In June, Ana Endsjo, Stacey Mullis, and Kara Kopplin were guests on the podcast RN Huddle. This 2-part series was a continuation of RN Huddle’s partnership with the National Pressure Injury Advisory Panel (NPIAP) and focused on wheelchair wounds. In part 1, they discuss their seating and wound expertise and how to help prevent pressure injuries in patients. Ana, Stacey, and Kara talk through helpful tips and resources for healthcare professionals in multiple settings who work with wheelchair bound patients who are at risk or have current pressure injures. Today, we are looking at part 2 of the series where Ana, Stacey, and Kara continue their discussion with co-host Renee Paulin about the best practices related to preventing pressure injuries with an appropriate wheelchair seating system. Other topics include funding for various seating systems and Medicare HCPC coding. Click here to listen to the first part of the series and below is a transcript from that podcast.
Broadcasting from the UNMC College of Nursing. Get ready for RN Huddle, the podcast dedicated to bringing hot topics for and by nurses to the table.
KEELER: Thank you so much for joining us here at RN Huddle. This is your host, Heidi Keeler, and we are coming to you from Omaha, Nebraska, so thank you so much for joining us.
Today’s episode we are going to continue on our partnership with the National Pressure Injury Advisory Panel or NPIAP and we are also continuing a discussion on wheelchair wounds where our cohost, Renee Paulin, will continue the discussion with our guests; Ana Endsjo, Kara Kopplin and Stacey Mullis as they really dig into the more nitty-gritty details about managing and preventing wounds that occur from wheelchairs and their special situations. So, thank you Renée and guests for presenting your expertise. Let’s go ahead and get started.
PAULIN: We are back again for Part 2 of the Permobil/NPIAP podcast with the team of experts; Ana, Stacey and Kara to further talk about seating interventions and the funding surrounding these decisions for our patients and our residents. Welcome back.
KOPPLIN: Thank you. Glad to be here.
PAULIN: All right. So, there’s a wide range of cushions, as our listeners know and from what we’ve talked about in Part 1, and some can be very costly. So, what is the best way to approach this decision-making?
ENDSJO: I can go ahead and field that question first. So, this is Ana and, I think, the biggest thing when it comes to thinking of the cost, and that really actually, it’s a very different answer if you’re looking at what type of setting, we’re dealing with. So, I’m going to talk first about settings with funding and cost usually isn’t that big of a deal for them only because of the fact that if you can justify the need and look at the different codes that the products have and usually you can get that person, that product without any issues because they have funding.
Now, if you switch gears completely and you look at settings without funding. So, in the United States most of our nursing home settings, for example, do not have funding. There are small pockets of the country, a couple of states like Washington State, Ohio, that do have funding through Medicaid, but not many. Most of our states do not have any funding in the nursing home settings and so the burden of cost really falls on the shoulders of the facility themselves or maybe even family. So, that’s when it starts to get a little hairy and we have to really talk about the quality of the product and then, looking at the long-term cost, right? So, a lot of these facilities have very, very tight budgets, especially now after Covid, when pretty much all they could think about was getting enough PPE, right? And so, they really were even more aware of cost of cushions and back supports and the wheelchair themselves because they were so scared to not have money to buy all of the PPE that they needed.
But I always, kind of, make this analogy. There is a difference between a $20 cushion and a $250 cushion. And you can walk into Walmart today and you can buy a $20 pair of sneakers, or you can go to a specialized running shop and get yourself a $160 pair of sneakers. And you, kind of, have to think, Well, what do I need those sneakers for? And the $20 pair of sneakers it’s not going to have any arch support, it’s going to be made with the lowest quality cost-effective foam that’s out there, it’s just going to be a straight shoe, it doesn’t matter what your foot looks like, you’re just going to have to shove your foot in there and deal with it. Or you’re going to go to the shoe store and get that $160 pair of sneakers that has fantastic arch support, the toe box shape counts, the heel shape counts, the type of foam, the way that it’s going to immerse your foot, support your foot and the question is, Do you want to go run a marathon in the $20 Walmart pair of shoes? Or do you want to use the $160 pair of shoes that was built to last, run a marathon, and all the training up to that marathon? So, I think, that pretty much sums it up that do we want our clients that are high risk, that have multiple comorbidities, that have aging skin, that have that inability that the NPIAP talked about that’s the number one factor for pressure injury development? Do we want them sitting on something that’s constructed for 20 minutes or do you want something that’s constructed to last three to four to five years? And I think that that is very important to understand that we should maybe think about, I could buy the $20 cushion but in two months I’m going to have to buy it again and then, in two more months I’m going to have to buy it again.
