Documenting for Funding Assistive Technology

Purpose of LMN

• Documents the medical need for the recommended equipment

• Allows the payer to understand the needs and authorize the equipment

• Provides specs for the wheelchair checkout at delivery

AT Team

Client

Caregivers

Therapist

Supplier

Evaluation

• Detailed history

• Neuromuscular status

• Sensation

• Pain

• Functional status

• Social/living situation

• Mobility needs and recommendations

• Seating and positioning needs and recommendations

Justifying Durable Medical Equipment

Know your payer source
 Coverage depends on payer, dx and location of use
◦ Durable medical equipment (DME)
Usable life of 2 years or more
 Over a certain $ amount
 Deductibles and annual limits - Medicare B has 20% co-pay
◦ Medicaid will pay for certain items not covered by Medicare (must be
eligible)
 Bathroom equipment - grab bars, tub seats

Justification DME

Something that prevents the consumer from accomplishing his/her MRADLs (mobility related ADLs) at all, or places them at a heightened risk of morbidity or mortality because of the attempts to perform and MRADL, or to accomplish it in a reasonable time frame

Mobility Limitation or Deficit

Toileting
Dressing
Grooming
Bathing
Feeding

Medicare Algorithm

Trial with “optimally-configured” chair”
 Objective data about consumer’s performance: time/distance, heart rate,
pulse ox, blood pressure, perceived exertion
 Environment: smooth surfaces, carpet, rugs, door sills, ramps
 Availability of caregiver to push chair

Ruling out Manual Wheelchair

Safe transfer on and off
 Ability to sit on “fish-on” seat
 Use of both UEs
 Sufficient use of thumbs/fingers
 Sufficient room within the home
 Another criteria: the person “has not expressed an unwillingness to use the recommended device”

Justification Letter Guidelines for Prior Approval

Include:
• Identifying information
• Physical evaluation
• Functional abilities and safety (include living situation and mobility)
• Equipment currently used (type and age) and why it is no longer appropriate
• Equipment trial - list all alternatives tried and results

Equipment requested
 List all equipment
 State why each piece is medically necessary (justification)
 Show how equipment requested is least costly, most cost effective alternative
• Goals and benefits of prescribed equipment
• Summary paragraph at end
• Sign and date with credentials

Goals for Equipment Justification

Must be functionally stated (F)
 Must include the client (E)
 Must include what the client will be able to DO as a result of using the equipment (A)
 Must include the equipment needed to meet the goal (S)
 Include specific timeline if goal involves learning a skill with the equipment (T)
 Timeline is implied if gaining the equipment will meet the goal (do not need to state)

LMN Process

MD order for evaluation (MD)
 Generate OPP and goals with client (OT/client)
 Complete physical evaluation (OT)
 Generate list of needed equipment (OT/ATS)
 Write letter of medical necessity (justification letter) (OT)
 Submit letter to ATS (OT)
 Get MD order for equipment (ATS or OT)
 Submit for prior approval (ATS)
 Action from payer – approve, defer, or deny

Types of Language Used

In the Home:
◦ Getting to the bathroom for toileting, bathing, and grooming
◦ Getting to an area for dressing
◦ Getting to the bedroom for sleeping
◦ Getting to meals

Functions NOT included:
◦ Medical appointments
◦ Social events
◦ Exercise
◦ Getting the mail
◦ Doing laundry

Home Environment Justifications

Be clear about the type of equipment needed and why
◦ Must be medically necessary
◦ Must be related to a need created by the medical dx
 Identify all environments where equipment will be used
 Identify and justify all aspects of the equipment that are non-standard