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Permobil Blog / March 1, 2018

Q & A's: Insurance and Reimbursement Part 1


Part 1 in our series Wheelchair Seating and Positioning Misconceptions in Wound Care: Q & A's where Lindsey Sharpe PT, DPT answers questions asked by participants of the webinar by the same name. This week we're focusing on questions about insurance and reimbursement. 


1. Can we reasonably expect to have insurance companies pay for the more involved chair in a Home Health setting?

The short answer is: YES! You just need to be able to justify the need to the insurance company. Our role as therapists is to be a patient advocate and provide them with what they need for optimal safety, independence, and function. Don’t be afraid to ask for what they need!

Be sure to include all justification in your evaluation and/or progress notes. You also have the option of writing a separate letter of medical necessity but, for a K0004, submitting your evaluation and progress notes is enough AS LONG AS you include supporting details in your daily documentation.


The list below includes the justification for wheeled mobility:

  • Patient is non-ambulatory.
  • Demonstrates decreased safety with ambulation or is at risk for falls within the home. Ask about history of falls and perform an objective balance assessment i.e. BERG, DGI.
  • Requires assistance for ambulation within the home and wheeled mobility would allow independence.
  • Requires increased time for ambulation within the home and as a result is not able to perform ADL’s in a reasonable time frame. Perform a gait speed test and think about performing ADLs in a reasonable amount of time.
  • Unable to consistently ambulate throughout the day in the home which affects their ADLs. Look at a 24 hour period.


Here are scenarios to consider when deciding whether wheeled mobility would increase safety, independence, and function:

  • They can ambulate but are at high risk of falls.
  • They have frequent urge incontinence because they are unable to get to the restroom on time. 
  • Their O2 saturations drop below or heart rate increases above a safe range with ambulation. 
  • Their daily routine involves sitting in a recliner and transferring to a bedside commode as needed, and wheeled mobility would allow them increased independence in the home.


Next, you need to know that K0001-K0003 are meant for SHORT TERM USE ONLY and these are HEAVY and NON-ADJUSTABLE/offer minimal adjustability. These are only meant for clients who will be sitting in a WC for LESS THAN 2 hours/day. A K0004 chair is the first chair in the WC line-up that is intended for long term use.


To qualify for the K0004:

  • Patient qualifies for a basic manual chair, but requires a seat width, depth, or height that can’t be accommodated by a basic MWC (K0001-K0003).
  • They are unable to perform all ADLs efficiently in a basic MWC (K0001-K0003).
  • They use a wheelchair more than two hours per day; so, the MAJORITY of our clients will qualify for the K0004 based on this alone!


Example of justification for a K0004 manual WC:

K0004 Wheelchair: This wheelchair was selected for the variety of standard features it offers that meet the user’s needs. This chair comes with adjustability features for the seat-to-floor height, which is beneficial for transfers and accommodating the patient’s lower leg length. The seat slope can also be set to allow the client adequate sitting balance in the system. The seat dimensions, setup, and adjustability cannot be achieved on a standard wheelchair. These features allow the user to be independent with ADL’s in a reasonable time frame.


You can add details specific to your client to the above “general” justification; i.e. you might add the adjustability of the seat-to-floor height is needed as your client is a foot propeller. Or, you might add that due to your client’s shoulder pain/history of shoulder surgery, because pushing the heavier alternatives places them at increased risk for shoulder injury/worsening pain.


If you have additional questions regarding the justification piece of this, please feel free to contact our education department at ANY time, and we can talk through how to justify the chair for your specific patient!



2. Do you get much push back from insurance in ordering the K0004 model? Any suggestions for documentation to support the need in a Home Health setting?

Yes, insurance companies only want to pay for what is MEDICALLY NECESSARY. They do not want to pay for more than what the patient can “get by with”, if you will. However, this is why it is so important for us to advocate for our patients and make sure we are including all information that would help to justify the need in our documentation.

Please refer to the answer in the question above for details on suggestions for justification. And again, please feel free to contact our education department at ANY time, and we can talk through how to justify the chair for your specific patient!



3. Do you know the difference in cost between the K0001 and the K0004?

This certainly depends on the manufacturer and the quality of the chair, but typically a K0001 chair is going to cost between $400-$500 while a K0004 costs somewhere around $1000 (obviously, the K0002 and K0003 being in between those). This may seem like a big cost difference but remember: providing a chair that correctly fits a patient and can be adjusted to fit their needs will minimize risk of pressure injury and falls!



Next week we'll look at the rest of the questions relating to insurance and reimbursement. 


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Lindsey Sharpe, PT, DPT
Lindsey Sharpe graduated with a BA in Exercise and Sport Science from the University of North Carolina at Chapel Hill in 2007 and with her Doctor of Physical Therapy from Elon University in 2010. Lindsey was a practicing clinician for seven years primarily focusing on neurological conditions and wheelchair seating and positioning.

Lindsey was first introduced to wheelchair seating and positioning during her time on the spinal cord injury team at the University of Virginia's acute rehab hospital where she discovered her interest in and passion for this niche in the therapy world. Lindsey went on to open a brand-new seating clinic with Carolinas Healthcare System in Concord, NC where she advanced her knowledge and skills performing both inpatient and outpatient seating evaluations for clients of all ages having a variety of diagnoses.

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