POWER MOBILITY DEVICE (PMD)/POWER WHEELCHAIR

face-to-face examination must be conducted by the ordering physician before the prescription (7 element order) is written and must consist of:

- An in-person visit between the ordering physician and the patient that includes the reason for the visit was a mobility examination. This visit must document the decision to prescribe a PMD; and

- A medical evaluation performed by the ordering physician. The evaluation must clearly document the patient’s functional status with attention to conditions affecting the patient’s mobility and his/her ability to perform mobility related activities of daily living (MRADL) within the home. This may be done all, or in part, by the ordering physician. If all or some of the medical examination is completed by another medical professional, the ordering physician must sign off on the report and incorporate it into his/her records.

-Exception to the F2F. A beneficiary discharged from a hospital does not require a separate F2F examination if the physician or treating practitioner that performed the F2F during the hospital stay issues the PMD prescription and supporting documentation to the supplier within 45 days after the date of discharge.

The physician may refer the patient to a PT or OT who has experience and training in mobility evaluations.

If a patient was referred by the PT or OT before visiting the physician, then once the physician has received and reviewed the written report of this examination, the physician must see the patient and perform any additional examination that is needed

Chart notes from the F2F examination MUST include the following elements:

History of present condition and relevant past medical history, including:

- Signs/symptoms that limit ambulation;

- Diagnoses responsible for these signs/symptoms;

- Medications or other treatment for these signs/symptoms;

- Progression of ambulation difficulty over time;

- Other diagnoses that may relate to ambulatory problems;

- Distance the patient can ambulate without stopping and with what assistive device (e.g., cane, walker);

- Pace of ambulation;

- History of falls, including frequency, circumstances leading to falls, what ambulatory assistance (e.g., cane, walker, wheelchair) is currently used, and why it is not sufficient;

- What changed in the patient’s condition that now requires a PMD;

- Reason for inability to use a manual wheelchair, such as assessment of upper body strength;

- Reason the patient needs a PMD rather than successive levels of MAE (e.g, can, walker, optimally configured manual wheelchair, POV) and reasons that the patient should not or could not use a cane, walker, optimally confused manual wheelchair, or POV in the home to satisfy his/her needs; AND

- Physical examination relevant to mobility needs, including;

- Height and weight;

- Trunk stability (sitting/standing);

- Cardiopulmonary examination; and

- Musculoskeletal examination, including arm and leg strength and range of motion; AND

Neurological examination, including;

- Gait;

- Balance and coordination; and

- If the patient is capable of walking, a documented observation of ambulation (with the use of a cane or walker as appropriate).

Physician Orders/Statement of Medical Necessity:

The prescription for the PMD must be in writing and signed and dated by the physician or treating practitioner who performed the F2F examination, and must received by the supplier within 45 days after the F2F

MUST include all 7 elements:

- Patient’s name

- Description of item that is ordered. May be a general description (“power operated vehicle”, “power wheelchair”), or more specific

- Date of completion of the F2F examination

- Pertinent diagnoses/conditions that relate to the need for a PMD

- Length of need

- Physician signature and NPI

Date of physician signature

The following criteria must be met for a PMD to be covered:

The beneficiary has a mobility limitation that significantly impacts his/her ability to participate in one or more mobility-related activities of daily living (MRADL) such as toileting, feeding, dressing, grooming and bathing in customary locations in the home.

A mobility limitation is one that:

- Prevents the beneficiary from accomplishing an MRADL entirely; OR

- Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; OR

- Prevents the beneficiary from completing an MRADL within a reasonable time frame

The beneficiary’s mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker.

The beneficiary does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to perform MRADL’s during a typical day

- Limitation of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function

- An optimally-configured manual wheelchair is one with an appropriate wheelbase, device weight, seating options, and other appropriate non-powered accessories, AND

The beneficiary does NOT meet criteria for a power operated vehicle (POV)/scooter

The beneficiary is not able to:

- Safely transfer to and from a power operated vehicle (POV), AND

- Operate a tiller steering system, AND

- Maintain postural stability and position while operating a POV in the home, AND

The beneficiary’s mental capabilities (e.g. cognition, judgment and physical capabilities (e.g. vision) are sufficient for safe mobility using a POV in the home, AND

The beneficiary’s home provides adequate access between rooms, maneuvering space and surfaces for the operation of the POV that is provided, AND

The beneficiary has the mental and physical capabilities to safely operate the power wheelchair that is provided, OR

If the beneficiary is unable to safely operate the power wheelchair, the beneficiary has a caregiver who is unable to adequately propel and optimally configured manual wheelchair, but is available, willing and able to safely operate the power wheelchair that is provided, AND

The beneficiary’s weight is less than or equal to the weight capacity of the power wheelchair that is provided and greater than or equal to 95% of the weight capacity of the next lower weight class PWC, AND

The beneficiary’s home provides adequate access between rooms, maneuvering spavce, and surfaces for the operation of the power wheelchair that is provided, AND

Use of a powered wheelchair will significantly improve the beneficiary’s ability to participate in MRADL’s and the beneficiary will use it in the home. For beneficiaries with severe cognitive and/or physical impairments, participation in MRADL’s may require the assistance of a caregiver, AND

The beneficiary has not expressed an unwillingness to use a powered wheelchair in the home.