Principle measurements

– Surface Area in Square Centimeters

– Peak Pressure in the area containing the boney prominences ofthe pelvis

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Existing Cushion

• J2 DC 16x18 with bilateral fluidsupplement pads placed overtop of existing fluid pad andcustom foam piece taped tobottom of well front right side.

• Presents on cushion with leftobliquity and compensatingscoliosis – trunk collapsing toleft – head and shoulders toright

• Pelvis and trochantershydrostatically loaded

• AM checks for bottoming outevery day

• Not bottomed out at time ofassessment

Frontof Wheelchair

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Existing Cushion

• Peak pressure at right ischialtuberosity

Frontof Wheelchair

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Mat Table

• Pelvis collapsed to left

• Increased loading on right sideof back support in scapulararea

• Limited loading on left side ofback support

Frontof client

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Mat Table

• Client generates excessiveloading at right ischialtuberosity

Front

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1st Trial (J3CD1618BFVS)

• J3 Deep cushion with B PelvicLoading Area (P.L.A.) and fieldvariable fluid

• Change in cushion heightrelative to footplate adj. resultsin decreased femoral loading

Frontof Wheelchair

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1st Trial (J3CD1618BFVS)

• ASIS presents as level, pelvicobliquity corrected due toloading on left trochanter

• Load on left trochanter higherthan acceptable andinsufficient load redistributed toright

Frontof Wheelchair

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2nd Trial (J3CD1618CFVS)

• Changed to C Pelvic LoadingArea (P.L.A.)

• Low loading about the leftramus.

• Need to increase seat angleand lower footplates

Frontof Wheelchair

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2nd Trial (J3CD1618CFVS)

• Excessive loading on lefttrochanter.

• Although the pelvis appearslevel load is still on the left.

Frontof Wheelchair

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3rd Trial (J3CD1618CFVS)

• Medium Fluid supplementadded to left front of FieldVariable (FV) fluid pad

• Increased seat angle andadjusted footplate

Frontof Wheelchair

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3rd Trial (J3CD1618CFVS)

• Loading area about left ramusincreased resulting in decreasedleft trochanter pressure.

• Peak load shifted to righttrochanter, pelvis is level withmore uniform pressuredistribution.

Frontof Wheelchair

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Comparison Chart

94 mmHG(right greater trochanter)

1217.55 cm2J3 Deep, C PLAWith medium fluid supplement added to left front

163 mmHG(left greater trochanter)

1180.65 cm2J3 Deep, C PLA

136 mmHG(left greater trochanter)

1139.42 cm2J3 Deep, B PLA

106 mmHG(right ischial tuberosity)

1115.54 cm2Existing J2DCWith supplement pads and foam insert anterior toright ischial

Peak Critical PressureSurf ace AreaTrial

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Conclusion

• Anne Marie is now sitting with a functionally symmetricalposture for the first time since her surgery in 2007

• Her surface contact area has improved with this J3 deep

cushion

• She is showing a decrease in her peak pressures withthe load now being more evenly distributed

• Less loading on her right ischial with improved

distribution throughout her left ramus and bilateralfemurs which means her residual left IT and Right IT are

more protected

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Essential Clinical Questions

• Will the client be able to consistently orient to the pelvicloading area

• What changes are predicted to occur with the client?

• How capable and compliant will the client or caregiver be

at needed maintenance?

• What are the lifestyle considerations?

– Transferring

– Transporting

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Essential Clinical Questions

• Can the client carry out all functional activities on theselected product

• IS IT COMFORTABLE? …For the client!! Has sitting

tolerance been increased?

• Have we provided all the necessary justification

• What is the consequence of the client not getting thisequipment

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Case Study: Meet Ryan

• Age 7

• Diagnosis: Spastic Diplegic-CP

• Equipment being used to date

– Uses a walker in school

– Manual wheelchair at home and getting to and from school

• Therapeutic goals

– Improve standing and walking

– Fine motor skills

• Mobility Goals

– Encourage walking

– Provide fully independent mobility in all areas of life

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Goals For Ryan’s Seating System

• Posterior lateral pelvicsupport to inhibit “collapsing

posture”

• Posterior thoracic supportthat does not inhibit upper

extremity function

• Intermittent lateral thoracicsupport for fine motor skills

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Case Study: Meet Hunter

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Hunter Does NOT Like This!

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Custom Fabricated Seatingto Match Hunter’s Body Angles

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Severe Posterior Pelvic Tilt

• This young man was in amolded back support in this

position.

• He was experiencing

respiratory complications andspeech output challenges

even with tilt

– Is it fixed or flexible or tolerableof correction?

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Severe Posterior Pelvic Tilt

• He was not fixed

• Did experience some painwith extension after all thetime he had spent in Ccurve collapsed posture.

• Suitable candidate for anoff the shelf back supportwith shape and angleadjustment that could bechanged as he slowlyregained his uprightposture with support.

