Power Mobility Devices – Medical Review
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- Are there any resources available to help us educate physicians/treating practitioners on information that should be included in a face-to-face evaluation for power mobility devices?
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The four DME MAC Medical Directors have written a letter to physicians, Dear Physician – Power Wheelchairs and Power Operated Vehicles, which explains the physician's/treating practitioner's documentation responsibilities in regard to a beneficiary's need for power mobility. Suppliers are encouraged to use this letter in their education efforts. When questioned, remind treating practitioners that the information regarding the beneficiary's mobility limitations should be objective or measurable. Subjective statements are open to individual interpretation and do not offer a clear picture of the beneficiary's mobility status. Objective information, on the other hand, provides a common quantifiable reference. Examples are listed below:
Subjective Information Objective Information The patient has difficulty walking and can only walk short distances. The patient becomes short of breath after walking 15-20 feet and must stop and rest. The patient needs power mobility in order to complete MRADLs. He is too unstable to use a cane or walker and does not have the endurance to propel a manual wheelchair. The patient does not have the stability to walk from the bedroom to other rooms in the house with either a cane or walker. He has experienced two falls in the past month in his home despite use of a wheeled walker. A trial with a lightweight manual wheelchair failed. Severe osteoarthritis in shoulders and wrists has resulted in limited range of motion and propelling the wheelchair more than 15 feet results in pain rated at 7/10. The patient has weakness in the upper extremities. Strength in right upper extremity is 3/5 and 2/5 on the left. Patient cannot lift more than 5 pounds. Originally published: 02.20.17
Reviewed: 12.06.23
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- What measurements should be included in a home assessment for a beneficiary receiving a power mobility device?
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The Power Mobility Devices local coverage determination (LCD) requires that the supplier or practitioner perform an onsite evaluation of the beneficiary's home prior to or at the time of delivery. There is no requirement that specific measurements be taken. However, the assessment must verify and record that the beneficiary can adequately maneuver the device that is provided considering the home's
- Physical layout
- Doorway widths
- Doorway thresholds
- Floor surfaces
If the report notes that the beneficiary cannot access certain rooms with the wheelchair, there must be an explanation of how that will be mitigated. Failure to provide this explanation will result in claim denial. When completed, the report should be signed or initialed and dated by the person who performed the assessment and available to either the DME MAC or other Medicare contractors upon request.
Originally published: 02.20.17
Reviewed: 12.06.23
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- I know that suppliers are not allowed to complete any part of the order for a power mobility device. But can a treating practitioner’s employee write or type the other elements of the order, as long as the treating practitioner signs the order?
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The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) is the basis for many of the current documentation rules concerning power mobility. The MMA requires that the physician or treating practitioner ordering the device create the written prescription. Therefore, all elements of the order should be entered by the treating practitioner. This order can either be handwritten or electronic.
Originally published: 02.20.17
Reviewed: 12.06.23
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- Even though certificates of medical necessity (CMNs) are no longer required for manual or power wheelchairs, can suppliers continue to use them in lieu of a detailed SWO and to gather medical information?
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Suppliers shall not use any retired CMS documents, including the manual and power wheelchair CMNs. It is a misrepresentation of Medicare policy, if the CMN has been retired, to request the treating practitioner to complete section B and sign and date section D. In the event of a prepayment or post payment claim review, a retired CMN will not be accepted as a substitute for a SWO.
Originally published: 02.20.17
Reviewed: 12.06.23
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- Medical Review denied one of my claims because the reviewer could not read the order. Many physicians are now using prescription pads with anti-tampering watermarks that obscure information when the order is copied or faxed. How can I make sure my claims do not get denied because of illegible faxed documents?
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It is the supplier's responsibility to assure that all Medicare documentation requirements are met and that legible copies can be made available upon request. If in doubt as to whether a document will be legible if faxed, we suggest that the supplier fax a test copy to themselves. In situations where the faxed document is too dark to read, photocopying may provide a more readable document. Suppliers have the option of sending the records via mail or delivery service. Refer to the development letter for the address and mailing instructions.
Originally published: 02.20.17
Reviewed: 12.06.23
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- In response to a development letter requesting additional documentation, I faxed a copy of my records to CGS. It has been several weeks since I sent the information and a payment decision has not shown up on a remittance notice. Should I resend the information or rebill the claim?
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According to CMS guidelines, Medical Review has up to 30 days from the date of receipt to review additional documentation and make a claim determination. Once a supplier has responded to an additional documentation request (ADR), they should take no further action unless they receive notice of a claim denial. In that situation, if the supplier disagrees with the decision, they should follow the appeal process.
Originally published: 02.20.17
Reviewed: 12.06.23
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- Does documentation of the beneficiary's weight need to be submitted to justify the power wheelchair (PWC) or power operated vehicle (POV) ordered?
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For nonstandard weight bases (heavy duty, very heavy duty, or extra heavy duty), the beneficiary's weight must be submitted to justify the ordered PWC/POV.
Originally published: 11.17.17
Reviewed: 12.06.23
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- Can the supplier or assistive technology professional (ATP) provide the beneficiary weight to justify a heavy duty, very heavy duty, or extra heavy duty PWC or POV?
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No, the beneficiary's weight, used to justify a heavy duty, very heavy duty, or extra heavy duty PWC/POV, must be included in the medical documentation provided by the physician/practitioner.
Originally published: 11.17.17
Reviewed: 12.06.23
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- What should a supplier do if the beneficiary weighs more than the weight capacity of the beneficiary-preferred wheelchair?
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The supplier should advise the beneficiary that exceeding the weight capacity for a wheelchair is a safety risk; moreover, because the preferred wheelchair is not rated for the beneficiary's weight, the wheelchair may be damaged more easily. This could result in excessive repairs for which Medicare may not make full payment or replacement.
Originally published: 11.17.17
Reviewed: 12.06.23
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- What is the timeframe for delivery of a power wheelchair under the Condition of Payment Prior Authorization or Advance Determination of Medicare Coverage (ADMC)?
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The delivery of the power mobility device (PMD) that has received a Condition of Payment Prior Authorization or ADMC affirmative determination must be within six months following the determination.
Originally published: 11.17.17
Reviewed: 12.06.23
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- What is the correct coding when a standard proportional remote joystick is provided at the time of initial issue of a power wheelchair?
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There is no separate billing for a standard proportional remote joystick when it is provided at the time of initial issue of a power wheelchair. Payment is included in the allowance for the power wheelchair base. If a nonexpandable controller is provided at the time of initial issue, payment is also included in the allowance for the wheelchair base, and there is no separate billing.
If an expandable controller is provided at the time of initial issue, code E2377 (expandable controller) and E2313 (harness for upgrade to expandable controller) are separately billable and payable. If a power seating system is provided and if the system is controlled through the drive control interface, code E2310 or E2311 is used. There is no additional separate billing using code E2399 or K0108 for any components of a nonexpandable or an expandable controller.
Refer to the Coding Guidelines section of the Wheelchair Options and Accessories Policy Article for definitions of the components described above and additional coding information.
Originally published: 02.20.17
Reviewed: 12.06.23
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Additional Resources
- Standard Documentation Requirements for All Claims Submitted to DME MACs PA
- Power Mobility Devices LCD
- Power Mobility Devices PA
- Power Mobility Devices Weight Requirements Tool
- Prior Authorization
- Documentation Checklists
- Power Mobility Device (PMD) Required Prior Authorization – What Suppliers Need to Know
- Prior Authorization – HCPCS Code Lookup