AT FOR POINT A TO B

WHEELED MOBILITY
AS A TOOL
TOWARD INDEPENDENCE
Midnight Sun
Assistive Technology Conference

August 5, 2009

Presented by
Lisa E. Maurer MS, PT, ATP

with

Jerry Godden, CRTS, ATP

Wayne Gould, CRTS, ATP
 ________________________________________________________________

SESSION OUTLINE
__________________________________________________________________

INTRODUCTION
OBJECTIVES
HISTORY / DEFINITIONS
SERVICE DELIVERY
INFORMATION GATHERING
THE EVALUATION
EQUIPMENT OPTIONS
EQUIPMENT TRIALS
EQUIPMENT SPECIFICATION
CASE STUDIES
FUNDING AND DOCUMENTATION
DELIVERY AND FOLLOW-UP
REFERENCES
RESOURCES
APPENDICES
 __________________________________________________________________

INTRODUCTIONS
__________________________________________________________________

THE SPEAKERS

Lisa Maurer MS, PT, ATP is the Program Coordinator at The Wheelchair and Seating Clinic at
Providence. A physical therapist for 19 years, and a Certified Assistive Technology Practitioner
since 1997, she has extensive experience in multi-disciplinary Assistive Technology services,
specializing in seating and mobility.

Jerry Godden, ATP is a Rehabilitation Technology Supplier with Geneva Woods Home Medical
Supply in Anchorage. An advocate for people with disabilityʼs since 1990, and a Certified Assistive
Technology Practitioner since 2004, he 13 years of experience in custom rehab equipment.

Wayne Gould, CRTS, ATP is a Rehabilitation Technology Supplier and Rehab Manager at Frontier
Medical in Anchorage. He been working with people with disabilities for 20 years, and has 10 years
of experience in custom rehab equipment.
 _________________________________________________________________

OBJECTIVES
__________________________________________________________________

 Participants will understand the role of mobility products as assistive technology.

 Participants will demonstrate knowledge of the referral process for obtaining recommendations for
wheeled mobility products.

 Participants will have an understanding of the evaluation process, funding coverage criteria, and
documentation requirements for mobility products.

 Participants will have an understanding of the various types of wheelchairs currently available.
 _________________________________________________________________

HISTORY
__________________________________________________________________

WHEELCHAIRS AS ASSISTIVE TECHNOLOGY?

Excerpts from CMSʼs “Decision Memorandum for Mobility Assistive Equipment (CAG-00274N),” May 5,
2005:
“The use of assistive technology to aid ambulation goes back into prehistoric times when the simplest crutches
and canes to compensate for functional disabilities were fashioned from sticks. Since then, the evolution of
mobility assistance equipment has become increasingly more technological - from King Phillip II of Spainʼs rolling
chair with foot rests in 1595 to the paraplegic watchmaker Stephen Farflerʼs self propelled chair which he built for
himself in 1655 at the age of 22 to the specialized power wheelchairs of today.”

“For many beneficiaries, a device of some sort is compensation for (a) mobility deficit.”
 _________________________________________________________________

DEFINITIONS
__________________________________________________________________

Wikipedia:
“Assistive technology (AT) is a generic term that includes assistive, adaptive, and rehabilitative devices for
people with disabilities and includes the process used in selecting, locating, and using them…
AT promotes greater independence by enabling people to perform tasks that they were formerly unable to
accomplish, or had great difficulty accomplishing, by providing enhancements to or changed methods of
interacting with the technology needed to accomplish such tasks.”

Durable Medical Equipment (DME): an assistive technology “product”

• Seating products that assist people to sit comfortably and safely (seating systems, cushions,
therapeutic seats)
• Standing products to support people with disabilities in the standing position while
maintaining/improving their health (standing frame, standing wheelchair, active stander).
• Walking products to aid people with disabilities who are able to walk or stand with assistance (canes,
crutches, walkers, gait trainers).
• Advanced technology walking products to aid people with disabilities, such as paraplegia or cerebral
palsy, who would not at all able to walk or stand exoskeletons).
• Wheeled mobility products that enable people with reduced mobility to move freely indoors and
outdoors (wheelchairs/scooters)
• Robot-aided rehabilitation is a sensory-motor rehabilitation technique based on the use of robots and
mechatronic devices
CENTERS FOR MEDICARE AND MEDICAID SERVICES
CHANGING DEFINITIONS…

Excerpts from CMSʼs “Decision Memorandum for Mobility Assistive Equipment (CAG-00274N),” May 5,
2005:
“Recent allegations of wheelchair fraud and abuse have focused considerable public interest on the
provision of wheelchairs under the Medicare benefit. The agency has responded with a multifaceted plan to
ensure the appropriate prescription of wheelchairs to beneficiaries who need them.”

Mobility Assistive Equipment (MAE): described by CMS as:

(equipment which is) “reasonable and necessary for beneficiaries who have a personal mobility deficit
sufficient to impair their participation in mobility-related activities of daily living such as toileting, feeding,
dressing, grooming, and bathing in customary locations in the home.”

Includes devices such as:

• canes
• crutches
• mobile geriatric chairs
• motorized wheelchairs
• quad-canes
• rolling chairs
• safety rollers
• walkers
• manual wheelchairs
• power operated wheelchairs
• specially sized wheelchairs
• power operated vehicles
 _________________________________________________________________

SERVICE DELIVERY MODEL

__________________________________________________________________

THE GOOD OLD DAYS

THE HERE AND NOW

“The demand in health care today is to do everything

we used to do with the same amount of money or less,
and with the same staff or less.”

- Mark Schmeler, OTR/L, ATP 1999.

 _________________________________________________________________

INFORMATION GATHERING
__________________________________________________________________

REFERRAL AND INTAKE

Wheelchair
and
Seating
Clinic
Referral
Form
(see
Appendix)


Key Information:
• Client
contact
info

• Client
Date
of
Birth

• Diagnoses

• Funding
sources
 

• Physician
contact
info

Reason for Referral:
• Why
is
evaluation
being
requested?

• What
type
of
wheelchair
or
equipment
being
used?

• In
what
condition
is
the
current
equipment?

• Current
skin
breakdown?



Physician
Order

Payor
Authorization
(VA,
TriWest)

PRE-SCREENING
Clinical
review

Enough information to schedule?
Request for additional information/reports if needed
Therapist
reports

• School
• Private
Medical
reports

Rehabilitation
Technology
Supplier
information

• Past equipment
• Documentation on past attempts at obtaining equipment
Determination
of
services

Seating/Mobility Evaluation
Clients
typically
have
one
or
more
of
the
following
impairments:

• Impaired mobility function
• Impaired postural control or alignment
• Inappropriate wheelchair or seating system
• Discomfort with prolonged sitting
• Endurance limitations affecting mobility and/or functional abilities
• Current skin breakdown
• History of compromised skin integrity
• Severe deformities
• Need for customized seating intervention
• Chronic or severe pain related to positioning/prolonged sitting
• Severe spasticity or postural instability which compromises safety and/or mobility
function
• Medical issues necessitate Physical Medicine examination prior to evaluation of
positioning and mobility needs.

General Therapy Evaluation/Treatment

PT
Evaluation
is
a
component
of
the
Wheelchair
and
Seating
Evaluation.

General
PT
or
OT
evaluation
may
be
useful
to
determine
need
for
further
services

Determination
of
services
(cont’d)

Other Assistive Technology Services
Augmentative
communication

Environmental
control

Computer
access

Home
or
worksite
modification

Job
accommodation

Vision
or
hearing
aids

Vehicle
modification

Driving
Evaluation


Comprehensive Assistive Technology Evaluation

Client
has
needs
spanning
all
areas
of
assistive
technology,
or
his/her
needs
are
very

complex,
requiring
the
involvement
of
specialists
in
several
disciplines.

Determination
of
team
members

Family and caregivers are a given
Role of therapists
Physical
Therapist

• Evaluates physical performance and mobility function, balance, coordination, and
posture
• Brings knowledge of anatomy, palpation of bony landmarks, lower
extremity/pelvic/trunk range of motion/flexibility
• Division of labor: wheelchairs and accessories
Occupational
Therapist

• Evaluates functional, perceptual, and cognitive performance; sensorimotor
impairments; and posture
• Brings knowledge of anatomy, upper extremity/hand range of motion/flexibility, fine
motor function, access, and environmental accessibility
• Division of labor: cushions and backs
Assistive
Technology
Practitioner

• Clinician has RESNA required clinical experience and credentials, and has passed
the RESNA national certification examination.
Determination
of
team
members
(cont’d)

Role of supplier
Works
with
the
evaluation
team
to
recommend
technology
options,
procures
the

equipment
through
funding
source,
delivers
and
fits
equipment,
trains
client/family
in

use,
maintains
and
repairs
equipment




Rehabilitation
Technology
Supplier

• NRRTS definition
“… A SPECIALIST WHO PROVIDES ENABLING TECHNOLOGY IN THE AREAS OF WHEELED
MOBILITY, SEATING AND ALTERNATIVE POSITIONING, AMBULATION ASSISTANCE,
ENVIRONMENTAL CONTROL, AUGMENTED COMMUNICATION, AND/OR ACTIVITIES OF
DAILY LIVING. “
“… EMPLOYED BY A COMPANY THAT SELLS DURABLE MEDICAL EQUIPMENT AND OFFERS
CONSUMERS PRODUCT CHOICES, ALONG WITH PRICING AND FUNDING INFORMATION. “
“… MEETS BASIC STANDARDS OF ACCEPTABLE PRACTICE IN THE PROVISION OF
EQUIPMENT, INCLUDING: ORDERING, ASSEMBLING, ADJUSTING, DELIVERING, AND
PROVIDING ON-GOING SUPPORT AND SERVICE…”

• Credentialing
CRTS: CERTIFIED REHABILITATION TECHNOLOGY SUPPLIER
Has met NARTS certification requirements for rehabilitation technology
suppliers

ATP: ASSISTIVE TECHNOLOGY PRACTITIONER

Has RESNA required clinical experience and credentials, and has passed
the RESNA national certification examination for assistive technology
practitioners.
Determination
of
team
members
(cont’d)

Durable
Medical
Equipment
Dealer/Supplier/Vendor

• Essentially performs the same functions as the RTS, but is not certified, and not
bound to the standards of the CRTS
• Scope of practice and level of experience varies greatly
• Choose wisely based upon reputation, credentials, demonstrated knowledge, and
past experience.