• Respiratory function andspeech output muchimproved

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Is This Child's Sitting Footprint Optimized?

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Is He a Suitable Candidate For a Molding Trial?

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Case Study: Meet JC

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Direct Mold

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Molding “On The Spot”

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Can Try It Before It’s Set

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JC’s Trial

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Finalize Once Client & Caregivers Are Happy

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Before & After The Trial

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The “On The Spot” Process

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Meet Mr. C

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Note From My Colleague, Scott

We have used molded seating as protection andcontainment in some cases. Those clients would have

done fine with configured/custom seating but those types ofseating components have a lot of exposed metal hardwareand pieces that are adjustable but more easily broken off of

the chair or knocked out of place. JK is a good example.He has a diagnosis of Ballistic Athetoid but often presents

as hypotonic or even completely flaccid when not excitedor scared. He would hurt himself on anything else.

A Different application for Molding…

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Meet JK

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Meet Ken

• Ken, at age 19, is independent in power mobility.

• He exhibits low tone with extreme orthopedic

involvement.

• Each winter he experiences severe respiratory infections

with poor blood gases and poor prognosis.

• Postural presentation is severe rotoscoliosis – leftribcage and left iliac crest overlap.

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Ken’s Results

• After 8 hours in a molding frame and constant adjustinghe receives a molded seating system and tilt.

• The back stop behind the right elbow is critical frodriving. His tilt was unique in that he did best with

posterior and left lateral tilt which loaded his spine andallowed some correction with any little flexibility he had.

• The outcome was he had increased blood O2 followingthe mold and posterior/lateral tilt. 5 years later he was

still going strong…

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This Young Girl Has Outgrown Her Molded System

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Her Two Back Supports ???

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Mapping

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Case Study: Meet Luz

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Luz Presents With

• 30 years old

• Cerebral Palsy

• Developmental delay

• Scoliosis

• Epilepsy

• Asthma

• History of Skin integrity issues

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Luz

• Resides in a group home facility

• Caregivers do not like her current system

– Solaria 15 degrees of tilt

– Molded seating

– Foot rests non supportive

– Has had arms tied down

• Dependent for all ADLs (Feeding tube)

• Incontinent x2

• Is transported by van – needs tie downs

• Transferred with dependent lift

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Luz’s Care Giving Team Wants

• Tilt

• No molding if possible

• Transit tested equipment

• Headrest

• Least removable/moving components

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Luz: On Evaluation

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Luz: On Evaluation

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Luz: On Evaluation

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Luz: On Evaluation

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Luz: On Evaluation

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Luz: On Evaluation

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Luz: On Evaluation

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Luz: On Evaluation

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Luz: On Evaluation

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Luz: On Evaluation

• Pelvis/spine:– Reduced lumbar curve:– Harrington rods– Rightobliquity +++

• Pelvis/Hips:– R osteolysis-head and neck of femur– L hip flex limited 82°

• LE’s R and L:– Bilateral 90° hamstrings– Ankles pronated and dorsiflexed; toes flexed

• Trunk/Spine:– Mild scoliosis to left– Harrington rods

• UE’s R&L– Elbows flexed and ext. rotated when unsupported

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Luz: On Evaluation

• Sitting balance:

– Dependent

• Functional weight shift

– Dependent

• Propuls ion

– Dependent

• Transfers

– Dependent - sling

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Luz: On Evaluation

• Measurements

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Luz: On Evaluation

• Desired equipment

– IRIS

• 45° tilt for weight shifting

• 20° tilt for positioning and feeding

– Configurfit seating- custom built

• Curved back - 3” contour on R and 6”on left

• Split seat - 15° open on L - 6” lateral contour on R 4” on Lwith leg length discrepancy accommodated

• Foot box – accommodating lower leg length discrepancy

• Whitmyer contour plus headrest

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Translation to Order Form Critical

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Luz’s Fitting

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LUZ, Before & After

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LUZ, Before & After

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Luz

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Luz: On Delivery

• Custom contours fit perfectly

• 20° of tilt appears ideal

• When body and head is supported – arms relax-headrest needed most adjusting

• Modified left side of foot box insert

• Team has never seen Luz so happy and comfortablyseated

• Not crying or aggressively screaming

• Overall footprint of new system 8” shorter than old

system – team love this…

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Meet Carolyn

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Carolyn Presents With…

• 58 years old

• Cerebral Palsy with spastic quadriplegia andchoreoathetosis

• Moderate developmental disability

• Presents with right obliquity and right rotation, scoliosisand feet not in contact with her footplate. Collapses toleft side when fatigued.

