Once you've determined from the face-to-face mobility examination that your patient's mobility needs would best be served with a power wheelchair, you'll need to provide the following documentation within 45 days of your face-to-face mobility examination:
Once the supplier has determined the specific power mobility device that is appropriate for the patient based on the physician's order, the supplier must prepare a written detailed product description (DPD) that lists the specific base (HCPCS code and either a narrative description of the item or the manufacturer name/model) and all options and accessories that will be separately billed.
The physician must sign and date this detailed product description and the supplier must receive it prior to delivery of the electric wheel chair or electric scooter.
The 7-element written order must include:
Beneficiary's (patient's) name
Detailed description of item that is ordered
Date of the face-to-face examination
Pertinent diagnosis/conditions that relate to the need for a power wheelchair
Length of time the patient will need the device
Date of physician's signature
The face-to-face examination shall provide information relating to the following questions
Chief complaint - the major reason for the office visit was to contact Mobility Examination.
Complete Physical Assessment as relevant to mobility limitations.
What medical condition(s) limit your patient's ability to participate in Mobility Related Acts of Daily Living (MRADLs) in their home?
List what MRADLs in the home are impaired due to your patient's mobility limitation.
Why can't a cane or walker meet your patient's mobility needs in the home?
Why can't a manual wheelchair meet your patient's mobility needs in the home?
Why can't an electric scooter (POV) meet your patient's mobility needs in the home?
Does this patient have the physical and mental abilities to operate an electric wheel chair safely in the home?
Is the patient willing and motivated to use a power wheelchair?
The chart note shall provide pertinent information about the following elements, but may include other details. Each element would not have to be addressed in every evaluation.
How long the condition has been present
Interventions (including medications) that have been tried and the results
Past use of walker, manual wheelchair, electric scooter, electric wheel chair and the results
Impairment of strength, range of motion, sensation, or coordination of arms and legs
Presence of abnormal tone or deformity of arms, legs, or trunk
Neck, trunk, and pelvic posture and flexibility
Sitting and standing balance
Functional assessment – any problems with performing the following activities:
The need to use a cane, walker or the assistance of another person
transferring between a bed, chair, and PMD
walking around their home – to bathroom, kitchen, living room, etc.
provide information on distance the patient is able to walk without stopping, speed and balance
The elements that are addressed will depend on the diagnoses that are responsible for the mobility deficit. For example, for patients with COPD, heart failure or arthritis, the major emphasis will be on symptoms and history of the progression of their condition rather than on the physical examination.
Physicians shall also provide reports of pertinent laboratory tests, x-rays, and/or other diagnostic tests (e.g., pulmonary function tests, cardiac stress test, electromyogram, etc.) performed in the course of management of the patient.
Although patients who qualify for coverage of a power chair may use that device outside the home, because Medicare's coverage of a wheelchair is determined solely by the patient's mobility needs within the home, the examination must clearly distinguish the patient's abilities and needs within the home from any additional needs for use outside the home.
Physicians shall document the evaluation in a detailed narrative note in their charts in the format that they use for other entries. The note must clearly indicate that a major reason for the visit was a mobility evaluation.
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