Rehabilitation
Technology
Supplier
Selection
Criteria

• Client is first priority
Responsive to clients
Timely
Available in emergency situations
• Willingness to be a “team player”ʼ
Responsive to therapists and other team members
Timely
Available as necessary
• Relationships with a variety of manufacturers
• Wide range of technologies and services
• Availability of equipment for trials prior to procurement
• High value placed on informing and educating clients
• Knowledge of service provision
Procurement
Coverage criteria
Required documentation
Payor specific processes and procedures
Handling of denials and appeals
Repair and servicing
Warranty servicing and repair
Willingness to consider servicing equipment provided by other dealers
• Qualified and competent staff
Trained regarding specific technologies
Attendance of manufacturersʼ technical schools
Regular continuing education/equipment inservices
Attendance of trade shows
RTS Certification
• Membership in NRRTS, NAMES, RESNA
• Adherence to NRRTS and NAMES Standards of Practice
• Joint Commission accreditation
• Receptive to new ideas and techniques
Other team members


Physician
(MD)

• Determines diagnoses and prognosis, writes orders for the evaluation, certifies medical
necessity of equipment by signing required documentation
• Physiatrist and Orthopaedic Surgeons are often more involved in the evaluation process,
and are often team members in some settings
Speech‐Language
Pathologist

• Evaluates cognitive and language abilities, and oral motor function (speech, swallowing,
drooling)
• Typically involved if seating/positioning affects swallowing, communication, or
augmentative communication use, or if cognitive factors have a significant affect on
mobility function
• Division of labor: mounting of AAC device, access of AAC device, integration of AAC
device with wheelchair where appropriate.
School
Therapists,
Teachers

• May provide valuable information relating to positioning and mobility function within the
educational setting; may identify accessibility and transportation concerns/requirements.
• Equipment may affect current treatment, treatment plan, and goals.
Private
Therapists

• Client may be receiving general therapy services elsewhere, but therapists may not be
able to complete seating/mobility evaluation. Incorporate their input, and prevent
duplication of services or conflict of therapeutic goals. Many payors will not cover both
services, but in some case will recognize the role of PT and OT in seating/mobility as a
separate specialized service.
Other team members (contʼd)


Rehabilitation
Engineer

• Modifies equipment to meet the clientʼs specific needs, designs and fabricates customized
equipment when commercially available products are inappropriate.
Nurse

• Caregiver
• Specialist in wound management (enterostomal nurse)
Orthotist/Prosthetist

• Typically involved when seating intervention consists of an actual orthosis or prothesis
(i.e. polypropylene TLSO, bilateral hip disarticulation or hemipelvectomy prosthesis)
Case
Manager

Payor

Employer

Other
Support
Systems

VERIFICATION OF BENEFITS


PT/OT
coverage

If
currently
receiving
general
therapy
services
by
another
provider,
ensure
coverage
for

PT/OT
for
seating/mobility
as
a
specialized
service
(vs.
duplication
of
services)

Coverage
for
extended
evaluation/extended
evaluation
rates

May
request
information
on
content
of
evaluation,
length
of
time
required


Requirement
for
use
of
specific
RTS/Dealer

Some
payors
have
participating
RTS/Dealers
that
they
will
use
exclusively

Some
state
agencies
may
require
several
bids
before
processing
through
one
RTS/Dealer;

some
RTS/Dealers
may
not
wish
to
be
involved
if
they
will
not
“get
the
sale.”

VERIFICATION OF BENEFITS (CONTʼD)


Coverage
of
durable
medical
equipment

RTS/Dealer will handle funding issues, but therapists must have general knowledge to
plan for the evaluation, select equipment, and complete documentation.
Funding source should not determine the equipment evaluated or drive the selection
process, but must be taken into consideration.
Payor for equipment may be different from payor for services
Covered items
Allowables,
caps

Percentages

Amount
of
client
responsibility
may
limit
options

Some clients may not wish to be evaluated if they are responsible for a large portion
of the cost.
Medical necessity vs. educational, vocational or other restriction on environment
Appropriate
for
use
in
home
environment

Use
outside
of
payor‐covered
environment
(i.e.
school,
workplace)

SCHEDULING
Location

Notification
of
team
members

Client/family
Therapists
RTS/Dealer

Transportation
to
appointment

Coordination
of
equipment

Specific cushions, backs, wheelchairs needed

REQUEST FOR CURRENT PHYSICIAN ORDERS

“Physical
Therapy
Evaluation
for
Seating/Mobility”

 _________________________________________________________________

THE EVALUATION
__________________________________________________________________

REVIEW OF INFORMATION
Pertinent
demographic
information

Diagnoses
Primary

• Primary diagnosis relating to present concerns (e.g. cerebral palsy with spastic
quadriplegia and scoliosis)
Secondary

• Additional pertinent diagnoses
Functional
or
treatment
diagnoses


• Hemiplegia, etc.
• Abnormal posture
• Abnormal involuntary movement
• Gait abnormality
Specific
dates
of
onset


Prognosis

Progress

Contraindications/precautions
affecting
equipment
use

• Uncontrolled seizures
• Orthostatic hypotension
• Open skin areas
Pertinent
demographic
information
(cont’d)

Pertinent medical/surgical history
Past
hospitalizations

History
of
skin
breakdown

Relevant
surgeries

• Orthopaedic
• Skin flaps
• Bone shavings
Pertinent medications
Current or past services
Date
last
seen
by
MD

Current
therapy
and
emphasis

Referral source
Reason for referral
Height, weight
Subjective
information

Client, caregiver, referral source goals
General
Expectations

• What type of equipment does the client want?
• What does the client want to be able to do?
• What are the clientʼs priorities?
• What are the clientʼs expectations of this evaluation?
Functional
goals

Vocational
goals

Recreational/lifestyle/personal
goals

Current problems
Level
of
satisfaction
with
equipment

Likes/dislikes

Broken
parts

Functional
implications/deficiencies
related
to
current
equipment

Service
history

Pain/discomfort
Functional
implications

Relation
to
equipment

Past equipment experiences
Successes/failures

Tolerance/willingness
to
change

Past
experience
with
RTS/Dealer

Recent changes in function
Related
or
unrelated
to
equipment

Subjective
information
(cont’d)


Environmental issues
Home
environment

• General accessibility
Levels of home
Type of entrance/exit
Layout
Dimensions of smallest doorways, halls
Does current wheelchair fit through all doorways?
• Location (i.e. rural, suburban)
Work,
school,
other
environments

• General accessibility
• Requirements
Caregiver


• Role
• Availability
• Abilities
Transportation

• Type of vehicle
• Method of loading of wheelchair
• Driver vs. passenger
• Type of tie-down system
Subjective
information
(cont’d)

Psychosocial issues
Lifestyle

• Passive
• Active, involved
• Risk taker
Activity
level

• Daily routine
• Amount of time up in wheelchair during day
• Work
• School
• Day program
• Recreation/leisure
Motivation

Support
system

Cultural
influences

Family
dynamics/involvement

PHYSICAL EXAMINATION
Strength/Motor
Control

Gross motor control – manual muscle testing
Fine motor control
Quality of movement
Coordination
Reaction time, ability to initiate or stop movement
Tone/spasticity
Reflex activity
Movement patterns
Volitional

Involuntary

Functional use of extremities
Effect
on
mobility,
posture

Range
of
Motion/Flexibility

Tolerance of corrective forces/pressure
Effect on mobility, posture
Endurance

Cardiopulmonary
Shortness
of
breath

• At rest
• With activity (i.e. after propelling wheelchair 20 ft.)
Labored
breathing

• At rest
• With activity
Vital
capacity

• May change with provision of postural support
Endurance
(cont’d)

Muscular
Ability
to
generate
and
sustain
force

Ability
to
perform
repetitive
contractions

Tolerance
of
sustained
activity

• Wheelchair propulsion
General
activity
tolerance



Sensation



Pressure
relief

Technique
Standing

Constant
shifting/changing
of
position

Wheelchair
push‐ups

Manual
tilt/recline

Power
tilt/recline

Frequency
Effectiveness
Current
skin
breakdown

Location
Typically
over
bony
prominences

Occasionally
over
soft
tissue

Severity
Measurements
Drainage
Current management
Type
of
dressing

Frequency
changed

Potential causes
Extrinsic
factors

• External pressure
• Shearing forces
• Heat
• Moisture
Intrinsic
factors

• Immobility
• Lack of sensation
• Poor nutrition
• Decreased tissue elasticity/resiliency with age
• Skin changes due to previous breakdown
Pain


Location
Severity
Length of time present
Possible causes
Functional implications

Balance/Postural
Control

Head control
Ability
to
achieve
and
maintain
midline
position

Influence
of
tone,
reflexes

Trunk control
Sitting
with/without
external
support

Ability
to
assume
and
maintain
erect
posture

Influences
of
tone,
reflexes

Standing with/without external support
Static sitting and standing balance
Dynamic sitting and standing balance
Functional implications
Activities
of
Daily
Living