• No known history of skin breakdown

• Anemia

• Chronically underweight (G-tube placed Sept. 2008)

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Carolyn’s Environment

• Resides in a group home facility

• Caregivers do not like her current system

– Manual tilt-in-Space

– Molded seating that she does not sit into

– Foot rests non supportive, uses her arms for stability

– Not stable enough to consistently use communication device

• Dependent for all ADLs (Feeding tube)

• Incontinent x2

• Is transported by van or school bus – needs tie downs

• Transferred with mechanical lift, or 2-person

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Carolyn’s Care Giving Team Wants

• Tilt with 12” wheels, semi-pneumatic

• Tilt for feeding by mouth

• No molding if possible

• Transit tested equipment

• Headrest

• Increased stability in sitting to use communication device

mounted on her tray

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Carolyn: On Evaluation

• Pelvis/Spine:

– Right pelvic obliquity (flexible)

– Right pelvic rotation (non-correctable)

– Reduced lumbar curve

• Pelvis/Hips:

– R hip subluxation history (ROM WFL for sitting)

– L hip flex limited 80° (non-correctable)

• LE’s R and L:

– Bilateral 90° hamstrings

– Tone ++ bilaterally (triggered by activity)

– Ankles WFL

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• Trunk/Spine:

– Fixed scoliosis, apex to the right, head to the left

– Fixed Kyphosis

• UE’s R&L

– ROM WFL, influenced by tone

– Some reach, unable to grasp

• Head control:

– Not consistently voluntary

• Tone:

– Fluctuating, increased tone triggered by activity, inhibited byintimate contact

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• Sitting balance:

– Dependent

• Functional weight shift

– Dependent

• Propuls ion

– Dependent

• Transfers

– Dependent – two person or mechanical lift

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• Desired equipment

– Manual Tilt-in-Space (IRIS)

• 45° tilt for weight shifting

• 20° tilt for positioning and feeding

• transit

– Configurfit seating- custom built

• Curved back - 6”on Left

• Split seat – to accommodate pelvic obliquity and left hipROM limitation (right pelvic rotation)

• Custom footplates – accommodating tonal influences andangle and height differences due to hip limitations

• Whitmyer headrest

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Final Fitting

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Carolyn’s Summary

• She has her own tilt chair with the desired 12” wheels

• Will spend majority of time in 20 degrees of tilt

• The immersion inhibits tone and give forgiveness formultiple caregiver using slings

• Sitting with a better posture and happier

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• Consistency of care

• Transfer technique

• Growth or future change

• Heat and moisture

• Weight shift ability

• Relationship with gravity

Things To Think About.. With Custom Shaping

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Things To Think About

• In some cases it is easier to attain consistentpositioning/targeting with a mold needing lessadjustment or repositioning after transfer.

• Molding systems allow direct involvement of the clinicianin the final shape as opposed to taking measurements.

• Molding systems that rely on vacuum to achieve a shapeusually offer the opportunity to simulate the final shapeover a long period.

• Molds eliminate moveable, adjustable parts – can bepositive

• Molds eliminate adjustment and fine tuning – can benegative

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Things To Think About

• Some molded systems can not be field modified; someare final shape from the factory.

• Some molding systems rely on simulators, some can bedone in the clients own mobility device allowing theachievement of a more real time set up..

• Are there winter clothes to factor in?

• The effect of higher skin temperatures may need to beconsidered for some clients - layering a wicking materialmay help.

• Molding systems that can be manipulated out of asimulator or molding frame can be used to form headsupports, foot supports, or other orthotic interventions

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Question To Ask Yourself

1. Have I specified that the recommended seating &positioning product is in fact the minimal equipment

essential to this client?

2. Have I demonstrated how I ruled out lesser levelproducts?

3. Has the coverage policy been adhered to?

4. Is the equipment that I am recommending in fact the

least costly alternative?

5. Has your documentation ruled out why “off the shelf”

seating systems do not meet your client’s medicalneeds?

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What About Upgrades?

• Claims that do not qualify, will now deny as “notreasonable or necessary.

• No more downcodes – just denials.

• When it comes to upgrades, you must be realistic

• Providers must be smart on the business side of this

• Upgrades must be understood to protect you &ensure success.

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What if Funding is Denied?

• Don’t forget… The provider needs to stay in business.

• The therapist’s input will be better than the provider’s,and many times required.

• Help fight for your patient (within their insurance plan).

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Advise From Steve

• Always ask ourselves – does the posture have flexibleand or fixed components?

• Have we identified the cause of the problem or only thesymptom?

• Have we maximized the potential seating footprint foroptimal function and safety?

• Have we considered the caregiver?

• Have we considered transfer technique?

• Have we considered foreseeable change? e.g. growth

• Is the client comfortable and happy?!

• Is our documentation funding proof?

MANUAL POWER ADULT PEDIATRICS SEATING GERIATRICS CONTROLS FUNDING

Thank You For Attending!“I wish you success with your seating and mobility opportunities. I hope you find each assessment as

fulfilling, challenging and fun as I do!”

Steve Boucher, [email protected]

“Always remember that at the end of the day, your client is your number one priority!”

Angie Kiger, Clinical Education [email protected]

Documents

CustomSeating Is it really that complicated?