Pay attention to the details of CMS' mobility documentation requirements and get paid faster with fewer hassles.

The last couple of years have been full of change for mobility suppliers. The coverage criteria have been completely changed, and new codes have been implemented. The result has been many denied claims and lots of frustration. The key to avoiding these denials is knowing the coverage criteria inside and out, and ensuring that documentation is present and supports the need for equipment before delivery.

BASIC COVERAGE CRITERIA

All of the following basic criteria must be met for a power mobility device (PMD)—K0800 to K0898—or a push-rim activated power assist device (E0986) to be covered.

A) The patient has a mobility limitation that significantly impairs their ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home.

B) The patient's mobility limitation cannot be sufficiently and safely resolved by an appropriately fitted cane or walker.

C) The patient does not have sufficient upper-extremity function to self-propel an optimally configured manual wheelchair in the home to perform MRADLs during a typical day.

POWER OPERATED VEHICLES (POVS: K0800-K0808, K0812)

A POV is covered if all of the basic coverage criteria have been met, and if the following criteria are also met.

A) The patient is able to:

1. safely transfer to and from a POV;
2. operate the tiller steering system; and
3. 3) maintain postural stability and position while operating the POV in the home.

B) The patient's mental capabilities (cognition, judgment) and physical capabilities (vision) are sufficient for safe mobility using a POV in the home.

C) The patient's home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the POV that is provided.

D) The patient's weight is less than or equal to the weight capacity of the POV that is provided.

E) Use of a POV will significantly improve the patient's ability to participate in MRADLs, and the patient will use it in the home.

F) The patient has not expressed an unwillingness to use a POV in the home.

Group 2 POVs (K0806-K0808) have added capabilities that are not needed for use in the home. Therefore, if a Group 2 POV is provided, and coverage criteria for a POV are met, payment will be based on the allowance for the least costly medically appropriate alternative.

POWER WHEELCHAIRS (PWC [K0813-K0891, K0898])

A power wheelchair (PWC) is covered if:

A) all of the basic coverage criteria are met; and

B) the patient does not meet coverage criteria for a POV.

Coverage is also met if:

1. the patient has the mental and physical capabilities to safely operate the power wheelchair that is provided;
2. the patient is unable to safely operate the power wheelchair;
3. the patient has a caregiver who is unable to adequately propel an optimally configured manual wheelchair—but is available, willing, and able to safely operate the power wheelchair that is provided;
4. the patient's weight is less than or equal to the weight capacity of the power wheelchair that is provided;
5. the patient's home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the power wheelchair that is provided;
6. use of a power wheelchair will significantly improve the patient's ability to participate in MRADLs, and the patient will use it in the home (for patients with severe cognitive and/or physical impairments, participation in MRADLs may require the assistance of a caregiver);
7. the patient has not expressed an unwillingness to use a power wheelchair in the home; and
8. any coverage criteria pertaining to the specific wheelchair type are met.

LEAST COSTLY ALTERNATIVE

Denise M. Fletcher

Coverage criteria for PMDs are based on a stepwise progression of medical necessity. If coverage criteria for the device that is provided are not met, and if there is another device that meets the patient's medical needs (as defined in this policy), payment will be based on the allowance for the least costly medically appropriate alternative. Determinations of least costly alternative will take into account the patient's weight, seating needs, and needs for other special features (power seating systems, alternative drive controls, and ventilators).

The delivery of the PMD must be within 120 days following completion of the face-to face examination. There is an exception for PWCs that go through the advance determination of Medicare coverage (ADMC) process, and receive an affirmative determination. In such cases, the delivery must be within 6 months following the determination.

For claims with dates of service on or after April 1, 2008, the specialty evaluation required for patients receiving a PWC other than Group 1, or a push-rim-activated power assist device for a manual wheelchair, must be performed by a RESNA-certified assistive technology practitioner (ATP) specializing in wheelchairs, or a physician who is board-

certified in physical medicine and rehabilitation. The ATP or physician may not have any financial relationship with the supplier. In addition, the wheelchair must be provided by a supplier that employs a RESNA-certified assistive technology supplier (ATS) specializing in wheelchairs who is directly involved in the wheelchair selection for the patient.

DOCUMENTATION REQUIREMENTS

In addition to specific documents required by the PMD policy, it will be necessary to provide medical records to determine the medical necessity of a PMD. The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other health care professionals, and test reports. Medical records must be available upon request.

For a POV or power wheelchair to be covered, suppliers must receive a written order from the treating physician containing all the elements specified in the documentation requirements section of the local coverage determination (LCD) within 45 days after the physician's face-to-face examination and prior to delivery of the device.

The order must contain the beneficiary's name and a description of the item that is ordered. This may be general—POV, PWC, or PMD—or may be more specific. Additional specifics include:

• date of the face-to-face examination;
• pertinent diagnoses/conditions that relate to the need for the POV or power wheelchair;
• length of need;
• physician's signature; and
• date of physician signature.