Transfers
Feeding
Bathing
Communication
Dressing
Hygiene
Bowel/bladder
Household/community activities
Aides/caregivers
Employment/educational activities
Assistance
provided

Time
available

Implications of positioning, mobility

Vision

Acuity
Neglect
Blurred vision
Forward gaze
Depth perception
Field losses
Scanning
Perceptual deficits
Cognition

Ability to follow directions (simple vs. complex)
Attention span
Judgment
Distractibility
Understanding of cause/effect
Neglect
Effect on use of equipment

Communication

Ability to communicate functionally
Effect of positioning on communication/interaction
Management of secretions
Use of augmentative communication device
Transport/mounting
considerations

Integration
considerations

EVALUATION OF CURRENT EQUIPMENT
Seating
System
(cushion,
back,
other
supports)

Manufacturer, model
Age
Dimensions
Condition
Repair history
Estimated cost of repairs
Estimated remaining life expectancy
Comfort
Effect on positioning/pressure distribution
Pressure mapping
Acceptability to use
Appropriateness
Wheelchair

Manufacturer, model
Age
Dimensions
Components
Seat
and
back
upholstery

Armrests

Legrests

Footplates

Wheels/casters

Tires

Condition
Estimated cost of repairs
Estimated remaining life expectancy
Comfort
• Effect on positioning/pressure distribution
• Effect on mobility function
Acceptability to user
Appropriateness
Fit

Function

Accessibility

SEATING/POSITIONING ASSESSMENT
Basic
Principles

Review of normal postural alignment
Pelvis
neutral
(or
slightly
anterior)
and
symmetrical

Trunk
erect
with
slight
lumbar
and
cervical
lordosis,
slight
thoracic
kyphosis

Thighs
and
legs
separated

Knees
and
ankles
flexed
to
90
degrees,
with
feet
resting
on
floor
or
support
surface

Head
upright
and
in
midline

Shoulders
and
arms
relaxed
and
supported


Characteristics
of
normal
posture

Provides
stable
base
of
support;
stability
precedes
mobility


Active
and
dynamic

• “Dynamic posture is crucial for function in or out of a chair.”
• “Mobility is superimposed on an active, responsive base.”
• “Quality of posture determines motor skill capability.”
• “Motor function is the interplay between posture and movement.” – Ball 1996
Allows
horizontal
gaze
and
optimal
visual
field

Allows
optimal
arm
and
hand
function

Pelvic
position
largely
determines
posture

Examination
of
resting
posture
in
Wheelchair/Seating
System

Note position of
Pelvis

Trunk/spine

Head/neck

Hips/legs

Knees

Ankles/Feet

Shoulders

Arms

Observe and palpate symmetry of bony landmarks
Shoulders

Ability to self-correct or move into neutral alignment
Postural changes with volitional/non-volitional movement



Examination
in
supine

Pelvic mobility
Lower extremity flexibility
Range of motion
Spinal flexibility
Examination
in
sitting
at
edge
of
mat

Sitting balance/trunk control
How
much
effort
is
required
to
maintain
this
neutral
posture
with
the
influence
of

gravity?

Posture
Note
posture
under
the
influence
of
gravity
as
compared
to
that
observed
when
sitting

in
current
seating
system

• Pelvis
• Trunk/spine
• Head/neck
• Hips/legs
• Knees
• Ankles/Feet
• Shoulders
• Arms
Note
postural
changes
with
volitional/non‐volitional
movement


Observe
and
palpate
symmetry
of
bony
landmarks


Re‐evaluate
flexibility
of
deviations
observed
in
supine

Provide
support
to
correct
flexible
deviations,
accommodate
fixed
deformities,
and

allow
individual
to
maintain
neutral
posture.

• Location of needed corrective support was indicated during supine assessment.
• May require additional support, or support in other areas when influenced by
gravity.
• May require change in orientation (i.e. tilt-in-space)
Begin
thinking
of
what
type
of
supports
may
be
necessary
to
replicate
the
supportive

force.

MOBILITY ASSESSMENT
Primary
means
of
mobility

Ambulation
Manual wheelchair
Power wheelchair
Scooter
Other
Dependently
carried

Crawling,
creeping


Ambulation

Level of independence
Type of assistive device used
Distance
Efficiency/energy expenditure
Safety
Need
to
hold
on
to
walls,
furniture

Frequency
and
severity
of
falls

Functional for home or other environments
Impact on “Mobility Related Activities of Daily Living”
Manual
wheelchair


Level of independence
Propulsion technique
Arms

Legs

One
arm

Arm/leg
combination

Distance
Efficiency/energy expenditure
Postural changes during propulsion
Obstacle management
Performance/safety on varied terrain
Flat,
level
surfaces

Carpet

Ramps/inclines

Grass

Gravel

Maneuvering/managing wheelchair during transfers
Manual
wheelchair
(cont’d)

Advanced skills
Loading
wheelchair
into
vehicle

Curbs

Ramps

Stairs

Falling

Righting
the
wheelchair

Cushion
adjustment

Narrowing
the
wheelchair

Wheelies

Glides
in
a
wheelie

Turning
on
a
dime


Impact on “Mobility Related Activities of Daily Living”

Power
wheelchair


Level of independence
Access point
Hand

Head

Chin/mouth

Other
body
part

Input device
Hand
control/joystick

Head
control

Chin
control

Pneumatic/sip&puff

Switches

Distance
Efficiency
Postural changes during operation
Obstacle management
Performance/safety on varied terrain
Flat,
level
surfaces

Carpet

Ramps/inclines

Grass

Gravel

Maneuvering/managing wheelchair during transfers
Scooter/Power
Operated
Vehicle

Level of independence
Type of control
Distance
Efficiency
Postural changes during operation
Obstacle management
Performance/safety on varied terrain
Flat,
level
surfaces

Carpet

Ramps/inclines

Grass

Gravel

Maneuvering/managing scooter/seat during transfers
 _________________________________________________________________

EQUIPMENT OPTIONS
__________________________________________________________________
SEATING INTERVENTION
Forms
of
postural
support

Spinal fixation (i.e. Harrington rods)
Intimate support (i.e. body jacket, corset)
Adaptive seating

Goals
of
adaptive
seating

• Support neutral posture or posture required for function. - J. Zollars
• “Provide sufficient external support to restore normal sitting posture without
restricting function, and to maximize pressure distribution to prevent tissue trauma.”
- J. Minkel
• Obtain optimal postural alignment. – M. Ball
• Provide postural support for symmetrical biomechanical alignment
• Correct or accommodate postural deformities
• Inhibit abnormal tone and reflexes to prevent abnormal postural alignment and
deformities
• Improve safety
• Improve respiratory function
• Provide pressure relief or reduction to prevent compromise of skin integrity
• Equalize pressure distribution
• Increase sitting tolerance to level sufficient for requirements of daily activities
• Improve interaction with other individuals and the environment
• Improve function in ADL, self-care, mobility, and communication
• Improve comfort
Classification
of
Support
Surfaces

Primary
Cushion/seat

Back

Secondary
Headrest

Footrest

Armrest

Pelvic/thigh
supports

Trunk
supports

Shoulder
supports

TYPES OF PRIMARY SUPPORT SURFACES (CUSHIONS/BACKS)
Fluid/Flotation

Air
Contains
one
or
multiple
air
bladders
or
cells

Advantages

• Excellent pressure relief
• Lightweight
• Easy to clean
• Air may flow between cells
Disadvantages

• High maintenance
• Poor durability
• May make transfers difficult
Water
Sealed
cushion
with
water‐based
fluid
inside

Not
a
frequently
used
type
of
cushion

Advantages

• Good pressure relief
• Reduces shearing
• Dissipates heat well
Disadvantages

• Heavy
• Assumes ambient temperature
CAN FREEZE
CAN GET VERY HOT
• May make transfers difficult
Fluid/Flotation
Cushions/Backs
(cont’d)


Viscous fluid
Gels
or
fluids
contained
in
oversized
flexible
membranes

Typically
used
in
combination
with
some
type
of
foam
base/shell

Advantages

• Good pressure relief
• Reduces shearing
• Easy to clean
• Dissipates heat well
• Maintains fairly stable temperature
Disadvantages

• Heavy
• Can be uncomfortable if sensation is intact
• May make transfers difficult
Elastomer gel
Firm
gel
contained
in
flexible
membranes
(similar
to
Jello)

Typically
used
in
combination
with
some
type
of
foam
base/shell

Advantages

• Dissipates heat well
• Maintains fairly stable temperature
• Reduces shearing
Disadvantages

• Poor durability
• Difficulty attaching to foam surface
Polyfoams

Planar
Flat
surface,
typically
plywood
covered
with
foam
and
upholstery.


Advantages

• Adjustable (i.e. for growth)
• Modular components
• Available from many manufacturers
• Offers minimal support
• Accommodates a wide variety of postures
• Lightweight
• “Inexpensive”
• Easiest to maintain
• Least interference with transfers
Disadvantages

• No pressure relieving properties
• Often result in localized pressure over bony prominences, with greater risk of
shearing forces developing under weighted areas
• Least surface contact
• Provide least support for maintaining neutral posture
Typical
applications

• Good pelvic and trunk control
• Frequent changes in position
• Pediatric clients
• Progressive disabilities
• Short periods of sitting
Polyfoams
(cont’d)


Contoured
Commercially
fabricated
contoured
surface
of
pre‐determined
size
and
shape
based

upon
anthropomorphic
data.

Typically
a
combination
of
molded
plastic
shell
and

contoured
foam,
occasionally
with
pressure
relieving
gel
or
air
inserts.