And that, kind of, brings me back to my own personal experience when I first started in seating and positioning, I was working in a nursing home setting, and I just did not have a lot of experience. I was one of those people that came out of school and maybe I got a whopping four hours in my masters’ program and so when my facility said, You know, you really have to think of cost, I would buy a $35 cushion. And I am not kidding you, and we kind of joked and we would call these patients repeat offenders, but they kept coming back to me on caseload every one-and-a-half month to two months because that cushion had completely compressed, it had worn out and I had to get them the same cushion. So, I kept buying the same cushion over and over, this $35 cushion, if you kind of do the math, that’s about what? $210, $230 a year to buy the same cushion over and over that kept wearing out. Where I could’ve just bought the high-quality great cushion that has built-in properties to protect that person at $250, right? And that $250 cushion would’ve lasted three to four years, where this one last maybe one-and-a-half to two months. So, there is a big difference, and I think we have to think again about the long-term cost, not just say, Oh, gosh I’m going to have to spend $250 upfront.
PAULIN: So, that’s very good. I like the analogy and detail. And then, the manufacturers then they’re going by standards, correct, and there’s testing involved? What should a clinician be looking at or should they be involved in that?
KOPPLIN: Yeah, this is Kara, I’m glad to answer that. We have a few different layers here in the Clinical Practice Guideline that was created by the NPIAP. They do describe some of those features of a cushion, or any support surface that provides that skin protection. And one of those features is immersion and envelopment or it can be offloading. So, I’m personally actively involved with the international standards that are developed for wheelchair seating and we do have specific tests that have been developed that are performed in a lab, and so these are more engineering-based mechanical tests of cushions to see if they have those beneficial properties of immersion and envelopment and other properties as well like stability and lateral and forward and backwards, but these are voluntary standards. However, they are based on understanding the body and what it needs for prevention. So, we know now that pressure injuries don’t just come from cutting off blood flow, it’s also the deformation of those tissues and the cell death that results.
So, that’s why the Clinical Practice Guidelines says that you need to manage those tissues by immersing and enveloping or offloading. So, there is an ISO standard, an International Standard for Immersion, for example, that measures how deep really a simulated pelvis can go into a cushion. Is it deep enough or contoured enough to support the greater trochanters and the ischial tuberosities? So, this is a very simple test that can be performed if you have a thin, flat, like, general-use cushion it’s not going to give that contouring and that support that the body needs. (8:27)
So, in the US, the Medicare system has recognized that, and they’ve adopted part of that ISO standard to take just that measurement. So that’s the measurement that they use to decide if a cushion is a skin-protection cushion or not. So, the simple measure of immersion, does it have the contouring and the structure and the strength to let the pelvis sink in 40 mm, plus allow for another 5 mm of overload? And if so, then, it’s qualified that way. So, that’s a really great basic line in the sand that’s been drawn and, as Ana said, the number one risk for the seated person or for anyone for pressure injuries is immobility. And so, everyone in a wheelchair is at risk. And honestly, I would think that everyone would want to have a skin-protection cushion or recommend that for their clients because of that.
PAULIN: Are there legalities surrounding this as well, these standards, these tests?
KOPPLIN: So, when the standards are developed, they are voluntary standards until a regulatory body adopts them. And so, from a manufacturer’s standpoint, for example, if there is a cushion that is designed and developed to be a skin-protection cushion, it needs to have that evidence behind it. So, there’s a process when a cushion is submitted to the funding system, the Medicare funding system, that they have to perform that ISO test and show the data that they did immerse and envelop, per the requirements of those HCPCS codes, for skin protection or adjustable skin protection cushions.
And after this whole package of information is put together with that test, inflammability tests and information about the cover and even how it performs after simulated aging. So, all of that is submitted and then, if it’s approved, then, that HCPCS code is issued for a skin protection or adjustable skin-protection cushion. So, there is that obligation to meet that requirement but, as was mentioned before, not all clients are getting cushions that are through the Medicare or Medicaid system and so that’s where you need to take a step back. This test standard for immersion is based on anatomy. And so, even if your client is not part of funding, if they’re in a long-term care facility or a different situation, you should still require that they have that level of protection, that that test still applies, and so it’s a question that can be asked if there’s not a HCPCS code with a product it’s appropriate to ask the manufacturer, Do you meet the ISO standard? Or do you meet the Medicare standard for skin protection? Because I want to make sure the clients protected.
PAULIN: Okay. Can you tell us a little bit more about these Medicare HCPCS codes and what that means for our listeners?
KOPPLIN: Sure. This is the Healthcare Common Procedure Coding System and they do have, of course, have requirements for who’s eligible to get different types of cushions and the types of cushions. The categories that Medicare has designated are general use skin protection, nonadjustable skin protection, adjustable positioning cushions, and then adjustable skin and positioning. So, on the design side of things, speaking as the engineer in the group, there are these guidelines or requirements that are laid out for a manufacturer to register their product in one of those categories and that is reviewed by some agencies within Medicare. So, for example, for a positioning cushion you have to pick two features. There has to be pre-ischial bar or ridge, or lateral pelvic supports or medial thigh supports that are 25 mm high. So, you have to design that into your cushion to be able to demonstrate that it can provide some positioning. If it’s just a flat piece of foam that’s just general use. And then on the most adaptable and adjustable end of things, you have the adjustable skin-protection cushions and that’s where you have to demonstrate that immersion, plus show that you can adjust to the person and that the adjustability relates to the skin protection part of the cushion. So, like you couldn’t just have a cushion that could get wider or deeper, it has to be adjustable where you have that need for protection like under the IT’s. And so, every manufacturer that applies for these codes puts together this package of information with the test data and the engineering drawings and a checklist showing that they’ve met all of these features that have been identified through the FDA and Medicare is being critical for these cushions.
