Is Your Seat 5 Years Old? If Not, Then What? - Resna

Is Your Seat 5 Years Old?
If Not, Then What?
Wayne Rydberg, BS, ATP
Patti Bahr, MSE, RET
Gillette Children’s Specialty Healthcare

Objectives
• Define a strategy for collecting useful data
on risks for development of pressure ulcers
• Describe a strategy for adjusting or
repairing products with consumers and their
family members
• Identify specific documentation
recommended for systems under 5 years, if
needed

Gillette History
• First publicly funded hospital in the
nation for “crippled and indigent
children” – 1897
• State hospital to Not for Profit – 1977
• Lifetime Clinic – 2001
• United Cerebral Palsy Affiliate - 2012

Gillette Today
• Inpatient hospital - 2,328 inpatients in 2012
• Outpatient clinics - 147,984 visits in 2012
– 5 clinics in Twin Cities metro
– 3 clinics in greater Minnesota
– Mobile Outreach Clinic - 17 communities in
greater Minnesota
• In the past 10 years, Gillette has served patients
– every (89) Minnesota county
– 48 of the United States
– 4 Canadian provinces
– 30 other countries

Gillette Culture
• Not for Profit
• Local competition is free for service
• Mostly CP kids with Medicaid or some
combination of private insurance & MA
• Traditionally a small population of Medicare
patients

Lifetime Specialty
Healthcare since 2002
• Lifetime Growth (new site too)
– 2002 844
– 2007 5,746
– 2012 8,449
• Medicare patients increasing
accordingly
• Patients 18+ were 22.7% of Gillette
population in 2011

Historical Seating at Gillette
• History – since early 1980s
• Culture – provide same day service
– If MD requests
– If patient lives outside of Twin Cities
– If you have time (retro PAs OK if MMA)
• 80/20 Guideline
– Before 2011, Medicare was less than 20%

Seating at Gillette
• Sitting Support Orthosis (SSO)
developed from Orthotic Lab
• Upholstered Sitting Support Orthosis
(USSO)
• SureFit
• Custom Firm Seats and Backs
• Contoured Foam

Current Seating at Gillette
• Continue to provide same day adjustments
and repairs
• 90% of people are pressure mapped
– 10% have SSOs (visual check), have good skin,
healthy tissue, adequate bottoms, use briefs
• Over 1000 Seating & Mobility Evals yearly
• Over 600 new seats yearly

Referrals
• Ongoing seating care
– Internal MD/NP for check-ups, yearly (or sooner)
– Seating only services
• New seating services
– New patients to organization
– Commercial seating doesn’t work
– Pressure issues needing topical, nutritional, and
custom seating support

Pressure Issues Addressed
• Wound Care Committee for Inpatients
– Nurse Practitioner (NP)
– Seating Practitioner
– Nurse
• Community Network
– Wound Care Nurse
– Plastic Surgeon
– NP at Regional Hospital

Find Origin of a Wound
• History
• Other Questions
– Previous ulcers – Toileting/shower
– Medical condition routine
• spine/pelvic asymmetry – Sleep routine
• incontinence
– Skin check routine
• nutrition
– Hours in chair
• What has changed? – Pressure relief
– Medical concerns
routine
– Medications
• Micro Climate
– Transfers
– Nutrition
– Care givers
– Moisture
– Weight gain/loss – Heat

Seating and Mobility
Evaluations (1,000 yearly)
(Exemption from Lifetime criteria)
• OT or PT
• Seating Practitioner
• Durable Medical Equipment Vendor of
patient’s choice
• Others

What we Compared
• UNDER 5 years old
Medicaid or Private
– # Paid
– # Denied
• OVER 5 years old
Medicaid or Private
– # Paid
– # Denied
• UNDER 5 years old
Medicare
– # Paid
– # Denied
• OVER 5 years old
Medicare
– # Paid
– # Denied

Data Collected on 255 Fittings
Aug 2011 – Jan 2012
• Diagnosis
• Primary/secondary insurance
• Existing seating system at evaluation
• Age of existing seating system
• Adjustments to seating system
• Type of new seating system recommended
• Reason for needing new seating system

Data Excluded from Study
• Only private insurance (14)
• MC and never had seating before (10)
• MA and never had seating before (8)
• No billing information found (6)
• Patient died (1)
Also,
If unable to determine how old existing
system was, included in under 5 years.