Advantages

• Pre-contoured for a generic body type
• Offers moderate support
• Greater pressure distribution
• Reduces risk of peak pressures under weighted soft tissues
• More forgiving than an intimately contoured surface
• Some adjustability
Disadvantages

• Offers minimal postural accommodation
• Not contoured to an individualʼs shape
• May have to add accessories to achieve adequate support
• May restrict postural adjustments
• Components typically require constant monitoring to insure proper placement
• May require some maintenance
Typical
Applications

• Fair trunk control and balance
• Specific body types and postural deformities compatible with specific products
• Need for pressure reduction or equalized pressure distribution
• Need for portability
Polyfoams
(cont’d)


Molded
Contoured
surface
created
to
fit
the
exact
contours
of
a
single
user.

Advantages

• Offers maximum support
• Best pressure distribution
• Best accommodation of deformities
• Individualized shape
• Least peak pressures and shear
Disadvantages

• Requires skilled clinician and supplier
• Reduced air flow between support surface and skin
• Total support may prevent development or improvement of postural control
• Restriction of movement prevents postural adjustments and weight shifting
• Minimal adjustability
• Labor intensive and costly
Typical
Applications

• Poor trunk control and balance
• Severe fixed deformities
Oscillating

Contain air cells that alternately inflate and deflate, or alternately change mechanical
pressure.
Advantages
Excellent
pressure
reduction,
possibly
promoting
healing
of
open
areas
while
allowing

for
limited
sitting
time.

Disadvantages
Very
costly

TYPES OF SECONDARY SUPPORT SURFACES (ACCESSORIES)
Pelvic
and
thigh
control
components

Medial thigh supports
Lateral thigh supports
Lateral pelvic supports
Anterior pelvic supports
ASIS
pads/bar
pelvic
positioner

Pelvic
belt

Safety
belt


Trunk
control
components

Lateral thoracic supports
Posterior lumbar supports
Sacral supports
Anterior trunk support

Shoulder
control
components

Posterior shoulder supports
Anterior shoulder supports
Superior shoulder supports
Head/neck
control
components

Posterior neck support
Posterior head support
Lateral head support
Anterior head support
Circumferential head/neck support (i.e. cervical collar)

Upper
extremity
control
components

Arm support
Arm trough
Tray
Provides
support
to
the
arms
and
upper
extremities;
can
be
used
to
assist
upper
trunk

or
arm
positioning.

Lower
extremity
control
components

Posterior calf support
Calf
strap

Calf
pad

Foot support
Foot
platform
–
one
piece

Footplates
–
individual

• Fixed angle
• Angle adjustable
Foot
positioner

• Heel loops
• Ankle straps
• Toe straps
• Shoe holders
Anterior knee support
Anterior leg support
DYNAMIC PRESSURE RELIEVING SEATING SYSTEMS
Tilt‐in‐space

Seat-back angle is maintained as the seating system rotates around a fixed or sliding
pivot point.

Typically tilt in a posterior direction to re-distribute and relieve pressure.

May also be used to provide rest from the upright position, and gravity assisted
positioning to improve posture and head control.

• Manual
• Power
• Posterior tilt
• Anterior tilt
• Lateral tilt



Recline

Seat-back angle to increase as the backposts are reclined.

Typically used for accommodation of severe hip extension contractures, orthostatic

hypotension, and pressure re-distribution for prevention of skin breakdown.

May result in tendency to slide forward in the seat.

May cause shearing at the sacrum and low back.

• Manual
• Power
• Low Shear



Standers

Manual or power systems which move from the seated to standing positions.

Typically used for environmental access and pressure relief.

MOBILITY INTERVENTION
Goals
of
Wheeled
Mobility

• Provide a means of independent mobility
• Maximize performance of activities of daily living
• Allow access to all terrain and environments encountered during the course of the
day
• Provide support of neutral posture
• Provide orientation in space required for optimal posture and function
• Provide a base for the adaptive seating system
• Provide a means of pressure relief
• Accommodate changes in size and weight
TYPES OF MOBILITY BASES
Dependent
mobility
bases

Strollers
Typically
used
for
dependent
community
mobility
for
children


Some
models
have
higher
weight
limits
suitable
for
small
adults



Variety
of
seating
options


Transport wheelchairs
Lightweight
chair
with
small
wheels
used
for
dependent
transportation
over
level

surfaces



Very
few
options

Manual
wheelchairs

Standard
Medicare
classification
(K0001)

Traditional
wheelchair
with
no
adjustability
and
very
few
options



Very
heavy,
requiring
good
strength
and
sitting
balance
to
operate
effectively


Very
durable

Few
options

Standard hemi
Medicare
classification
(K0002)

Traditional
wheelchair
with
a
lower
seat
height

Allows
for
propulsion
with
feet

Few
options

Lightweight
Medicare
classification
(K0003)

Similar
in
appearance
to
traditional
wheelchair,
but
slightly
lighter
weight



May
have
some
axle
adjustability.



Beneficial
for
individuals
with
slight
upper
extremity
weakness


Few
options

High-strength lightweight
Medicare
classification
(K0004)

Lightweight
wheelchair
of
durable
construction

Limited
axle
adjustability;
may
have
1
or
2
positions,
or
some
horizontal
or
vertical

adjustability

Variety
of
components
available
as
options

Most
models
have
hemi
option

Some
models
offer
one‐arm
drive
mechanism

Manual
wheelchairs
(cont’d)


Ultra-lightweight
Medicare
classification
(K0005)

Greatest
degree
of
adjustability
maximize
user
efficiency
and
function

Axle
adjustability
allows
center
of
gravity
of
the
user
to
be
changed
in
relation
to
the

wheel
base

Previously
used
by
high
functioning
users

Frequently
used
by
individuals
with
severe
weakness,
fatigue,
or
complex
positioning

requirements
due
to
ability
to
maximize
efficiency



Folding
frames

• Traditional cross-brace frame
• Offers greatest ease of folding
• Greater shock absorbancy
• Can be narrowed to get through doorways
• Can be grown by replacing cross tubes and upholstery
• Less efficient propulsion
Rigid

• One-piece frame, typically with horizontal cross bars
• Offers greater durability
• Lighter weight
• Offers more efficient ride
• Less shock absorbancy
• May be difficult for some individuals to “fold”
Heavy-duty
Medicare
classification
(K0006)

Traditional
wheelchair
with
no
or
limited
adjustability

Durable
construction
for
users
weighing
more
than
250#


Very
few
options

Very
heavy

Extra Heavy-duty
Medicare
classification
(K0007)

Traditional
wheelchair
with
no
or
limited
adjustability

Durable
construction
for
users
weighing
more
than
300#
Very
few
options

Very
heavy

Custom
Medicare
definition
(K0008)

• Uniquely constructed or modified for the specific beneficiary
• Feature needed not available on an already manufactured base
• Must be customization of the frame, not components
Other/miscellaneous wheelchair base
Medicare
definition
(K0009)

• Includes pediatric wheelchair bases and other bases
Dynamic
pressure
relieving
bases

• Manual tilt
SEAT-BACK ANGLE MAINTAINED AS SEATING SYSTEM ROTATES AROUND A FIXED OR
SLIDING PIVOT POINT
MAINTAINS SITTING POSTURE WHILE ORIENTATION TO GRAVITY IS CHANGED
TYPICALLY REQUIRES A LONGER, HEAVY BASE
DIFFICULT TO PROPEL
• Manual recline
SEAT-BACK ANGLE INCREASES AS THE BACKPOSTS ARE RECLINED
TYPICALLY REQUIRES A LONGER, HEAVIER BASE
DIFFICULT TO PROPEL
• Standing wheelchairs
MANUAL WHEELCHAIR WITH AN ADDED STANDING FEATURE
ALLOWS INDIVIDUAL TO COME TO A STANDING POSITION FOR ADL’S
Wheelchair Componentry
Seat

• Upholstery
NYLON
NAUGAHYDE
• Solid
• Adjustable angle


Back

• Upholstery
NYLON
NAUGAHYDE
ADJUSTABLE TENSION
Can accommodate slight postural deviations
Can be kept tight to prevent sling over time
• Back-posts
STRAIGHT BACK-POSTS
8-10 DEGREE BEND
ADJUSTABLE ANGLE
PUSH HANDLES


Legrests

• Select based upon functional need
ALLOW FOR TRANSFERS
ACCOMMODATE KNEE CONTRACTURES
REDUCE EDEMA
REDUCTION OF SPASTICITY/TONE
• Swing-away
EASIEST TO REMOVE FOR TRANSFERS
CAN BE REMOVED TO INCREASE ACCESSIBILITY
MECHANISM MAY BE DIFFICULT TO MANEUVER, AND MAY WEAR-OUT WITH TIME
• Rigid/fixed
GREATER DURABILITY
MAY MAKE TRANSFERS DIFFICULT
CANNOT REMOVE TO IMPROVE ACCESSIBILITY
• Semi-rigid
SWING-AWAY LEGRESTS JOINED TOGETHER AT THE FOOTPLATE
IMPROVES DURABILITY
• Elevating
USEFUL IN CASES OF LIMITED ROM, EDEMA
INCREASES OVERALL CHAIR LENGTH
MAY COMPROMISE PELVIC POSITION BY STRETCHING HAMSTRINGS
QUESTIONABLE BENEFIT FOR EDEMA REDUCTION
INCREASES LENGTH OF CHAIR, DECREASES ACCESSIBILITY
MECHANISM DIFFICULT TO OPERATE
• Articulating
LEGRESTS EXTENDS AS IT ELEVATES, ALLOWING TRUE ELEVATION WITHOUT CAUSING
THE KNEE TO FLEX
• Tapered
INCREASED ACCESSIBILITY
IMPROVED LEG ALIGNMENT
DECREASED CALF SPACE
• Hanger angle


