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Manuals and Forms

The 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

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 power mobility device and all accessories. The order must be available on request.

Once the supplier has determined the specific power mobility device 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 manufactuer name/model) and all options and acceessories 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. The detailed product description must be available on request.

FACE-TO-FACE EXAMINATION:

The report of the face-to-face examination (see Policy Article) should provide information relating to the following questions.

For POVs and PWCs	What is this patient’s mobility limitation and how does it interfere with the performance of activities of daily living?
For POVs and PWCs	Why can’t a cane or walker meet this patient’s mobility needs in the home?
For POVs and PWCs	Why can’t a manual wheelchair meet this patient’s mobility needs in the home?
For POVs	Does this patient have the physical and mental abilities to transfer into a POV and to operate it safely in the home?
For PWCs	Why can’t a POV (scooter) meet this patient’s mobility needs in the home?
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, but may include other details. Each element would not have to be addressed in every evaluation.

The evaluation should be tailored to the individual patient’s conditions. The history should paint a picture of the patient’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 patient’s ambulatory difficulty or impact on the patient’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 upon 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. Suppliers are encouraged to help educate physicians on the type of information that is needed to document a patient’s mobility needs.

Physicians shall also provide reports of pertinent laboratory tests, x-rays, and/or other diagnostic tests (e.g., pulmonary function tests, cardiac stress test, electromyogram, etc.) performed in the course of management of the patient. Upon request, suppliers shall provide notes from prior visits to give a historical perspective of the progression of disease over time and to corroborate the information in the face-to-face examination.

If the report of a licensed/certified medical professional (LCMP) examination is to be considered as part of the face-to-face examination (see Policy Article), there must be a signed and dated attestation by the supplier or LCMP that the LCMP has no financial relationship with the supplier. (Note: Evaluations performed by an LCMP who has a financial relationship with the supplier may be submitted to provide additional clinical information, but will not be considered as part of the face-to-face examination by the physician.)

Although patients who qualify for coverage of a power mobility device may use that device outside the home, because Medicare’s coverage of a wheelchair or POV is determined solely by the patient’s mobility needs within the home, the examination must clearly distinguish the patient’s abilities and needs within the home from any additional needs for use outside the home.