Power tilt and recline: Yes, both can be medically necessary

Medicare will consider power tilt, power recline or a combination of power tilt and recline for coverage and reimbursement when: The beneficiary is at high risk for the development of a pressure ulcer (injury) and is unable to perform a functional weight shift, or the beneficiary utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to the bed, or the power seating system is needed to manage increased tone or spasticity.

Does that mean the beneficiary needs to satisfy one of these criteria for power tilt and a different criterion for power recline in a multiple power option system? The answer is no. In fact, since the national roll out of prior authorization as a condition of payment for the Group 3 single (K0856) and multiple (K0861) power option bases on July 17, 2017, providers have confirmed that the multiple power option base they are recommending is being approved when both power seat functions are used to manage the same issue—pressure management.

The No. 1 reason a combination of power tilt and recline may be medically necessary for an individual with a disability is because it allows them to redistribute and relieve pressure on the seated surface independently. For individuals with absent or impaired sensation, the risk for development of a pressure injury at the ischial tuberosities, sacrum and/or coccyx is significant. The same holds true for individuals with a diagnosis like amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS) or muscular dystrophy (MD), where sensation is intact, but they may not have the balance, strength, muscle endurance, physiological endurance and/or coordination to shift their weight a sufficient number of times per day, for a sufficient duration each time to allow for reperfusion of the skin and muscles, which is essential to maintain or improve cellular health and tissue integrity.

Studies have shown that wheelchair users need to perform pushups for at least two minutes, regardless of frequency, to reduce oxygen tension in the tissue to the same levels as when the tissue is unloaded. While a wheelchair pushup is one way to perform a functional weight shift, most individuals who qualify for a complex rehab power wheelchair do not have the capability of self-propelling a manual wheelchair or lift their body weight off the seat for two minutes once, let alone multiple times per day.

Another way to perform a functional weight shift is for the individual to lean to each side, outside their base of support, to unweight the opposite ischial tuberosity. If the individual has normal to good sitting balance, the ability to self-correct destructive postural tendencies and does not use any postural support components in his or her power wheelchair, this method may be effective, with the use of an appropriate cushion. The problem with this technique is that significant pressure is exerted on the side the person is leaning to, putting him or her at heightened risk for pressure injury, especially below the surface of the skin at the bony prominence where it can go undetected.

A third method of unweighting the seating surface is to have the individual independently stand up repeatedly throughout the day. Again, most persons with a disability who meet the coverage criteria for a Group 3 power wheelchair are unable to perform this technique and rely on the mechanical means to change their position in the chair during the 12 to 18 hours they are using the chair for mobility.

While power tilt or power recline may have a positive impact on tissue perfusion, the RESNA Position on the Application of Tilt, Recline, and Elevating Legrests for Wheelchairs Literature Update, available at www.resna.org confirms that:

Tilt and recline affect pressure and perfusion at the skin and muscle tissue at the ischial tuberosities, and to a minimum extent, at the sacrum;

The greatest reductions in pressure are seen when tilt and recline are used together, either at tilt of 35 degrees with recline 100 degrees, or tilt of 15-25 degrees with recline of 120 degrees;

Greater angles of tilt and recline generally provide better pressure relief; and, three  minutes duration of 35 degrees tilt with recline of 120 degrees is more effective than one minute.

Unless the use of power tilt or power recline is medically contra-indicated, the combination of the two may provide a much better clinical outcome for persons with disabilities for the prevention and treatment of pressure injuries. It also may explain why the combination of power tilt and recline has continually outpaced the provision of power tilt and power recline since the codes were implemented in 2004. The benefit of prior authorization is that clinicians and providers now have verification that the need for both power seat functions has been reviewed, and indirectly approved when the base code, K0861 is approved.

Julie Piriano, PT, ATP/SMS, is vice president of clinical education and rehab industry affairs, and compliance officer for Pride Mobility Products.