Footplates

• Composite or Aluminum Flip-up
• Extended
• Platform
• Angle adjustable
• Tubular
• High-mount


Armrests

• Selection based upon how used by individual
STABILIZATION OF TRUNK
STABILIZING POINT FOR PUSHING UP TO STAND OR FOR PRESSURE RELIEF
ATTACHMENT POINT FOR TRAY
• Fixed Height
• Adjustable height
• Removable vs. Flip-back
• Tubular/swing-away
• Desk length vs. full length
Axle

• Non-adjustable/single position
• Semi-adjustable
• Adjustable/multi-position
• Amputee/extended
• Quick release
ALLOWS REMOVAL OF REAR WHEELS
REQUIRES GOOD HAND FUNCTION
• Quad release
ALLOWS PERSON WITH LIMITED HAND FUNCTION TO REMOVE REAR WHEELS
MAY ACCIDENTALLY DISENGAGE
• One-arm drive


Wheels

• Spoke
• Mag
• Composite
Tires

• Diameter and composition affect rolling resistance
• Solid/polyurethane
GOOD FOR INDOOR USE
NO MAINTENANCE
DURABLE
ROUGH RIDE OUTDOORS
HEAVY
HIGH OR LOW PROFILE
High profile offers some traction
• Pneumatic
LESS ROLLING RESISTANCE
GOOD ON ROUGH TERRAIN
GOOD TRACTION
LIGHTWEIGHT
AIR PRESSURE MUST BE MAINTAINED FOR PERFORMANCE
• Airless/foam inserts
MAKES PNEUMATIC TIRES FLAT-FREE
ADDS WEIGHT
• Kevlar
REINFORCED, PUNCTURE RESISTANT TIRE
• Knobby
ALL TERRAIN TIRE WITH SIGNIFICANT TREAD
INCREASED TRACTION
PUNCTURE RESISTANT
• High-pressure
HIGH PERFORMANCE
LIGHTWEIGHT
REQUIRES PRESTA VALVE (SMALL BICYCLE-TYPE VALVE)


Hand‐rims

• Anodized aluminum/chrome
• Plastic coated
• Molded
• Projections
Wheel
locks

• Push-to-lock
• Pull-to-lock
• Scissor
• High-mount
• Low-mount

Casters

• Small front wheels attached to fork, swivels about stem bolt
• Large casters (6-8”)
LEAST ROLLING RESISTANCE
IMPROVED MANEUVERABILITY OVER UNEVEN TERRAIN
INCREASED CLEARANCE BETWEEN FOOTPLATE AND GROUND
CAN BE USED TO ACHIEVE POSTERIOR TILT-IN-SPACE
• Small casters (3-5”)
MORE RESPONSIVE TO QUICK TURNS
AID IN CURB MANEUVERABILITY
INCREASED CLEARANCE BETWEEN FOOTPLATE AND CASTER
LESS SHIMMY (SIDE-TO-SIDE FLUTTER AT HIGH SPEEDS)
GREATER ROLLING RESISTANCE
DECREASED ABILITY TO ROLL OVER OBSTACLES
• Solid
NO MAINTENANCE
LEAST ROLLING RESISTANCE
Casters
(cont’d)


• Pneumatic
MOST SHOCK ABSORPTION
OFFER SMOOTHER RIDE
EASE OF MANEUVERING OVER UNEVEN SURFACES
• Semi-pneumatic
NO MAINTENANCE
COMPROMISE BETWEEN ABOVE
• Caster stem bolt
LONG STEM BOLT IMPROVES CLEARANCE BETWEEN FOOTPLATE AND FLOOR
INCREASES TILT WITHOUT CHANGING CASTER
• Caster fork
LONGER FORK INCREASES TILT WITHOUT CHANGING CASTER
DECREASES CLEARANCE BETWEEN HEEL AND CASTER
• Quick release casters
USEFUL FOR THOSE WHO EXCHANGE FRONT CASTERS FOR DIFFERENT ACTIVITIES
• Caster pin locks
PROVIDE ADDITIONAL STABILITY OF WHEELCHAIR DURING TRANSFERS
DIFFICULT TO MANAGE
Accessories

• Anti-tippers
MAY INTERFERE WITH NEGOTIATION OF ROUGH TERRAIN; DECREASES GROUND
CLEARANCE
REAR
FRONT
• Brake extensions
BRAKE IS EASIER TO REACH AND ENGAGE
USEFUL FOR HEMIPLEGICS
DECREASE BRAKE DURABILITY
MAY INTERFERE WITH TRANSFERS AND PROPULSION
• Grade aids
PREVENTS WHEELCHAIR FROM ROLLING BACKWARD WHEN ASCENDING INCLINES
MUST BE USED ON TIRE WITH TREADS (I.E. PNEUMATIC)
DIFFICULT TO PROPEL WHEN ENGAGED
MAY ENGAGE INADVERTENTLY
MAY PREVENT RECOVERY FROM BACKWARD FALL
POOR DURABILITY
• Clothing guards
PREVENT HIPS AND THIGHS FROM RUBBING TIRES
CAN BE USED TO CENTER CUSHION OR PERSON IN SEAT
RIGID
Must remove for lateral transfers
Limit use of larger cushion if increased width needed
CLOTH
Does not need to be removed for transfers
Allows for use of wider cushion if necessary
Needs to be tightened
Allows for slipping of cushion
Accessories
(cont’d)


• Spoke guards
PROTECTS FINGERS FROM INJURY
PREVENTS DAMAGE TO SPOKES
MAY NEED TO REMOVE IN ORDER TO TIE-DOWN IN VEHICLE
MAY RATTLE IF NOT TIGHT
• Leg straps/heel loops
MAINTAIN FOOT POSITION
MAY BE USEFUL DURING TRANSFERS BETWEEN CHAIR AND FLOOR
MAY MAKE TRANSFERS DIFFICULT
TYPES OF MOBILITY BASES (CONTʼD)


Scooters/Power
Operated
Vehicles



Typically steered with a tiller
Speed is controlled by thumb lever
Typically used for community mobility by individuals with limited ambulatory function
Three-wheeled
Narrow
base
of
support

High
center
of
gravity

Unstable

Requires
good
trunk
control
and
good
upper
extremity
function

Large
turning
radius

Four-wheeled
More
stable

Requires
good
trunk
control
and
good
upper
extremity
function

Large turning radius
Power
Wheelchairs
(PWC)

Group 1 PWC; K0813 – K0816
• Standard integrated or remote proportional joystick
• Non-expandable controller
• Incapable of upgrade to expandable controller
• Incapable of upgrade to alternative control devices
• May have crossbrace construction
• Accommodates non-powered options and seating systems (e.g., recline-only
backs, manually elevating legrests) (except captains chairs)
• Length - less than or equal to 40 inches
• Width - less than or equal to 24 inches
• Minimum Top End Speed - 3 MPH
• Minimum Range - 5 miles
• Minimum Obstacle Climb - 20 mm
• Dynamic Stability Incline - 6 degrees
Power
Wheelchairs
(cont’d)


All Group 2 PWC; K0820 – K0843

• Standard integrated or remote proportional joystick
• May have crossbrace construction
• Accommodates seating and positioning items (e.g., seat and back
• cushions, headrests, lateral trunk supports, lateral hip supports,
• medial thigh supports) (except captains chairs)
• Length - less than or equal to 48 inches
• Width - less than or equal to 34 inches
• Minimum Top End Speed - 3 MPH
• Minimum Range - 7 miles
• Minimum Obstacle Climb - 40 mm
• Dynamic Stability Incline - 6 degrees

Group 2 No Power Options PWC; K0820 – K0829

• Non-expandable controller
• Incapable upgrade to expandable controller
• Incapable of upgrade to alternative control devices
• Incapable of accommodating a power tilt, recline, seat elevation, standing system
• Accommodates non-powered options and seating systems (e.g., recline-only
backs, manually elevating legrests) (except captains chairs)


Power
Wheelchairs
(cont’d)



All Group 3 PWC; K0848 – K0864
• Standard integrated or remote proportional joystick
• Non-expandable controller
• Capable of upgrade to expandable controller
• Capable of upgrade to alternative control devices
• May not have crossbrace construction
• Accommodates seating and positioning items (e.g., seat and back cushions,
headrests, lateral trunk supports, lateral hip supports, medial thigh supports)
(except captains chairs)

All Group 3 PWC; K0848 – K0864 (2)

• Additional requirements:
• Drive wheel suspension to reduce vibration
• Length - less than or equal to 48 inches
• Width - less than or equal to 34 inches
• Minimum Top End Speed - 4.5 MPH
• Minimum Range - 12 miles
• Minimum Obstacle Climb - 60 mm
• Dynamic Stability Incline - 7.5 degrees




Power
Wheelchairs
(cont’d)


Group 4 PWCs K0868 – K0886

• Have added capabilities not needed for home use
• If provided and coverage guidelines met for Group 2 or 3, allowance based on least
costly alternative medically appropriate PWC
• If billed with KX modifier, allowance based on comparable group 3 PWC

Group 5 PWC; K0890 – K0891

• Standard integrated or remote proportional joystick
• Non-expandable controller
• Capable of upgrade to expandable controller
• Capable of upgrade to alternative control devices
• Seat Width: minimum of 5 one-inch options
• Seat Depth: minimum of 3 one-inch options
• Seat Height: adjustment requirements-≥ 3 inches
• Back Height: adjustment requirements minimum of 3 options
• Seat to Back Angle: range of adjustment-minimum of 12 degrees
• Accommodates non-powered options and seating systems
Power
Wheelchairs
(cont’d)


Group 5 PWC; K0890 – K0891 (2)

