• Overview
• Equipment Delivery Timeline
• Tips For Therapists

Healthcare Providers

Tips for Therapists by Gayle Talley, MPT, ATP

• Power Wheelchair Base is required to accommodate for a limitation or absence in the physical capacities required to ambulate or use any type of manual wheelchair or Scooter (POV) for functional residential mobility. Patient is unable to ambulate with any kind of assistive devices. Patient is unable to functionally propel any type of manual wheelchair base, even if modified.

• Pediatric Power Wheelchair Base is required to provide a means of independent mobility within residential and community environments. Patient is unable to ambulate functionally or utilize a manual wheelchair base, even when modified.
• Power Seat Tilt is required to provide a means of independent pressure reliefs. It can also provide gravity-assisted, upright positioning to accommodate for a lack in strength and/or coordination for upright sitting tolerance.
• Power Back Recline is required to allow for a means of independent pressure relief and positional changes for pain relief, postural control, and assistance with performance of ADL’s such as dressing or genitor-urinary care.
• Power Tilt/Recline Combination System is required to provide a means of pressure relief, pain relief and gravity assisted positioning that can not be accommodated using a tilt or recline only system. The pressure relieving and pain relieving components of a combination system provide enhanced pressure and pain relieving characteristics.
• Power Seat Elevation System for Independent Transfers is required to assist with transfers in and out of the wheelchair so that a downhill, gravity assisted transfer can be accomplished using diminished or absent strength or coordination.
• Power Elevating Leg rest/Foot rest Assembly is required to allow independent knee angle adjustments for edema and contracture management as well as pain relief associated with passive movement of lower extremities.
• Tilt-in-Space Positioning Manual Wheelchair Base is required to provide a manual wheelchair base that can allow positional changes quickly and efficiently to accommodate for decreased trunk control and provide for pressure relief while seated in the wheelchair. Patient is non ambulatory and can not functionally propel any type of manual wheelchair. This feature is only available in chairs of this class/code.
• Ultra Light Weight Manual Wheelchair Base (K0005) is required to provide the most light weight, efficient manual propulsion system available. This class of chair has an adjustable axle plate that allows the wheelchair to have the center of gravity set up in the most optimal position for independent propulsion. It will also allow the chair to have a seat to floor height change from the front to back to have a downward slope, thereby improving stability and function enhancing performance of all Mobility Related Activities of Daily Living (MRADL’s).
• Custom configured Manual Wheelchair Base (K0009) is required to provide the most light weight, efficient manual propulsion system available. This class of chair has an adjustable axle plate that allows the wheelchair to have the center of gravity set up in the most optimal position for independent propulsion. It will also allow the chair to have a seat to floor height change from the front to back to have a downward slope, thereby improving stability and function enhancing performance of all Mobility Related Activities of Daily Living (MRADL’s). These systems are significantly lighter than K0005 counterpart chairs and will allow the least amount of strength, coordination and energy to functionally propel a manual for long periods of time without the development of Upper extremity repetitive strain injuries such as Carpal Tunnel Syndrome.
• Pressure-relieving Seat Cushion is required to provide a pressure-relieving seated surface to protect the insensate, partially insensate or hypersensitive seated surface of this patient.
• Positioning Cushion is required to properly support and position the patient’s seated surface to accommodate for a pelvic obliquity, leg length discrepancy, pelvic tilt, or other orthopedic deformity/anomaly.

• Pressure-relieving/Positioning Cushion is required to provide a stable base of support for positioning and pressure relief in the seated surface. A pressure relieving cushion does not provide enough stability and a posture/positioning cushion does not provide adequate pressure relief.
• Solid Backrest is required to support and position the patient’s trunk and spine for accommodation of orthopedic deformities/anomalies as well as providing pressure relief.
• Pelvic Positioning Belt is required to support and position the patient’s pelvis in the wheelchair in the most optimal position for functional activities and stability.
• Anterior Shoulder Support is required to provide anterior trunk support in the absence of upper trunk control and stability.
• Thoracic Lateral Supports and Hardware are required to provide lateral trunk support in the absence of lateral upper trunk control and stability.
• Lateral Hip Supports and Hardware are required to provide lateral hip positioning and stability while reducing hip abduction. These can also be used to maintain proper alignment and pelvic control in chairs where width adjustments will be expected.
• Headrest and Hardware is required for head and neck support and positioning to accommodate for decreased head and/or neck control.
• Specialty Power Wheelchair Driver Controls are required to allow independent powered mobility in the absence of the physical capacities to utilize a standard joystick for the operation of the power mobility device.
• Enhanced Power wheelchair controller is required to provide an electronics platform that will allow fine tuning and programmability to enhance the user’s functional ability to use a powered mobility device.
• Harness for expandable electronics is required to interface electronics to the motors and driver control in a powered mobility device.
• Retractable Joystick Hardware is required to allow the joystick to be retracted allowing access to functional spaces for ADL performance. This can also assist with the ability to transfer independently.
• Foot/Ankle/Toe Positioning devices are required to provide stability to patient’s lower extremities while seated in the wheelchair.
• Arm Troughs and Hardware are required to accommodate for decreased arm function, strength and/or coordination while seated in the wheelchair.
• Switches (electrical or mechanical) are required to access driver control functions, power seat functions, mode select, reset, or chair on/off functions.

Forms for Therapists

• Blue Cross/Blue Shield Wheelchair Medical Necessity Form
• PECOS Enrollment Letter
• Medicaid Bath Chair Form
• Medicaid Bed/ Pedi-Bed Forms
• Medicaid Car Seat Form
• Medicaid Evaluation
• Medicaid Gait Trainer Form
• Medicaid Manual Wheelchair Criteria
• Medicaid Power Wheelchair Criteria
• Medicare 7 Element Written Order Form
• Medicare Documentation Requirements Guide
• Medicare Cushion Qualifying Codes
• Licensed Clinical Medical Professional Functional Mobility Evaluation Guide
• Medicare Seating Evaluation