Determining Your Patient’s Mobility Needs
Application of the National Coverage Determination
The Centers for Medicare and Medicaid Services (CMS) implemented a National Coverage Determination for all mobility assistive equipment which includes power wheelchairs and power operated vehicles (scooters) that utilizes a sequential or algorithmic approach to prescribing these devices.
In order to determine the patient’s mobility needs, Medicare requires physicians to conduct a face-to-face mobility examination of the patient prior to prescribing a power mobility device. The DME MACs have created Medicare Minute MD℠: Power Mobility Pearls for the Practicing Physician and a “Dear Physician Letter- Power Wheelchair and Power Operated Vehicles – Documentation Requirements” to provide guidance for practitioners on conducting and documenting a comprehensive mobility examination.
When conducting a mobility examination, a practitioner must conduct a targeted functional assessment of the patient and carefully document objective measurements in the patient’s chart. Additionally the chart note must contain documentation by the physician or health care practitioner that clearly states that one of the reasons for the office visit was to conduct a face-to-face mobility examination. Below are items that should be addressed in during the face-to-face mobility examination.
1. Physical Assessment
A physical assessment targeting the patient’s specific condition(s) and functional limitations that are causing the patient’s mobility to be impaired, including:
- Weight and Height
- Cardiopulmonary Examination
- Oxygen desaturation levels on RA and with activity
- Ejection fraction
- Musculosketal Exam
- Arm and leg strength (I.E.: RUE=2/5, LLE=2/5…)
- Grip strength
- Range of motion deficit measurements
- Neurological Examination
- History of falls
- Balance and coordination
- Patient’s ability to walk
2. Medical Coverage & Mobility Limitation
Describe, in detail the medical condition and mobility limitation that that significantly impairs the patient’s ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. A mobility limitation is one that:
- Prevents the patient from accomplishing an MRADL entirely, or
- Places the patient at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or
- Prevents the patient from completing an MRADL within a reasonable time frame.
3. Mobility Related Activities of Daily Living
Describe the specific Mobility Related Activities of Daily Living (MRADLs) that your patient’s medical condition(s) has limited or impaired in their home on a typical day? These daily activities would be things like dressing, grooming toileting, feeding, and bathing.
4. Objective Measurement of Patient's Physical Limitations
Evaluate and discuss why the patient’s mobility limitation cannot be sufficiently and safely resolved by the use of a cane or walker. Include objective measurements of the patient’s physical limitations to support your evaluation. For example:
- Unsteady gait and poor balance
- History of 3 falls over past month
- Upper Extremity (UE) and Lower Extremity (LE) strength of 2/5
- Desaturates to 87% on RA with activity
5. Evaluation of Upper Extremity Functions
Evaluate and discuss why the patient does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to perform MRADLs during a typical day. Include in your evaluation items such as:
- Limitations of strength (I.E.: Upper Extremity (UE) strength of 2/5, right-sided weakness of 1/5 due to CVA, grip strength of 2/5, contractures of the hands)
- Endurance (I.E.: becomes SOB with activity and desaturates to 85%)
- Range of motion (I.E.: Decreased ROM of shoulder & joints
- Presence of pain,(I.E.: include the patient’s pain scale for the appropriate location such as pain level of 8/10 in shoulders and hands)
- Deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function
6. Evaluation of POV Applicability
Evaluate and describe why a scooter (POV) can't meet your patient's mobility needs in the home. Include the following in your evaluation:
- Can the patient safely transfer to and from a POV?
- Can the patient operate the tiller steering system?
- Can the patient maintain postural stability and position while operating the POV in the home?
- Will the patient’s home environment provide adequate access for maneuvering POV?
7. Mental Capabilities for Safe Operation
Does the patient have the mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) to sufficiently and safely operate a power wheelchair in their home?
8. Willingness & Motivation
Is the patient willing and motivated to use a power wheelchair?