• Additional requirements:
• Accommodates seating and positioning items (e.g., seat and back cushions,
headrests, lateral trunk supports, lateral hip supports, medial thigh supports)
• Adjustability for growth (minimum of 3 inches for width, depth and back height
adjustment)
• Special developmental capability (i.e., seat to floor, standing, etc.)
• Drive wheel suspension to reduce vibration
• Length - less than or equal to 48 inches
• Width - less than or equal to 34 inches
• Minimum Top End Speed - 4 MPH
• Minimum Range - 12 miles
• Minimum Obstacle Climb - 60 mm
• Dynamic Stability Incline - 9 degrees
• Crash testing - Passed
Power
Wheelchairs
(cont’d)


Power seating options

Dynamic
pressure
relieving
seating
system

• Power tilt
SEAT-BACK ANGLE MAINTAINED AS SEATING SYSTEM ROTATES AROUND A FIXED OR
SLIDING PIVOT POINT
MAINTAINS SITTING POSTURE WHILE ORIENTATION TO GRAVITY IS CHANGED
TYPICALLY REQUIRES A LONGER, HEAVY BASE
NEW FORWARD SLIDING SYSTEMS ALLOW USE OF SHORT BASE
• Power recline
SEAT-BACK ANGLE INCREASES AS THE BACK-POSTS ARE RECLINED
TYPICALLY REQUIRES A LONGER, HEAVIER BASE
MAY INCLUDE SELF-ELEVATING LEGRESTS (AUTOMATICALLY ELEVATE AS BACK
RECLINES)
• Power stand
SEATING SYSTEM MOVES FROM SITTING TO STANDING
ALLOWS INDIVIDUAL TO COME TO A STANDING POSITION FOR ADL’S
MAY OR MAY NOT BE ABLE TO BE DRIVEN IN STANDING POSITION
• Power elevating seat
SEATING SYSTEM IS RAISED OR LOWERED
ALLOWS FUNCTIONAL HEIGHT FOR ADL’S, TRANSFERS, INTERACTION WITH OTHERS
• Power elevating legrests
LEGRESTS ELEVATE EXCLUSIVE OF THE SEATING SYSTEM
ALLOWS INDEPENDENT LOWER EXTREMITY ELEVATION FOR EDEMA REDUCTION OR
POSITIONING
Power wheelchair components
Input
devices

• Allow user to input the speed, direction, and command to stop the wheelchair
• Proportional
DIRECTION AND SPEED OF THE CHAIR ARE IN PROPORTION TO AMOUNT OF MOVEMENT
AT THE INPUT DEVICE
JOYSTICK
Hand control
Chin control
Head controlled joystick
PEACHTREE HEAD CONTROL
• Digital
SWITCHES ARE EITHER ON OR OFF
NON-PROPORTIONAL
BODY/CONTACT SWITCHES
Switch activated by direct pressure
Each switch controls a direction or function
May be used at nearly any access point, in any combination
PROXIMITY/NON-CONTACT SWITCHES
Switch activated by movement toward or away from the switch
Each switch controls a direction or function
May be used at nearly any access point, in any combination
PNEUMATIC (SIP&PUFF)
Motors

• Allow movement of the chair
• Belt or direct drive
• Mounted to front, mid, or rear wheels
Controller

• Brain of the wheelchair
• Allows adjustment of parameters (how wheelchair responds to input from the user)
MAXIMUM SPEED
LOW SPEED
ACCELERATION
DECELERATION
TURNING SPEED
TREMOR DAMPENING
Also called sensitivity
Makes wheelchair more or less responsive to joystick movement
Useful in cases of tremor or extraneous movement
JOYSTICK THROW
Amount of joystick movement necessary to obtain full speed and direction
control
Often reduced for users with limited ROM
MOMENTARY CONTROL
Chair operates as long as input is provided
Chair stopped when no input
LATCHED CONTROL
Either on or off
Chair operates continuously in response to single activation of switch
Subsequent activation of switch stops movement
Batteries

• Sealed (gel cell)
NO MAINTENANCE (OTHER THAN CHARGING)
SAFEST
ACCEPTED ON AIRPLANES AND PUBLIC TRANSPORTATION
• Lead acid (wet cell)
FLUID LEVELS MUST BE REGULARLY MAINTAINED
POTENTIALLY HAZARDOUS
NOT ACCEPTED ON AIRPLANES OR PUBLIC TRANSPORTATION
• Capacity
U1
Small capacity
For indoor or short-term use
22/24NF
Larger capacity
For full-time use
Necessary for powering of other systems (i.e. tilt, recline)
INTEGRATION ISSUES
Tilt/recline
systems

Compatibility with various manufacturers
Variations in tilt systems
Basic
tilt


Center
of
gravity
tilt


Forward
sliding/weight
shifting
tilt

Additional seat height
Attachment of after-market backs
Pinch points
Drive lock-out
Transportation
issues

Tie-down system
Lift/loading
Transfers
Driving
Alternative
methods
of
access

Compatible electronics
Sufficient access sites for all devices
Communication
devices/computer
access

Compatible electronics
Mounting of system to wheelchair
Placement of cables
Seat height
OTHER MOBILITY DEVICES
Push‐rim
activated
power
assist

Attach to manual wheelchair frames
Motor turns rear wheels
Allows use of wheelchair as manual or power
Weight negatively affects use as manual wheelchair
Easily removed to allow folding of wheelchair for transport

Beach
wheelchairs

Hand‐cycles

Sports
wheelchairs

 _________________________________________________________________

TRIALS
_________________________________________________________________

Start with least expensive mobility option that may meet their mobility and positioning
needs
• Wheelchair
• Wheelchair componentry

Add least expensive seating intervention that will provide amount of support deemed
necessary from the mat assessment
• Primary support surfaces
• Secondary support surfaces

Attempt to match the individualʼs dimensions as closely as possible

Assess for each option evaluated:

• Fit
• Comfort
• Positioning
• Mobility
• Transfers
• Functional abilities
 _________________________________________________________________

TRIALS (contʼd)
_________________________________________________________________

Determine effectiveness of least costly options, noting reasons why they did or not
work

Progress to other mobility and seating options, concluding when you have determined
the least costly option that will meet the individualʼs mobility, positioning, comfort, and
functional needs.

If no objective or subjective difference between options, chose the least costly option.
 _________________________________________________________________

EQUIPMENT SPECIFICATION
_________________________________________________________________

While
positioned
in
the
least
costly,
most
appropriate
intervention,
verify

the
individual’s
measurements
in
the
context
of
the
equipment

Collaborate
with
the
client
and
RTS/dealer
to


Determine appropriate equipment dimensions
Complete wheelchair and seating system order forms
Specify all components
Specify type and size of primary support surfaces
Specify type and size of secondary support surfaces
Ensure clientʼs understanding of all options specified

Incorporate
info
from
Vendor
home
assessment

 _________________________________________________________________

CASE STUDIES
_________________________________________________________________

Manual

C7
complete
tetraplegia

5’0”
woman
with
hemiplegia

Bilateral
LE
amputee

Decreased
vision

MS,
limited
ambulation,
impaired
coordination

400
pounds

Triplegia
(i.e.
only
left
arm
function)

Profound
MR,
severe
scoliosis,
pelvic
obliquity

Poor
judgment

Inability
to
perform
pressure
reliefs

Client
drives
own
car

 _________________________________________________________________

CASE STUDIES
_________________________________________________________________



Power

COPD,
oxygen
dependent

Severe
trunk
and
UE
ataxia

C4
complete
tetraplegia

Extreme
startle
reflexes

Impaired
vision

400
pounds

Inability
to
perform
pressure
reliefs

Distractibility,
poor
judgment

Rapidly
progressing
ALS

Use
of
public
transportation

Client
drives
own
van

 _________________________________________________________________

FUNDING AND DOCUMENTATION

_________________________________________________________________

THE OLD DAYS:

Medically
Necessary

Durable Medical Equipment is required for the treatment of the clientʼs documented
medical condition

Prescribed
by
a
Physician

Physician attests to the documented medical need of the covered device.
EVOLUTION OF MEDICARE COVERAGE
Typically
covers
older
adults
or
people
with
long
term
disabilities

Policies
largely
determine
industry‐wide
reimbursement

Coverage
Considerations:

Medicare is a defined benefit program.
An item or service must fall within one or more benefit categories, and not otherwise
be excluded by statute from coverage. Section 1861(n) of the Social Security Act lists
items that are included as durable medical equipment (DME), including wheelchairs.
MAE is covered under the benefit category of DME. DME is defined as equipment that
1)
can
withstand
repeated
use,


2)
is
primarily
and
customarily
used
to
serve
a
medical
purpose,


3)
generally
is
not
useful
to
an
individual
in
the
absence
of
an
illness
or
injury,
and


4)
is
appropriate
for
use
in
the
home
(42
C.F.R.
§
414.202).


CMS has several national coverage determinations (NCD) regarding various mobility
assistive equipment.
Recent
Events

Excerpted from May 5, 2005 CMS Decision Memo for Mobility Assistive Equipment
(CAG-00274N)
“On
December
15,
2004,
CMS
opened
an
NCD
on
mobility
assistive
equipment
to

examine
and
set
the
clinical
criteria
for
the
provision
of
this
equipment.

Recent
allegations
of
wheelchair
fraud
and
abuse
have
focused
considerable
public

interest
on
the
provision
of
wheelchairs
under
the
Medicare
benefit.
The
agency
has

responded
with
a
multifaceted
plan
to
ensure
the
appropriate
prescription
of

wheelchairs
to
beneficiaries
who
need
them.
One
facet
of
this
plan
is
the
delineation

of
suggested
clinical
conditions
of
wheelchair
coverage.”



