Explaining Medicare Requirements for Power Chairs/Scooters

A power wheelchair (K0010-K0014) is covered by Medicare when a patient's condition is such that without the use of a wheelchair the patient would be otherwise bed or chair confined. Additionally, the patient is unable to operate a manual wheelchair due to a severe neurologic or muscular condition of both arms and legs.

Examples of severe neurologic conditions might include spinal cord injury, cerebral palsy, advanced multiple sclerosis, or stroke with dense hemiplegia. In addition to the diagnosis of such a condition, there must also be functional impairment involving paralysis or such severe weakness of arms as well as legs that the patient is unable to propel a manual wheelchair within the confines of their home or individual living quarters.

The DMERC has received many claims with documentation of the need for power wheelchairs including statements signed by physicians, indicating a degree of functional impairment and use within the home or living quarters, which has not been corroborated when further investigated. In an effort to better determine the medical necessity for power wheelchairs (K0010-K0014), Region C DMERC may require information in addition to a CMN, which is normally submitted with the claim.

Suppliers may be notified of the need for this extra documentation before a claim for a power wheelchair is adjudicated for payment. The extra documentation requested will include the following elements:

The manufacturer and model/number of the power wheelchair ordered, delivered and used by the patient, which must be the same item for which the claim is being submitted.
Copies of the Progress Notes from the medical chart of the treating physician who is ordering the power wheelchair. These notes must be relevant to the diagnoses listed on the CMN, and address functional levels justifying the need for the power wheelchair (according to the DMERC RMRP). One entry in the Progress Notes should certainly refer to the ordering of the power wheelchair along with reasons for its need, considering the severity of the conditions for which power wheelchairs are required. It is also expected that several Progress Notes (with different dates of entry) will be present within the treating physician's medical chart, referring to the condition and associated limitations of function, and these notes are to be included as well. If hospital records such as a discharge summary adequately address a qualifying condition and functional level at the time of discharge justifying need for a power wheelchair in the home, these will also be helpful.

Physicians who express concerns about patient confidentiality may be reassured that when the patient signs the HCFA-1500 claim form which is submitted for the power wheelchair, the patient grants the Medicare Carrier (the DMERC) authority to secure medical records in order to establish the medical necessity of equipment for which Medicare is being billed. Since only Progress Notes pertaining to the relevance of the need for the power wheelchair are required, this information should not be considered beyond the professional scope of the supplier, who must properly equip and fit the beneficiary with this item (as well as assess the particular home environment in which it is to be used). Failure to provide adequate and relevant copies of the treating physician's Progress Notes from the physician's medical chart of the patient will be considered lack of adequate medical necessity documentation, and claims for K0010-K0014 will be denied as medically unnecessary.

If the Progress Note entries of the treating physician do not address the following details of a thorough functional assessment of the patient, it may also be necessary to obtain an evaluation by one of these professionals: 1) a physiatrist (physician specializing in rehabilitation medicine), 2) a physical therapist licensed in the state where the evaluation is being performed, or 3) an occupational therapist certified by the national certifying board and who has met any regulations for licensure, certification, or registration by the state in which the evaluation is performed. From whichever of these professionals, the following details of functional ability should be addressed: condition necessitating use of a power wheelchair; date of onset of this condition; progression of the condition and prognosis; semi-quantitative assessment of strength in the extremities; the presence or absence of increased muscle tone or spasms; trunk stability and sitting posture; quantification of the patient's ability to ambulate and what assistance (e.g., cane, walker, other person, etc.) is needed for this (if applicable); ability to transfer from bed/chair to wheelchair (including the ability to stand and pivot); endurance; cognitive abilities; visual impairments; description of current wheelchair (if applicable), age of equipment, and why it is being replaced.

Suppliers will also be asked to furnish a valid telephone number for the beneficiary, the ordering physician, and the physiatrist, physical therapist or occupational therapist who submitted the patient/wheelchair evaluation.

Failure to respond to a request for this extra documentation, or submitting documentation which is not complete in all of the requested details may result in claim denial if medical necessity cannot be established based on the information which is received.

If you are in need of powered mobility, call Rodney McCarthy, ATP today! 1-800-722-7313

www.protechdelivers.com

You can also view power chair videos at www.youtube.com/protechmedical