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Manual Wheelchairs

Documentation Requirements Include:

  1. Detailed written order;
  2. Medical records that support that the beneficiary meets the general manual wheelchair coverage criteria listed in the Manual Wheelchair Bases LCD;
  3. Medical records that support that the beneficiary meets one of the two K0004 HCPCS code-specific coverage criteria listed in the Manual Wheelchair LCD;
  4. Documentation of a home assessment (direct visit to the beneficiary's home or indirect assessment based upon information provided by the beneficiary or their designee) that verifies the beneficiary's home can accommodate the wheelchair;
  5. Delivery documentation;
  6. Any other pertinent records; and
  7. Copy of Advance Beneficiary Notice (ABN) if one was obtained.

Relevant medical records consist of physician notes, non-physician clinical notes, and non-physician clinical evaluations that verify that the patient's condition meets coverage criteria for manual wheelchair.

The source of these records may be a physician's office, hospital, nursing home, home health agency, wound clinic, etc. evaluations used to determine coverage must have been performed and recorded prior to delivery and performed by a clinician who does not have a financial relationship with the supplier

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