“Many
advocacy
groups
have
suggested
that
the
agency
adopt
a
function‐based

interpretation
of
its
historical
“bed
or
chair
confined”
criterion
for
wheelchair

coverage.”



“Historically,
wheelchairs
have
been
“covered
if
[the]
patient's
condition
is
such
that

without
the
use
of
a
wheelchair
he
would
otherwise
be
bed
or
chair
confined.
An

individual
may
qualify
for
a
wheelchair
and
still
be
considered
bed
confined.

Wheelchairs
(power
operated)
and
wheelchairs
with
other
special
features
are
covered

if
[the]
patient's
condition
is
such
that
a
wheelchair
is
medically
necessary
and
the

patient
is
unable
to
operate
the
wheelchair
manually.”



“In
June
of
2004,
CMS
formed
a
workgroup
(the
Interagency
Wheelchair
Work
Group‐
IWWG)
of
Federal
employees
to
review
its
current
policy
for
wheelchair
provision
and

to
analyze
the
published
scientific
literature
on
the
use
of
wheelchairs.
The
IWWG

made
several
recommendations
for
the
clinical
interpretation
of
CMS’
statutory,

regulatory
and
clinical
guidelines,
including
the
adoption
of
a
function‐based

determination
of
medical
necessity.
A
function‐based
determination
might
consider

the
beneficiary’s
inability
to
safely
accomplish
activities
of
daily
living,
such
as

toileting,
feeding,
dressing,
grooming,
and
bathing
with
and
without
the
use
of

mobility
equipment,
such
as
a
wheelchair.“



On
December
15,
2004,
CMS
initiated
the
national
coverage
determination
to
address

the
appropriate
prescription
of
Mobility
Assistive
Equipment.

“Consistent
with
IWWG
recommendations
and
our
internal
review,
CMS
chose
to
use

activities
of
daily
living
such
as
toileting,
feeding,
dressing,
grooming,
and
bathing
as

these
are
activities
necessary
to
serve
a
medical
purpose
in
the
home.
We
collectively

named
these
mobility
related
activities
of
daily
living
(MRADLs).”



RESULTING RECOMMENDATIONS FOR ASSESSMENT/PRESCRIPTION
Excerpted from May 5, 2005 CMS Decision Memo for Mobility Assistive Equipment
(CAG-00274N)



Appropriate
Prescription
of
Mobility
Equipment

An assessment of the beneficiaryʼs physical, cognitive, and emotional limitations and
abilities, willingness to use mobility assistive equipment on a routine basis, and the
beneficiaryʼs typical home environment is recommended to determine the appropriate
prescription of mobility equipment.

In order to facilitate the application of the new functional criteria, the IWWG proposed
the following suggestions for the provision of wheelchairs.
Provision
of
Mobility
Assistive
Equipment
Under
Medicare
Should
Include

All
Five
Points
Below

The beneficiaryʼs physical limitations (diminished strength, speed, endurance, range
of motion, coordination, sensation, deformity) prevent the beneficiary from
accomplishing mobility-related activities of daily living in the home.
The beneficiaryʼs mental capabilities (cognition, orientation, communication,
judgment, memory, comprehension, affect, and suitable behavior) are sufficient for
safe and adequate performance of mobility-related activities of daily living with the use
of mobility assistive equipment.
The beneficiaryʼs physical capabilities (strength, speed, endurance, range of motion,
coordination, sensation) are sufficient for safe and adequate performance of mobility-
related activities of daily living with the use of a mobility assistive equipment.
The characteristics of the beneficiaryʼs typical home environment in which the
activities of daily living are encountered (surfaces, presence or absence of surface
accommodations, obstacles, accessibility, changes in grade, and distances covered)
are suitable for use of the appropriate equipment.
The beneficiary demonstrates willingness to use the equipment routinely.
Clinical
Criteria
for
Wheelchair
Prescribing

The beneficiary, the beneficiaryʼs family or other caregiver, or a clinician will usually
initiate the discussion and consideration of wheelchair use.
Sequential consideration of the questions below provides clinical guidance for the
prescription of a device of appropriate type and complexity to restore the beneficiaryʼs
ability to perform mobility-related activities of daily living.
These questions correspond to the numbered decision points on the accompanying
flow chart.


 Clinical Criteria Algorithm for Wheelchair Prescribing

Request initiated for mobility

device for willing patient

Yes

No
#1: Mobility limitation?

Yes

Yes No
#2: Other limitations? #3: Compensated?

Yes
No

No
#4: Capable of safe use?

Yes

Yes Yes Canes

#5: Canes/walkers? Safe?
or walkers

No
No
Exit
No
# 6: Environment ?

Yes
Appropriate
Yes Yes manual
#7: Self-propel? Safe?
wheelchair
configuration
No No

Yes Yes
#8: POV? Safe? POV

No No

Yes Yes Power

#9: PWC appropriate? Safe?
wheelchair

No
No
Does
the
beneficiary
have
a
mobility
limitation
causing
an
inability
to
perform
one
or

more
mobility‐related
activities
of
daily
living
in
the
home?
A
mobility
limitation
is
one

that

• Prevents the beneficiary from accomplishing the mobility-related activities of daily
living entirely, or
• Places the beneficiary at reasonably determined heightened risk of morbidity or
mortality secondary to the attempts to perform mobility-related activities of daily
living, or
• Prevents the beneficiary from completing the mobility-related activities of daily
living within a reasonable time frame.

Are
there
other
conditions
that
limit
the
beneficiary’s
ability
to
perform
mobility‐
related
activities
of
daily
living
at
home?

• Some examples are significant impairment of cognition or judgment and/or vision.
• For these beneficiaries, the provision of a wheelchair might not enable them to
perform mobility-related activities of daily living if the comorbidity prevents effective
use of the MAE or reasonable completion of the tasks even with a wheelchair.
• If these other limitations exist, can they be ameliorated or compensated sufficiently
such that the additional provision of a mobility equipment will be reasonably
expected to materially improve the beneficiaryʼs ability to perform mobility-related
activities of daily living in the home?
Does
the
beneficiary
demonstrate
the
capability
and
the
willingness
to
consistently

operate
the
device
safely?

• Safety considerations include personal risk to the beneficiary as well as risk to
others.
• The determination of safety may need to occur several times during the process as
the consideration focuses on a specific device.
• A history of unsafe behavior in other venues may be considered.

Can
the
functional
mobility
deficit
be
sufficiently
resolved
by
the
prescription
of
a
cane

or
walker?

• The cane or walker should be appropriately fitted to the beneficiary for this
evaluation.
• Assess the beneficiaryʼs ability to safely use a cane or walker.

Does
the
beneficiary’s
typical
environment
support
the
use
of
wheelchairs
or

scooters/POVs?

• Determine whether the beneficiaryʼs environment will support the use of these
mobility assistive equipment.
• Keep in mind such factors as temperature, physical layout, surfaces, and
obstacles, which may render an item of mobility assistive equipment unusable in
the beneficiaryʼs home.
Does
the
beneficiary
have
sufficient
upper
extremity
function
to
propel
a
manual

wheelchair
in
the
home
through
the
course
of
the
performance
of
mobility‐related

activities
of
daily
living
during
a
typical
day?
• The manual wheelchair should be optimally configured (seating options,
wheelbase, device weight and other appropriate accessories) for this
determination.
• Limitations of strength, endurance, range of motion, coordination and absence or
deformity in one or both upper extremities are relevant.
• A beneficiary with sufficient upper extremity function may qualify for a manual
wheelchair. The appropriate type of manual wheelchair, i.e. light weight, power
assisted, etc. should be determined based on the beneficiaryʼs physical
characteristics and anticipated intensity of use.
• The beneficiaryʼs home should provide adequate access, maneuvering space and
surfaces for the operation of a manual wheelchair.
• Assess the beneficiaryʼs ability to safely use a manual wheelchair.

Does
the
beneficiary
have
sufficient
strength
and
postural
stability
to
operate
a
power‐
operated
vehicle
(POV/scooter)?

• A POV is a 3 or 4-wheeled device with tiller steering and limited seat modification
capabilities. The beneficiary must be able to maintain stability and position for
adequate operation.
• The beneficiary's home should provide adequate access, maneuvering space and
terrain for the operation of a POV.
• Assess the beneficiaryʼs ability to safely use a POV/scooter.
Are
the
additional
features
provided
by
a
power
wheelchair
needed
to
allow
the

beneficiary
to
perform
one
or
more
mobility‐related
activities
of
daily
living?

• These devices are typically controlled by a joystick or alternative input device, and
can accommodate a variety of seating needs.
• The beneficiary's home should provide adequate access, maneuvering space and
terrain for the operation of a power wheelchair.