A date stamp or equivalent must be used to document receipt date. If a written order containing all of these required elements is not received by the supplier within 45 days after completion of the face-to-face examination, an EY modifier must be added to the HCPCS codes for the PMD and all accessories.

DETAILED PRODUCT DESCRIPTION

Once the supplier has determined the specific PMD that is appropriate for the patient based on the physician's order, the supplier must prepare a written document (termed a detailed product description) that lists the specific base (HCPCS code and either a narrative description of the item or the manufacturer name/model) and all options and accessories that will be separately billed.

The supplier must list their charge and the Medicare fee schedule allowance for each separately billed item. If there is no fee schedule allowance, the supplier must enter "not applicable." The physician must sign and date this 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 receipt date.

FACE-TO-FACE EXAMINATION

For a POV or PWC to be covered, the treating physician must conduct a face-to-face examination of the patient 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. The physician may refer the patient to a licensed/certified medical professional (LCMP) such as a physical therapist or occupational therapist, who has experience and training in mobility evaluations, to perform part of the face-to-face examination. The LCD contains specific requirements, depending on the timing of the referral.

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

A) For POVs and PWCs: What is this patient's mobility limitation, and how does it interfere with the performance of activities of daily living?

B) For POVs and PWCs: Why can't a cane or walker meet this patient's mobility needs in the home?

C) For POVs and PWCs: Why can't a manual wheelchair meet this patient's mobility needs in the home?

D) For POVs: Does this patient have the physical and mental abilities to transfer into a POV and to operate it safely in the home?

E) For PWCs: Why can't a POV (scooter) meet this patient's mobility needs in the home?

F) For PWCs: Does this patient 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 (each element would not have to be addressed in every evaluation):

NETWORK WITH HOME MODIFIERS

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A) symptoms;

B) related diagnoses;

C) history;

D) how long the condition has been present;

E) clinical progression;

F) interventions that have been tried and the results;

G) past use of walker, manual wheelchair, POV, or power wheelchair and the results;

H) physical exam;

I) weight;

J) impairment of strength, range of motion, sensation, or coordination of arms and legs;

K) presence of abnormal tone or deformity of arms, legs, or trunk;

L) neck, trunk, and pelvic posture and flexibility;

M) sitting and standing balance;

N) functional assessment—any problems with performing the following activities, including the need to use a cane, walker, or the assistance of another person;

O) transferring between a bed, chair, and PMD; and

P) walking around the home—to the bathroom, kitchen, living room—provide information on distance walked, speed, and balance.

A date stamp or equivalent must be used to document receipt date. The written report of this examination must be available on request.

Many suppliers have created forms that have not been approved by CMS that they send to physicians and ask them to complete. Even if the physician completes this type of form and puts it in the chart, this supplier-generated form is not a substitute for the comprehensive medical record as noted above. Physicians shall also provide reports of pertinent laboratory tests, x-rays, and/or other diagnostic tests (pulmonary function tests, cardiac stress test, electromyogram) performed in the course of management of the patient. If the report of a 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 that the LCMP has no financial relationship with the supplier.

SPECIALTY EVALUATION

The specialty evaluation that is required for patients who receive a PWC other than Group 1, or a push-rim-activated power assist device, is in addition to the requirement for the face-to-face examination. The specialty evaluation provides detailed information explaining why each specific option or accessory is needed to address the patient's mobility limitation. There must be a written report of this evaluation available on request.

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 patient's home to verify that the patient 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.

DOCUMENTATION CONCERNS

If the requirements related to a face-to-face examination have not been met, the GY modifier must be added to the codes for the PMD and all accessories. If the PMD or push-rim-activated power-assist device that is provided is needed only for mobility outside the home, the GY modifier must be added to the codes for the item and all accessories.

A KX modifier may be added to the code for a PMD, and all accessories, only if: all of the coverage criteria specified in this LCD have been met for the product that is provided; or if there is an affirmative ADMC for the product that is provided; or if a Group 4 PWC is provided and if all of the coverage criteria for a comparable Group 3 PWC have been met.

The following PWCs are eligible for ADMC:

A) A Group 2, 3, 4, or 5 single power option or multiple power options wheelchair (K0835-K0843, K0856-K0864, K0877-K0891)—whether or not a power seating system will be provided at the time of initial issue.

B) A Group 3 or 4 no power option wheelchair (K0848-K0855, K0868-K0871) that will be provided with an alternative drive control interface at the time of initial issue.

Reimbursement for the wheelchair codes includes all labor charges involved in the assembly of the wheelchair. Reimbursement also includes support services, such as delivery, setup, and education about the use of the PMD.

Denise M. Fletcher, JD, is an attorney with the Health Care Group of Brown & Fortunato PC, an Amarillo, Tex-based law firm. She is Board Certified in Health Law by the Texas Board of Legal Specialization and represents DME companies, pharmacies, and other health care providers throughout the United States and Puerto Rico. Fletcher can be reached via e-mail: .

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