Medicare Documentation Templates

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7 Element Order Requirement

The 7 EO must contain all of the following elements:

  • Beneficiary's Name
    Description of the item that is ordered. This may be general – e.g., "power operated vehicle", "power wheelchair", or "power mobility device" - or may be more specific.
  • Date of the completion of the F2F examination
    Pertinent diagnoses/conditions that relate to the need for the POV or power wheelchair.
  • Length of Need
    Ordering Practitioner's Signature.
  • Date of Ordering Practitioner's Signature
    The 7-element order must be received within 45 days after the completion of the F2F examination.

The 7 EO also must contain a legible identifier for the ordering practitioner and be date stamped on receipt.

It is a statutory requirement that all items of the 7 EO be entered specifically by and only by the practitioner who has conducted the face-to-face requirements.

Download the template here: PMD 7 Element Written Order

Detailed Product Description (DPD) Requirement

Once the supplier has determined the specific power mobility device that is appropriate for the beneficiary based on the ordering practitioner's 7-element order, the supplier must prepare a written document termed a detailed product description.

This detailed product description (DPD) must comply with the requirements for a detailed written order as outlined in the Supplier Manual and CMS' Program Integrity Manual (Internet-Only Manual, Pub. 100-8), Chapter 5.

Regardless of the form of the description, there must be sufficient detail to identify the item(s) in order to determine that the item(s) dispensed is properly coded.

The physician must sign and date the detailed product description and the supplier must receive it prior to delivery of the PWC or POV. A date stamp or equivalent must be used to document the supplier receipt date. The detailed product description must be available on request.

Download the template here: Detailed Product Description

Home Assessment Requirement

Prior to or at the time of delivery of a POV or PWC, the supplier must perform an on-site evaluation of the patient's home to verify that the patient can adequately maneuver the device that is provided. There must be a written report of this evaluation available on request.

There is no requirement that specific measurements are taken. However, the assessment must verify and record that the patient can adequately maneuver the device that is provided considering the home's:

  • Physical layout,
  • Doorway widths,
  • Doorway thresholds, and
  • Floor surfaces

If the report notes that the patient cannot access certain rooms necessary to accomplish their MRADLs with the wheelchair, there must be an explanation of how that will be mitigated. Failure to provide this explanation may 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 the DME MAC or other Medicare contractor upon request.

Download the template here: Home Assessment Requirement

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