MULLIS: And I can just add to that and speak to the clinical side of the meaning of these HCPCS codes. Essentially, as a clinician, when I’m selecting a cushion for a client, I do my evaluation and I look at what the goals are, what I’m trying to accomplish, but when it comes to selecting an actual cushion whether this is good or bad, it can be both at times, but it’s dependent on diagnosis and presentation. But when it comes to wounds, essentially if someone has a wound they’re going to qualify for a skin-protection cushion. But they may also qualify for skin protection and positioning cushions. So, I guess that, when it comes to the HCPCS codes, it’s good in the sense that it kind of directs the selection process but then, sometimes there are instances when you really wish you could get a particular cushion and your client just doesn’t qualify for that particular cushion. So, there are some limitations in that process.
ENDSJO: I think that brings me to a point of, kind of, what my hope is and, again, what I love about how the NPIAP laid out the risk factors is that they’re opening peoples’ eyes, they’re opening physicians, nurses, therapists’ eyes that we have a tendency with Medicare and Medicaid to, kind of, just as Stacey said, group someone into a diagnosis. And if you have that specific diagnosis that is the code that they get qualified for and they can buy that particular type of cushion that Kara and Stacey had mentioned. And the problem with that is, we shouldn’t be defined by our diagnosis and the NPIAP laid it out very nicely for us that you should be looking at the risk factors. You know, someone without that diagnosis still might have all of those risk factors, so they still deserve, and probably should be, using a skin-protection product at a minimum in order to minimize their risk of developing a pressure injury. So, I’m hoping that as the NPIAP starts to collaborate more with the manufacturing side and the therapists’ side they’ll start to understand and be able to be even a stronger voice to Medicare and Medicaid in saying, Hey, think outside of the diagnosis. A person is not just their diagnosis, but they do have signs and symptoms that we should be considering making sure that we’re getting them the right equipment so that we can minimize the risk of pressure injuries which is a very serious issue within our healthcare system.
MULLIS: And the documentation of those risk factors is always crucial to justify what you’re using on the patient and how you’re using it and what for so forth.
KOPPLIN: And this is Kara. I’d like to add that the standards that have been developed for testing cushions also give one more tool in that toolkit in the clinical decision-making process. So, you should always ask for the data behind the claims for the cushions or seating systems that you’re looking at.
PAULIN: Well, this was all great. Do any of you have any other suggestions or resources to share with our listeners today to help further grasp the funding or the HCPCS codes?
ENDSJO: No. I think that the last thing that I’d like to leave you with is that I get asked a question very very often. And because I work in settings that do not have funding, so I work mostly with nursing home settings, and I do get asked that question all the time, Why should I go and buy the $250 cushion when there’s one right here that’s $30? So, I’m really hoping that with Kara’s explanation of how much on the engineering side, you know, we actually have to do to be able to create a product that can help immerse and envelop and all the things that it actually has to have inside of it, I’m hoping that that question is answered. Yes, there is a huge difference and, yes, someone with all the risk factors that have been mentioned deserves a product that is built to withstand all of those risk factors and really protect that person.
MULLIS: Yeah, and I would also just guide people to the NPIAP resource site and download or order the wheelchair seating pocket guide. As we mentioned in Part 1 of our podcast, it’s a great resource to really tie the practice guidelines to clinical practice and gives really practical suggestions as well.
KEELER: Well, that’s all for today and thank you to Ana, Stacey and Kara once again for being with us and sharing your wealth of knowledge on RN Huddle.
ENDSJO: Thank you for having us.
KEELER: We will link the resources on RN Huddle and, listeners, please be sure to visit the NPIAP site for a plethora of resources, as mentioned, and to listen to other podcasts surrounding pressure injury prevention. Listeners, if you want to hear more and have a request, please, visit the RN Huddle site where you can email us with any suggestions. We thank you for listening and stay tuned for more hot topics. Thank you.
KEELER: Wow, what an amazing discussion. Renée, Ana, Kara and Stacey thank you so much. You know, really talking about how you can prevent these wounds using different adaptive devices and, of course, it’s always helpful to know how the coding works and how you can get these resources to the patients who need them the most. So, thank you so much for this discussion. Thank you so much for this partnership, and I hope that you, out there in RN Huddle listener land, have enjoyed this as much as I have. So, thank you. Hopefully you’ll tune into another episode of RN Huddle.
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