Results
• UNDER 5 years old
Medicaid or Private
– 80 (100%) Paid
– 0 (0%) Denied
• OVER 5 years old
Medicaid or Private
– 35 (100%) Paid
– 0 (0%) Denied
• UNDER 5 years old
Medicare
– 48 (76%) Paid
– 13 (21%) Denied
– 2 (3%) in Appeal
• OVER 5 years old
Medicare
– 28 (74%) Paid
– 10 (26%) Denied

Discussion of Results
• 115 with Medicaid
– all paid (according to contractual agreement)
– age of seat did not matter
• 101 with Medicare
– 76 paid
• 48 (63%) under 5 years
• 28 (37%) over 5 years
– 23 denied
• 13 (57%) under 5 years
• 10 (43%)over 5 years

Discussion of Results
• 101 with Medicare (only or combination)
– 76 paid
• 48 under 5 years old
– 23 (48%) from commercial to custom seat (different
HCPCS code)
• 28 over 5 years
– 15 (54%)from commercial to custom seat (different
HCPCS code)

Discussion of Results
• 101 with Medicare (only or combination)
– 23 (23%) denials (11% of overall)
• 9 – no billing information or missed filing date
• 7 – managed care or skilled nursing facility
• 2 – lack of information
• 2 – no one paid
• 2 – same and similar

Conclusion
• Better screening of living situation needed
• Internal billing needs to be monitored
• Further investigation of amount paid needed
• Five year window importance was
inconclusive
• Documentation must support need for seats
– even if they are less than 5 years old

Documentation: Reason
for needing new seat
• Existing seat does not provide sufficient
support
• Mobility base change
• Posture or anatomical measurements
change
• Existing seat worn or broken
• Existing seat does not provide proper
pressure relief or management
• Other (weight change, medical change)

Reason for New Seating
Medicaid (MMA)
• PAID (115)
– 54 Base change
– 52 Support
– 34 Anatomical change
– 21 weight increase/growth
– 20 Pressure relief
– 15 Worn/broken 4 weight decrease
– 4 medical change
(Total is greater than 115 because more than
one reason could be used for justification.)

Reason for New Seating
Medicare (MC) UNDER 5
• DENIED
– 11 Support
– 7 Base change
– 5 Anatomical
change
– 3 Worn/broken
– 8 Pressure relief
– 1 Weight gain
• PAID
– 33 Support
– 23 Base change
– 18 Anatomical
change
– 12 Worn/broken
– 18 Pressure relief
– 9 Weight Gain

Reason for New Seating
Medicare (MC) OVER 5
• DENIED
– 7 Support
– 4 Base change
– 4 Anatomical
change
– 6 Worn/broken
– 5 Pressure relief
– 2 Weight gain
• PAID
– 19 Support
– 15 Base change
– 13 Anatomical
change
– 23 Worn/broken
– 13 Pressure relief
– 3 Weight gain
– 1 Weight loss

Other Findings
• Of SSOs replaced
– average age of seat = 6 years

Documentation for seats
• Therapy
– Medicare qualifications included in templates for
new electronic medical record
• Why is new w/c needed?
• Why is new seat needed?
• Prefabricated seat does not meet the needs of patient
because . . .
• Seating Practitioner
– Each code identified and possible reasons for
justification available to practitioner

Seating Sample Charting
Electronic Medical Record

Therapy Sample Charting
Electronic Medical Record

Billing Cycle
• Evaluation
• Prior Authorization with little
information
• More information requested
• Send Therapist note
• Send Letter of Medical Necessity
signed by MD/NP
• Send Seating Practitioner note

How Practice Has Changed
• Discussions with consumers and family
– Age of chair
– Age of seat
– Age of components
– ABN needed to bill secondary insurance
• Vendor communication
• Gather information on residence

How Practice Is Changing
• Repairs/adjustments
– Fewer same day
– Educate practitioners about need to adjust
before ordering new
• Intake Person
– Insurance check before eval
– Identify age of seat, diagnosis, place of
residence, guarantor
– Insurance check before fit

Insurance Check
• Medicare part A and B
• Medicare supplemental HMO/MCO
– Which is primary?
• Check
– 270/271
– Stonebridge
– IVR line
– Connex (soon)

Consumer & Family
Conversations
• Evaluations – culture of expecting new
– New chair and transfer seat
– Wait until chair/seat 5 years old
– May need to repair/adjust until 5 years old
– If can’t, this may be justification for new
– If under 5 years, may be harder to justify
• Insurance review
– Commercial to custom may be paid (different HCPCS
code)
– If Medicare criteria not met, ABN needed to bill secondary
insurance

Future Work
• Function not part of the data
– Study w/ therapy
• Determine functional measurements w/ OT
• Have OT test function in current chair/seat
• Have OT test function after new system
provided to:
– Ensure function not decreased
– Measure and document increased function

Thank You
• Wayne Rydberg
– 651 634 1902
– wrydberg@gillettechildrens.com
• Patti Bahr
– 651 634 1911
– pbahr@gillettechildrens.com