CMS has implemented a National Coverage Determination for all mobility assistive equipment which includes power wheelchairs and power operated vehicles. Listed below are the Medicare Power Wheelchair CHART NOTE Requirements.
Medicare requires physicians to conduct a face-to-face mobility examination prior to writing a prescription for a power mobility device. Your chart notes must include the following information.
1. Chief Complaint: The major reason for the office visit was to conduct a Mobility Examination.
2. Physical Assessment: Physical assessment as relevant to mobility limitations including:
- Weight, height
- Musculoskeletal Exam, Cardiopulmonary Exam,
- Neurological Exam, Oxygen saturation with exertion,
- Range of Motion (i.e.decreases ROM)
- Gait/Balance (i.e. unsteady gait-history of falls)
- Upper and lower Extremity Strength (MUST be included)
*RUE (i.e. 1/5) *RLE (i.e. 2/5)
*LUE (i.e. 1/5) *LLE (i.e. 2/5)
3. What medical condition(s) limit your patient's ability to participate in Mobility Related Activities of Daily Living (MRADLs) in their home?
4. List what MRADLs in the home are IMPAIRED due to your patient's mobility limitation? (This MUST be specific. Please list at least (1) MRADL, such as
- Dressing, Grooming, Toileting, Feeding, Bathing
5. Describe why a cane or walker can't meet your patient's mobility needs in the home? Some examples are:
- Unsteady gait - history of 3 falls over past month
- Upper Extremity (UE) and Lower Extremity (LE) strength of 2/5
- Desaturates to 87%, Poor balance
6. Describe why a manual wheelchair can't meet your patient's mobility needs in the home? Some examples are:
- UE strength of 1/5, Right sided weakness of 1/5 due to CVA
- Decreased ROM of shoulder & joints, Grip strength of 2/5
- Contractures of the hands, Pain level - 8/10 in shoulder and hands
7. Describe why a scooter (POV) can't meet your patient's mobility needs in the home? Some examples are:
- Cannot safely transfer in/out of POV
- Home environment does not provide adequate access for maneuvering POV
- Cannot operate tiller of POV; Lacks postural stability; UE strength of 1/5
8. Does the patient have the physical and mental abilities to operate a power wheelchair safely in the home?
9. Is the patient willing and motivated to use a power wheelchair?