COMPLEX REHAB TECHNOLOGY

Ditch the Frustrating Appeal Process

How to avoid denials & reduce delays in care

By Jennifer Craig

Funding for complex rehab technology (CRT) has never been more challenging than it is today. Therapists, physicians and assistive technology professionals (ATPs) put in countless hours evaluating patients, identifying appropriate equipment and writing their documentation, only to face denials and confusing appeal processes. While clinical expertise drives equipment recommendations, documentation is what ultimately tells the story payers use to make their coverage determinations.

The good news is that many denials stem from common and often avoidable issues. By adopting a few key habits, clinicians can improve approval rates, reduce delays in care and spend less of their precious time with frustrating appeal processes.

Habit No. 1:

Think like a reviewer.

Sounds simple enough, right? One of the easiest and most effective ways to improve documentation is to think about it from the perspective of the reviewer. The reviewer has never met the patient, observed their mobility limitations or witnessed the challenges they face each day.

Never assume prior knowledge. Instead, clearly explain the patient’s functional status, activities of daily living limitations and medical necessity for the recommended equipment.

For example, if a patient has multiple sclerosis and the treating therapist explains that this patient requires a particular wheelchair due to this diagnosis, seating system or positioning component. But diagnosis alone does not establish medical necessity. Instead, ask open-ended questions to uncover the specific details needed to clearly describe the patient’s functional challenges:

What tasks can they no longer perform independently?
How does weakness, fatigue, pain or loss of balance affect daily activities?
What is the risk if they do not receive the recommended equipment?

Strong documentation tells the complete clinical story, connecting the diagnosis to the functional impairments and clearly explaining how the recommended equipment addresses those limitations.

Habit No. 2:

Include these 3 documentation elements in every letter.

At Numotion, we see a lot of denials due to documentation that relies heavily on subjective descriptions rather than objective clinical evidence. Terms like limited, functional, weak or reduced are not measurable and do not paint a clear picture for the reviewer.

These three categories of objective information should consistently appear throughout the clinical documentation:

1. Measurements

Always include objective measurements. Examples may include skin integrity findings, postural asymmetries, pressure mapping results, range of motion measures and strength measures.

Rather than documenting “poor lower extremities strength,” it is important that objective findings are recorded, for example:

Hip flexion: 2/5 bilaterally
Right upper extremity: 2/5
Left upper extremity: 5/5

These details provide clear clinical evidence that supports the recommendation.

2. Functional Assessment Findings

Document how the patient performs activities such as transfers, mobility, pressure relief, dressing, toileting and self-care tasks. Be specific about the amount of assistance needed to complete mobility-related activities of daily living inside the home.

For example, instead of writing, “patient requires assistance for toileting,” consider documenting, “patient requires moderate assistance from one caregiver to safely complete toileting tasks due to poor trunk control and inability to maintain standing balance longer than 10 seconds.”

3. Endurance & Activity Tolerance

Many patients can technically perform an activity but cannot do so safely, consistently or for a reasonable duration.

Document endurance limitations, fatigue patterns, respiratory compromise, pain or cardiovascular restrictions that affect functional performance.

For example:

Use the pain scale instead of “increased pain during…”
Oxygen saturation and heart rate during and after functional tasks
Use standardized tests like the timed up and go or 30-second sit-to-stand test

Objective data transforms documentation from opinion into evidence, which is exactly what payers are looking for.

Habit No. 3:

Eliminate common errors that trigger denials.

Even strong evaluations may result in denials when there are inconsistencies within the supporting documentation. Denials are common when the medical record conflicts with the clinical evaluation. For example, a physician note may describe the patient as ambulatory, but the evaluation indicates that the patient cannot perform a functional weight shift.

When reviewers encounter inconsistencies, that can lead to an automatic denial. Clinicians aren’t out of luck here, though. Habit No. 3 means reviewing supporting records proactively so that any contradictions are addressed early. If a patient remains technically ambulatory for extremely limited distances at the beginning of the day but cannot safely and independently stand for pressure relief by the end of the day, that distinction should be clearly explained.

Another common denial reason is the failure to rule out less costly alternatives. Payers require that lower-level alternatives were considered (and sometimes trialed) and determined to be insufficient. This must be clearly stated in the clinical evaluation. If recommending a power wheelchair, documentation must explain why a cane, walker, manual wheelchair, scooter or lower-level mobility device will not meet the patient’s needs.

One of the most common examples of this is failure to sufficiently rule out the lightweight manual wheelchair (K0004) when requesting an ultralightweight manual wheelchair (K0005). This can be tricky, because the K0004 chairs now offer multiple features that the K0005 offers. A good rule of thumb here is to always request the specifications of the chair from the ATP. If the specs are unclear, the ATP can review them with the clinical team until they are easier to understand. After all, that’s why this process requires a team.

Here are a few details that can help rule out the K0004:

Axle configuration—functional things that happen at the axle:

Center of gravity moves wheels forward or backward to align with the patient’s shoulder (be specific about how much)
Moving the wheels forward can reduce overall wheelchair length, which results in increased accessibility in tight spaces
Rear seat to floor height provides “dump” or “slope” of greater than 2.5 inches
Camber provides varying degrees of lateral stability (be specific about how much and why); for example, does the patient need more lateral stability to be able to reach over and pick things up off the floor such as laundry in the dryer or scooping a child up?

Front seat to floor height:

With the thickness of the cushion considered, does the client need a higher or lower seat-to-floor height than is available on a K0004?

This is a lot to consider, even as an experienced clinician. But there are a few tools out there that can be helpful to improve documentation and reduce denials. Forms like the Houston Methodist and the Wheeled Mobility & Seating Evaluation are both nonsupplier-generated forms that have specific sections that can be completed by the ATP. It is important to remember that Medicare has very specific rules around compliant collaboration. Scribing and authoring are big no-no’s. An ATP can help clarify equipment details but cannot dictate the content or write documentation for the clinician. These forms allow for compliant collaboration between the clinician and the ATP, and in our experience, have the potential to reduce denials since they ensure all the required details are covered.

Ultimately, the form of documentation selected is up to the individual clinician. Whether using an electronic medical record or one of these tools, consistently applying these habits can reduce time spent addressing denials and allow more time to focus on helping patients access the equipment needed to achieve their goals.

Jennifer Craig is a clinical educator with Numotion. She earned her clinical doctorate in occupational therapy from Belmont University and has experience across skilled nursing, home health and specialty seating and positioning services. Craig is passionate about advancing complex rehab therapy education and clinical excellence. Visit academy.numotion.com.