The physician may refer the client to a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), who has experience and training in mobility evaluations to perform part of the face-to-face examination. This person may have no financial relationship with the supplier. If the client was referred before being seen by the physician, then once the physician has received and reviewed the written report of this examination, the physician must see the client and perform any additional examination that is needed. The report of the physician's visit shall state concurrence or any disagreement with the LCMP examination. In this situation, the physician must provide the supplier with a copy of both examinations within 45 days after the face-to-face examination with the physician.

If the physician saw the client to begin the examination before referring the client to an LCMP, then if the physician sees the client again in person after receiving the report of the LCMP examination, the 45-day period begins on the date of that second physician visit. However, it is also acceptable for the physician to review the written report of the LCMP examination, to sign and date that report, and to state concurrence or any disagreement with that examination. In this situation, the physician must send a copy of the note from his/her initial visit to evaluate the client plus the annotated, signed, and dated copy of the LCMP examination to the supplier. The 45-day period begins when the physician signs and dates the LCMP examination.

The evaluation should be tailored to the individual client's conditions. The history should paint a picture of your client'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 client's ambulatory difficulty or impact on the client's ambulatory ability.

A date stamp or equivalent must be used to document the date that the supplier receives the report of the face-to-face examination.

The written report of this examination must be available on request. Physicians shall document the examination 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 examination.

Many suppliers have created forms which have not been approved by CMS which they send to physicians and ask them to complete. Even if the physician completes this type of form and puts it in his/her chart, this supplier-generated form is not a substitute for the comprehensive medical record as noted above.

STEP 2 - 7 Element Order for PMDs

The order, referred to as the 7-element order, that the supplier must receive within 45 days after completion of the face-to-face examination (see Policy Article) must contain all of the following elements:

1. Beneficiary's name
2. 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.
3. Date of the face-to-face examination
4. Pertinent diagnoses/conditions that relate to the need for the POV or power wheelchair
5. Length of need
6. Physician's signature
7. Date of physician signature (with legible identifier (printed name)

The Supplier may provide a template order listing the seven required elements but is prohibited from completing any part of it.

The treating physician completing the face-to-face requirements must write the 7-element order. The 7-element order may only be written after the completion of the face-to-face exam requirements.

A date stamp or equivalent must be used to document receipt date.

STEP 3 - Detailed Product Description (DPD)

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

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 supplier MUST receive (and date stamp as proof) the 7 Element Order PRIOR to sending the DPD to the physician!

The physician must sign and date the detailed product description and the supplier must receive it prior to delivery of the PWC or POV!

The DPD must be received (and date stamped as proof) by the supplier within 120 days after the completion of the face to face examination!

A date stamp or equivalent must be used to document the supplier receipt date.

STEP 4 - Home Assessment

Prior to or at the time of delivery of a POV or PWC, the supplier or practitioner must perform an on-site evaluation of the client's home to verify that the client can adequately maneuver the device that is provided considering physical layout, doorway width, doorway thresholds, and surfaces. There must be a written report of this evaluation available on request.

If the supplier rules out the scooter due to the home environment, the home assessment must contain the following information:

• Make and model of product tried and failed or considered and ruled out
• Weight capacity of the client and the scooter (code)
• Dimensions of the scooter (length, width and turning radius)
• Make and model of the power wheelchair
• Dimensions of the power wheelchair (length, width and turning radius)
• Measurements of the home where the scooter cannot be maneuvered

STEP 5 - No Financial Relationship with PT/OT

The physician may refer the client to a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), who has experience and training in mobility evaluations to perform part of the face -to-face examination. This person may have no financial relationship with the supplier.

If the report of a licensed/certified medical professional (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 or LCMP that the LCMP has no financial relationship with the supplier.

STEP 1 - Face-to-Face Examination

For a power operated vehicle (POV) or power wheelchair (PWC) to be covered, the treating physician must conduct a face-to-face examination of the client before writing the order and the supplier must receive a written report of this examination within 45 days after completion of the face-to-face examination and prior to delivery of the device. If this requirement is not met, the claim will be denied as noncovered. (Exceptions: If this examination is performed during a hospital or nursing home stay, the supplier must receive the report of the examination within 45 days after discharge.

If the POV or PWC is a replacement during the 5 year useful lifetime of an item in the same performance group that was previously covered by Medicare, a face-to-face examination is not required. Note: Replacement during an item’s useful lifetime is limited to situations involving loss or irreparable damage from a specific accident or natural disaster [e.g., fire, flood, etc.]