National Coverage Determination for Power Mobility Devices (PMDs)

Updated December 2006

This document explains Medicare's updated requirements for scooters and power wheelchairs.  Please read this latest revision if you plan on applying for Medicare reimbursement for a Powered Mobility Devices (PMDs).  The document is focused on the physician's responsibilities when prescribing a PMD.

October 2005

Dear Physician,

The Centers for Medicare & Medicaid Services (CMS) has revised the national policy for coverage of power wheelchairs, power operated vehicles (POVs, also know as scooters), manual wheelchairs, walkers, canes and crutches. The new National Coverage Determination (NCD) became effective on May 5, 2005. This letter addresses only POVs and power wheelchairs – which are described by the term power mobility devices (PMDs). This letter is intended to highlight some of the key points in the NCD and to provide guidance on the documentation that is required to justify coverage of the device that you are ordering.

Background:

• The NCD describes the clinical criteria for coverage of mobility assistive equipment, which includes PMDs, in a series of nine questions and related definitions.
• The complete policy can be found on the CMS Web site at www.cms.hhs.gov/coverage, select National Coverage Determinations, then Mobility Assistive Equipment.
   

New requirements:

• There is a new requirement in the Medicare law that beneficiaries have a face-to-face examination by their physician to determine the medical necessity for the PMD.
• As the treating physician, you will need to provide a copy of the records from your examination as well as a prescription for the device to the DME supplier. (This information is in keeping with the HIPAA Privacy Rule. There is no need for any additional authorization from the beneficiary.)
• If you believe that other parts of the medical record such as test results, consultation reports or your notes from a prior visit will help to document the patient’s need for the PMD, you should include those as well.
• This documentation must be received by the supplier within 30 days after completion of your examination.
• A Certificate of Medical Necessity (CMN) is no longer required.
• You will bill an appropriate Evaluation and Management (E&M) code for the face-to-face examination.
• CMS is also creating a new G code (used in addition to the E&M code) to recognize the additional time and effort that are required to provide this documentation to the supplier. Information on the G code will be provided by your local carrier.

Documentation of the face-to-face examination:
When evaluating your patient for a POV or a power wheelchair (PWC), the report of the face-to-face examination should provide information relating to the following questions:

One important issue regarding coverage is that because of the way that the Social Security Act defines durable medical equipment (DME), a PMD is covered by Medicare only if the beneficiary has a mobility limitation that significantly impairs his/her ability to perform activities of daily living within the home. If the PMD is needed in the home, the beneficiary may also use it outside the home. However, in your examination you must clearly distinguish your patient’s mobility needs within the home from their needs outside the home. You may order a PMD that provides additional features that are of use outside the home. In that case, if the supplier obtains an Advance Beneficiary Notification (ABN), the beneficiary would be responsible for the additional cost for those features.
The following are elements that would typically be included in the report of your face-to-face examination. However, each element does not have to be addressed in every examination – just those that are pertinent. You may include other clinical details that are relevant.

• Symptoms
• Related diagnoses
• History
• How long the condition has been present
• Clinical progression
• Interventions that have been tried and the results
• Past use of walker, manual wheelchair, POV, or power wheelchair and the results
• Physical exam
• Weight
• Impairment of strength, range of motion, sensation, or coordination of arms and legs
• Presence of abnormal tone or deformity of arms, legs, or trunk
• Neck, trunk, and pelvic posture and flexibility
• Standing balance
• 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 their home – to bathroom, kitchen, living room, etc. – provide information on distance walked, speed, and balance

When you are performing and documenting your examination, please keep in mind the following points:

• Just document those elements that are pertinent to the need for the PMD.
• The amount of detail that is required depends on the nature of your patient’s condition. A patient with quadriplegia due to a C4 spinal cord injury will need much less information to justify a power wheelchair than a patient whose mobility needs are due to arthritis and COPD.
• Try to paint a picture of your patient’s functional abilities and limitations on a typical day.
• Try to be as quantitative as possible.

Therapist referrals:

• You may choose to refer your patient to another qualified medical professional, such as a physical therapist (PT) or occupational therapist (OT), to perform part of this examination. If so, it is important that this person have no financial relationship with the supplier. (Exception: If the supplier is owned by a hospital, a PT/OT working in the inpatient or outpatient hospital setting may perform part of the face-to-face examination.)
• Once you have received and reviewed the PT/OT’s written report, you must see the patient (if you did not do so prior to referral) and perform any additional examination that you deem necessary.
• The report of your visit should state your concurrence or any disagreement with the PT/OT examination. If you saw the patient to begin the face-to-face examination prior to referral to the PT/OT, you should note agreement, sign, and date their report but are not required to see the patient again.

Documentation of the prescription:
Medicare regulations mandate that all the following elements be included on the prescription for a PMD:

1. Beneficiary’s name
2. Description of the item that is ordered – e.g., “power operated vehicle,” “power wheelchair,” or “power mobility device.” (You may be more specific if you want.)
3. Date of completion of the face-to-face examination
4. Pertinent diagnoses/conditions that relate to the need for the PMD
5. Length of need
6. Physician’s signature
7. Date you sign the prescription

• One of the factors to be considered in determining the type of PMD to order is whether the beneficiary can maneuver a particular device in his/her home. The supplier may provide you with information such as the width of doorways or corridors, room size, or other physical features of the home to assist in that determination. If you do not have this information at the time that you perform your examination and if you decide that your patient has the physical and mental capabilities to operate either a POV and power wheelchair, you may enter “power mobility device” on the prescription.
• Once the supplier receives the prescription, he/she may help to determine what specific type of POV or power wheelchair is most appropriate as well as the accessories that are needed.
• The supplier will then send you a detailed order with that information. You should review and modify that as needed, sign and date the order, and return it promptly to the supplier.
• The supplier cannot provide the device to the beneficiary until they receive the signed and dated detailed written order from you. (A fax transmission is acceptable.)

Treating Physician-Supplier Partnership:

• As the treating physician, you must forward copies of the record of your face-to-face examination and the PT/OT examination report (if applicable) to the supplier so that they are received within 30 days following the completion of the examination.
• In addition to a copy of your examination, the supplier must also receive your prescription for the device within 30 days following completion of the face-to-face examination.

Your participation in this process and cooperation with the supplier will allow your patient to receive the most appropriate type of mobility equipment. We appreciate all your efforts in providing quality services to your Medicare patients.

Sincerely,


Stacey Brennan, MD
Region C DMERC Medical Director