Specific
Documentation
Requirements
for
Each
Category
of
MAE



See
Noridian
Documentation
checklists
(appendix)

• Manual wheelchairs
• Power wheelchair: Group 1/Group 2, no power options
• Power wheelchair: Group 2 Single/Multiple power options
• Power wheelchair: Group 3 Single/Multiple power options
• Power wheelchair: Group 3 No power options
• POV and Push-rim Activated Power Assist Device


See
Noridian
Power
Wheelchair
Documentation
Requirements
(appendix)



OTHER PAYORS
Medicaid

Coverage based upon income; low-income and disabled
Medicaid requires pre-authorization on certain items; this provides client and
dealer/supplier with verification of coverage prior to ordering
DME must be medically necessary; intended for use in home environment
Requires specific medical justification for different types of DME
Payor of last resort; must go through other sources first
Covers DME at allowable charge (payment made to supplier/dealer); opportunity for
individual consideration
Covers repairs
Covers DME for people in skilled nursing facilities through MAP 122 process
Coordinated
by
nursing
facility
social
worker

Supplier/dealer
must
be
willing
to
accept
MAP
122
assignment
(small
monthly

payments
over
an
extended
time
period)

DME for people in intermediate care facility, personal care homes, and adult homes is
handled through normal process
DME is owned by the client
Commercial
Insurance

Covers individuals under employersʼ group plan, responsible for paying their portion of
the premium
Also may be Medicare Supplemental plan
Coverage handbook typically offers vague summary of items covered
Most offer pre-authorization
DME must be medically necessary
Most require specific medical justification for DME, some require MD prescription or
letter only
May require use of a “participating” supplier/dealer
Covers DME at certain percentage (i.e. 80%) of a “reasonable" allowable charge;
often subject to a small cap
The supplier/dealer will bill the remaining percentage of the balance (i.e. 20%) to the
secondary insurance or to the client
Some cover repairs
Most do not cover DME for people in skilled nursing facilities
DME for people in intermediate care facility, personal care homes, and adult homes is
handled through normal process
DME is owned by the client
Workers’
Compensation

Covers individuals with work-related injuries
Typically offers pre-authorization, but must be coordinated through case manager
Equipment must be medically, vocationally, or functionally necessary (broad definition
of what is acceptable)
Most require some level of justification for equipment; some may required MD
prescription for certain items
May require use of a “participating” supplier/dealer
Covers equipment at 100%, but may obtain bids from several suppliers/dealers
Covers repairs
Equipment is owned by client
Division
of
Vocational
Rehabilitation

Covers individuals with an intent to return to work or school
Typically offers pre-authorization, but must be coordinated through field counselor
Equipment typically must be vocationally necessary, but often cover items medically
or functionally necessary (broad definition of what is acceptable)
Requires written justification of need for equipment
May require use of a contract supplier/dealer
Covers equipment at 100%, but must often obtain bids from several suppliers/dealers
Covers repairs
Equipment is owned by DVR

Other
Sources

Department of Veterans Affairs
Self-pay
Public Schools
Department of the Visually Handicapped
Community Service Fund
Community Service Board
Philanthropic organizations
Churches
Private/community fund raising
DOCUMENTATION
Equipment
Specifications/Quote

Therapist
Evaluation
Report
/
Letter
of
Medical
Necessity

Physician
Prescription

Medicaid:

Certificate
of
Medical
Necessity


Medicare:

(see
Noridian
checklists)

7 point physician prescription
Face-to-face examination by physician
Physician chart notes



 _________________________________________________________________

DELIVERY AND FOLLOW-UP

_________________________________________________________________

FITTING
Collaborate
with
the
RTS/dealer
to
ensure
that
all
equipment
is
as

recommended
and
configured
appropriately
prior
to
scheduling
delivery

Attach
primary
and,
if
possible,
secondary
support
surfaces
to
mobility
base

prior
to
client
arrival

ADJUSTMENTS
With
client
positioned
in
seating/mobility
system,
ensure
that
all

equipment
is
adjusted
properly

Cushion position
Back position
Armrest height
Legrest position
Secondary supports
• Headrest
• Lateral supports
• Pelvic positioning belts
Controls/switches

Securely
attach
all
equipment
once
final
position
is
achieved

Reassess
seating/mobility
system
for:


Fit
Comfort
Positioning
Mobility
Transfers
Functional abilities
TRAINING
Make
sure
client/family/caregiver
is
able
to
position
client
properly
in

seating/mobility
system

Make
sure
client/family/caregiver
is
able
to
disassemble/
reassemble
and

adjust
all
necessary
parts

Legrests
Armrests
Cushion
Back
Wheels
On/off

Air
pressure

Folding/loading wheelchair for transport
Charging wheelchair batteries

Recommend
therapy
program
for
additional
mobility
training
if
necessary

EDUCATION
Warranty
information

Care
of
equipment

Repairs
Cleaning

Contact
person
for
additional
questions/concerns
regarding

seating/mobility
system
(usually
RTS/dealer)


FOLLOW-UP
Encourage
coordination
of
equipment
issues
directly
with
RTS/dealer

Provide
client
with
therapist
contact
information
should
any
issues
arise

that
are
beyond
the
scope
of
the
RTS/dealer

Phone
follow‐up
at
regular
intervals
is
strongly
encouraged

 _________________________________________________________________

REFERENCES
_________________________________________________________________

Ball, M. (1996) A Multidisciplinary Approach to Dynamic Seating of the Multiply

Involved Client. Conference sponsored by Freedom Designs, Charlotte, NC.

Center for Assistive Rehabilitation Technology Training and Evaluation (CARTE),

Central Region Training Manual (1996). Virginia Department of Rehabilitative
Servcies, Virginia Assistive Technology System, University of Virginia, Woodrow
Wilson Rehabilitation Center.

Engstrom, B. (1993) Ergonomics: Wheelchairs and Positioning. Posturalis,

Hasselby, Sweden.

Hoppenfeld, S. (1976) Physical Examination of the Spine and Extremities. Appeton-

Century-Crofts, Norwalk, CT.

Huss, D. et al (1994) Recreating the Wheel: Howʼs and Whyʼs of Wheelchairs and
Seating for Neurologically Impaired Adults. Conference sponsored by Woodrow
Wilson Rehabilitation Center, Department of Physical Therapy, Fishersville, VA.

Kapandji, A. (1974) The Physiology of the Joints, Vol. 3: The Trunk and Vertebral
Column. Churchill Livingstone, New York, NY.
Kreutz, D. (1998) Fundamentals in Assistive Technology, 2nd Edition: Module VIII -
Characteristics of Seating and Positioning Technologies. RESNA Press, Arlington,
VA.

Maurer, L.E., and Vanhoy, M. (1998) AHCA Assistive Technology Services Assistive
Technology Training Program Manual, Module 1: Seating and Mobility. Ambulatory
HealthCare Corporation of America, Fredericksburg, VA.

Maurer, L.E., and Vanhoy, M. (1998) UVA-HealthSouth Seating and Mobility Training
Curriculum Manual. University of Virginia-HealthSouth Rehabilitation Hospital,
Charlottesville, VA.

Medhat, M.A., and Hobson, D.A. (1992) Standardization of Terminology and

Descriptive Methods for Specialized Seating: A Reference Manual. RESNA Press,
Arlington, VA.

Minkel, J.L. (1996) Sitting Solutions: Principles of Wheelchair Positioning and

Mobility Devices. Conference sponsored by Therapeutic Service Systems, Baltimore,
MD.

Nixon, V. (1985) Spinal Cord Injury: A Guide to Functional Outcomes in Physical

Therapy Management. Aspen Publishers, Inc., Rockville, MD.

Schuch, J. and Sprigle, S. (1995) Wheelchair Seating and Positioning: Improving

Your Services from Assessment Through Follow-Up. UVA Rehabilitation Engineering
Workshop, University of Virginia , Charlottesville, VA.

Zollars, J.A. (1996) Special Seating: An Illustrated Guide. Otto Bock Orthopedic
Industry, Inc., Minneapolis, MN.
 _________________________________________________________________

RESOURCES
_________________________________________________________________

Centers for Medicare and Medicaid Services

May
5,
2005
Decision
Memorandum

www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=143


Clinical Criteria for MAE Coverage

www.cms.hhs.gov/CoverageGenInfo/Downloads/MAEAlgorithm.pdf


NORIDIAN Administrative Services, LLC (Medicare Administrative Contractor,

Jurisdiction D)
Documentation
Checklists

www.noridianmedicare.com/dme/coverage/


NAMES National Association of Medical Equipment Suppliers

625 Sister Ln., Suite 200
Alexandria, VA 32314
(703) 836-6263
An
organization
of
suppliers
of
various
types
of
medical
equipment.

Their

“Re/habilitation”
Section
has
established
Standards
of
Practice
for
Rehabilitation

Technology
Companies.

They
sponsor
and
participate
in
several
trade
shows.


NRRTS National Registry of Rehabilitation Technology Suppliers
3223 South Loop 289, Suite 600
Lubbock, TX 79423
(800) 976-7787
An
organization
composed
of
Rehabilitation
Technology
Suppliers,
“dedicated
to
the

provision
of
high
quality
rehabilitation
technology
services
to
people
with
disabilities.


All
NRRTS’
members
meet
specific
professional
membership
requirements
and
agree

to
adhere
to
the
NRRTS
Code
of
Ethics
and
Standards
of
Practice.”


RESNA Rehabilitation Engineering and Assistive Technology Society of

North America
1700 N. Moore St., Suite 1540
Arlington, VA 22209-1903
(703) 524-6686
http://www.resna.org/resna/reshome.htm
An
interdisciplinary
association
of
professionals,
providers,
and
consumers
with

interests
in
disability
and
assistive
and
rehabilitative
technology.

RESNA
promotes

research,
development,
education,
advocacy,
and
provision
of
technology.

 

_________________________________________________________________

APPENDICES
_________________________________________________________________

Providence Alaska Medical Center, Wheelchair and Seating Clinic Referral Form

Noridian Documentation Checklists

www.noridianmedicare.com/dme/coverage/docs/checklists/manual_wheelchairs.pdf



www.noridianmedicare.com/dme/coverage/docs/checklists/group_1_pwc_and_group
_2_pwc_no_power_options.pdf



www.noridianmedicare.com/dme/coverage/docs/checklists/group_2_single_power_o
ption_group_2_multiple_power_option.pdf



www.noridianmedicare.com/dme/coverage/docs/checklists/group_3_single_and_mult
iple_power_options.pdf



www.noridianmedicare.com/dme/coverage/docs/checklists/group_3_power_mobility
_device_no_power_options.pdf


“Documentation Requirements for K0823 Power Wheelchair Claims.” Noridian, 2009.