Making Power Mobility
Work for You


A “How To” Guide to Successfully Implementing Medicare Coverage Requirements

The added complexities to the new Medicare coverage requirements for Power Mobility Devices have made it extremely difficult to operate a Power Mobility business; with increase in the manual audits and denial of claims an additional financial strain now exists. The new complex process and necessary procedures has left physicians, clinical, providers and clients equally confused. To fully understand the new Medicare coverage requirements, below is a reference on the necessary information that is essential to the successful operation of a Power Mobility organization.

The Center for Medicaid and Medicare ("CMS") has launched a new set of industry related definitions and acronyms that are essential to understanding the new Medicare claim procedures:

New Terminology, Definitions and Acronyms:

  • MRADL: Mobility Related Activity to Daily Living (ie: toileting, feeding, dressing, grooming, and bathing)
  • MAE: Mobility Assistive Equipment (ie: cane, crutch, walker, manual wheelchair, scooter or Power Wheelchair)
  • POV: Power Operated Vehicle (ie: Scooter)
  • PMD: Power Mobility Device (ie: Scooter or Power Wheelchair)
  • PWC: Power Wheelchair
  • LCMP: Licensed or Certified Medical Professional (ie: PT/OT)
  • IFR: Interim Final Rule
  • FTF: Face-to-Face required under IFR (Power only)
  • LCD: Local Coverage Determination

Understand the Old Rules to Learn the New Rules:

The Old Rules

  • No more "Bed or Chair Confined" rule.
  • No more Certificates of Medical Necessity (CMN's) for Mobility Assistive Equipment (MAE).
  • No longer necessary to require a specialist in physical medicine, orthopedic surgery, neurology, or rheumatology to provide a written order for Power Operated Vehicles (scooters).

New Provider Rules - Basic Principles

  • Mobility Assistive Equipment (MAE) coverage is based the client's ability to perform Mobility Related Activities to Daily Living (MRADL's) in the home.
  • Medicare does not cover any Mobility Assistive Equipment (MAE) for use outside the home.
  • The appropriate MAE is determined by an algorithmic process that sequentially considers the client's need and ability to use all types of MAE in his or her home
  • The client's medical record must document and justify the prescribed MAE. Without this justification, Medicare will deny the equipment.
  • There are specific requirements for the written prescription.
  • A face-to-face exam is required prior to prescribing any Power Mobility Device (PMD). Part of the face-to- face exam can be referred to a PT or OT.
  • Physicians can bill under a new G code for time required to prepare necessary documentation

Provider Responsibility - "Must Haves":

  • For power mobility devices, the supplier must prepare a "Detailed Product Description" that lists the specific wheelchair base and all options and accessories including the supplier charge and the Medicare allowable. The physician must sign and date the Detailed Product Description and return it to the supplier prior to delivery of the power wheelchair or POV.
  • The supplier must deliver the power mobility device within 120 days of the face to face examination. Exception to this is if part of the face to face examination is performed by a licensed/certified medical professional (LCMP) (ie: PT/OT) the 120 days does not begin until the treating physician signs the evaluation performed by the LCMP.
  • If part of the face-to- face examination is performed by a licensed/certified medical professional (LCMP) (ie: PT/OT), there must be a signed and dated attestation by the supplier that the LCMP has no financial relationship with the supplier.
  • The supplier must also perform an assessment of the home to verify the home will support the use of a wheelchair or power mobility

Conquering the Face-to-Face Exam

Medicare law now requires that beneficiaries have a face to face examination by their physician in order to determine if a Power Mobility Device (PMD), such as a power wheelchair or POV/scooter is reasonable and necessary. The face to face exam should address and document in the client's clinical record all of the points in the 9 step algorithm outlined above.

Keep in mind the following points when performing and documenting your examination of the client.

  • Document just those elements that are pertinent to the need for the Power Mobility Device.
  • The amount of detail required depends on the nature of your client's condition.
  • Paint a picture of your client's functional abilities and limitations on a typical day.
  • Be as quantitative as possible

The report of your face-to-face examination should provide information relating to the following questions:

  • What is this clients's mobility limitation and how does it interfere with the performance of activities of daily living?
  • Why can't a cane or walker meet this client's mobility needs in the home?
  • Why can't a manual wheelchair meet this client's mobility needs in the home?
  • If a POV is to be ordered, does this client have the physical and mental abilities to transfer into a POV and to operate it safely in the home?
  • If a power wheelchair is to be ordered, why can't a POV (scooter) meet this client's mobility needs in the home?
  • If a power wheelchair is to be ordered, does this client have the physical and mental abilities to operate a power wheelchair safely in the home?

The report should provide pertinent information about the following elements, but may include other details. Each element would not have to be addressed in every evaluation.

  • Symptoms Related diagnoses
  • History How long the condition has been present
  • Clinical progression Interventions that have been tried and the results
  • Weight Physical exam
  • Past use of walker, manual wheelchair, POV, or power wheelchair and the results
  • Impairment of strength, range of motion, sensation, or coordination of arms and legs
  • Sitting and standing balance Neck, trunk, and pelvic posture and flexibility
  • Presence of abnormal tone or deformity of arms, legs, or trunk
  • Functional assessment - any problems with performing the following activities including the need to use a cane, walker, or the assistance of another person
    • Transferring between a bed, chair, and PMD
    • Walking around the home - to bathroom, kitchen, living room, etc. - provide information on distance walked, speed, and balance

You may choose to refer your client to a licensed/certified medical professional (LCMP) (i.e.: PT/OT) to perform part of this examination.

  • Once you have received and reviewed the PT/OT's written report you must see the client (if you did not do so prior to the referral) and perform any additional examination necessary.
  • The report of your visit should state your concurrence or any disagreement with the PT/OT examination. If you saw the client prior to referral to the PT/OT, you should note agreement, sign, and date the report but are not required to see the client again.
  • Medicare's coverage of a wheelchair is determined solely by the client's mobility needs within the home, the examination must clearly distinguish the client's abilities and needs within the home from any additional needs for use outside the home.

It is important to emphasize that even if an LCMP performs a major part of the mobility evaluation, there still must be a face to face examination by the physician. The physician's examination can be before or after the LCMP's examination.

Necessary Documentation - Must be submitted for claim approvals:

Thorough documentation of your client's mobility status is essential to securing Medicare coverage for any present or future MAE you prescribe. Here are a few basic things to keep in mind when charting your client's condition with regard to mobility.

  • CMN's are no longer used to justify the need for MAE
  • The client's medical record must document the need for MAE
  • The Medical record should address all points in the algorithmic formula
  • Try to be as quantitative as possible in documenting your client's mobility condition
  • The level of documentation detail depends on the client's diagnosis. i.e.: A diagnosis of COPD needs more evidence to justify need than a diagnosis of MS
  • Documentation should be a detailed narrative in the same format as other chart entries. i.e.: No canned forms
  • The equipment supplier is required to obtain copies of pertinent parts of the client's medical record for manual wheelchairs, POV's and PWC's.
  • Prior to prescribing any power mobility device, you must conduct a fact to face examination of your client. Click here for more details.

Contact your DRIVE MEDICAL Industry Expert to Ask Questions or for More Information.

Drive Medical Drive Medical