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December 14, 2011

Power Mobility Documentation Requirements

A review of power mobility claims and ADMC requests submitted to Jurisdiction C shows continued uncertainty regarding the various assessment and evaluation documentation requirements. The following article reviews this information and includes a reference chart indicating the assessment and exam requirements for the various levels of power mobility.

Face to Face Exam

What is It?

The face-to-face examination is a statutory requirement for all power mobility devices (PMD). This exam consists of two separate elements, an in-person visit to the physician for the purpose of requesting a PMD, and a comprehensive medical examination. The evaluation should be tailored to the individual patient's conditions. The history should paint a picture of the patient's functional abilities and limitations on a typical day. It should contain as much objective data as possible. The physical examination should be focused on the body systems that are responsible for the patient's ambulatory difficulty or impact on the patient's ambulatory ability.

Who Can Perform It?

The treating physician must conduct the in-person visit. The comprehensive medical evaluation may be performed by the physician or may be referred to a licensed/certified medical professional (LCMP), such as a physical therapist or occupational therapist, who has experience and training in mobility evaluations to perform part of the exam. If the treating physician has referred the medical examination to a LCMP, the physician must review the findings after receiving the LCMP's report. In addition the physician must document their acceptance of this report in writing and sign and date the entry.

REMINDER: If the report of an LCMP examination is to be considered as part of the face-to-face examination, there must be a signed and dated attestation by the supplier that the LCMP has no financial relationship with the supplier.

How Should the Findings be Reported?

The in-person element of the face-to-face exam should indicate that a major reason for the visit was a mobility examination. The comprehensive medical examination may be documented either:

A supplier-generated form must not be used to document either the treating physician's or LCMP's exam since a supplier generated form is not considered to be a part of the medical record.

Suppliers should also be cautious about providing forms to physicians, such as those developed by the Texas or Florida Academy of Family Physicians, and try to create the impression that these documents are a sufficient record of an in-person visit and medical evaluation. There forms are designed to gather selected bits of information and are almost always insufficient. That is because they typically contain check-off boxes or space for only brief answers and thus do not provide enough detailed information about the patient's ambulatory abilities and limitations to allow the Medicare contractor to determine if coverage criteria have been met. What is required is a thorough narrative description of the patient's current condition, past history, and pertinent physical examination that clearly describes their mobility needs in the home and why a cane, walker, or optimally configured manual wheelchair is not sufficient to meet those needs.

See the “Dear Physician” letter, Power Wheelchairs and Power Operated Vehicles – Documentation Requirements, for additional information regarding the history and physical examination requirements for a power mobility face-to-face evaluation.

REMINDER: The supplier must receive a written report of the face-to-face exam within 45 days after its completion and prior to delivery of the wheelchair. A date stamp or equivalent must be used to document the receipt date.

Specialty Exam

What is It?

The specialty evaluation is a written report providing a detailed explanation of why a particular power wheelchair base and each specific option or accessory is needed to address the patient's mobility limitation.

A specialty exam is a mandatory requirement prior to dispensing a Group 2 Single Power Option or Multiple Options PWC, any Group 3 or 5 PWC, or a push-rim activated power assist device.

Who Can Perform It?

The specialty exam must be performed by a licensed/certified medical professional, such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations. The person performing this exam may, but is not required to be, a RESNA-certified Assistive Technology Professional (ATP).

REMINDER: The PT, OT, or physician performing the specialty exam may not have a financial relationship with the supplier.

How Should the Findings be Reported?

The policy does not prescribe a specific format for reporting the specialty exam findings. However, the report should be in the office or facility's usual medical record form; it should not be on a supplier-generated form.

Home Assessment

What Is It?

All levels of PMD require that an onsite evaluation of the patient's home be performed prior to or at the time of delivery. The person conducting this assessment should verify and document, in a written report, that the patient's typical environment supports the use of a PMD.

Who Can Perform It?

The home assessment can be performed by the supplier (or supplier's employee) or a practitioner (physician, physician's employee or LCMP, etc.).

How Should the Findings be Reported?

The policy does not specify a particular format or form to use. The policy, however, does state that the assessments and measurements should include physical layout of the home, doorway width, doorway thresholds and surfaces the device will have to move over. Additionally, if the report indicates that the patient is unable to access one or more rooms, e.g. the bathroom, while in the wheelchair, an explanation as to how this issue will be mitigated to allow the patient to complete his/her MRADLs must be provided.

ATP In-person Appraisal

What Is It?

As of April 1, 2008, suppliers providing certain wheelchairs as described in the PMD LCD must employ a RESNA-certified Assistive Technology Professional (ATP) and this person must have direct in-person involvement in the wheelchair selection process. For an in-depth review of this requirement, please refer to the article, Power Mobility Devices – Supplier ATP Involvement FAQs.

Who Can Perform It?

This process must be performed by an ATP who specializes in wheelchairs and is employed by the supplier.

NOTE: The requirement for the supplier to employ an ATP and for this person to have direct, in-person involvement in the wheelchair selection process is not waived if the specialty exam is performed by an ATP. The person performing the specialty exam cannot work for the supplier and the person involved in the ATP in-person appraisal must have a financial relationship with the supplier. Therefore, one individual cannot meet both requirements.

How Should the Findings be Reported?

There must be evidence in the supplier's file of direct in-person interaction with the patient by the ATP in the wheelchair selection process. The documentation must be complete and detailed enough so a third party would be able to understand the nature of the ATP involvement and to show that the standard was met. Just “signing off” on a form completed by another individual would not adequately document direct, in-person involvement. Also, merely signing a statement such as, “I am a RESNA-certified professional specializing in wheelchairs and had direct, in-person involvement in the wheelchair selection for this patient” does not sufficiently verify that this policy requirement was met. Finally, a home assessment completed by a supplier-employed ATP would not meet the requirement unless the documentation showed how the ATP applied the assessments and measurements to the wheelchair selection process.

REFERENCE CHART: PMD Evaluation/Assessment Requirements

PMD Group

HCPCS Code Range

Face-to-Face Exam

Specialty Exam

Home Evaluation

ATP In-person Appraisal

Group 1 POV

K0800-K0802

Yes

No

Yes

No

Group 2 POV

K0806-K0808

Yes

No

Yes

No

Group 1 PWC

K0813-K0816

Yes

No

Yes

No

Group 2 PWC – NPO

K0820-K0829

Yes

No

Yes

No

Group 2 PWC – SPO

K0835-K0840

Yes

Yes

Yes

Yes

Group 2 PWC – MPO

K0841-K0843

Yes

Yes

Yes

Yes

Group 3 PWC – NPO

K0848-K0855

Yes

Yes

Yes

Yes

Group 3 PWC – SPO

K0856-K0860

Yes

Yes

Yes

Yes

Group 3 PWC – MPO

K0861-K0864

Yes

Yes

Yes

Yes

Group 5 PWC

K0890-K0891

Yes

Yes

Yes

Yes

Abbreviation Key

PMD = Power Mobility Device

POV = Power Operated

Vehicle

PWC = Power Wheelchair

MPO = Multiple Power Options

NPO = No Power Options

SPO = Single Power Option

Refer to the Power Mobility Devices LCD for additional information on coverage and documentation requirements.