Medicare Coverage For
Mobility Assistive Equipment
A Changing Landscape
As you may have
heard, Medicare has completely revamped it's coverage criteria for Mobility
Assistive Equipment (MAE). This change has been an ongoing and often
confusing process that has left a lot of misunderstanding among doctors,
clinician's, equipment providers and patient's alike. Unfortunately,
it has been our experience that due to the relatively small educational
effort by Medicare, many physician's and clinician's are either unaware or
undereducated about these changes and the impact they have on them and their
In an effort to
help you understand the new process and save you valuable time, Clark's has
created this guide to step you through the new regulations for mobility
assistive equipment. These changes are important for you to
understand because they directly impact your Medicare patient's access to
all present and future mobility devices. We hope this guide helps
you understand these changes. Of course if you have any questions,
please feel free to call us and we'll be happy to talk with you.
Quick Links - Info At A Glance
The Old Rules
- Old rules that no longer apply
The New Rules
- A brief overview of the new rules
- A cheat sheet for many of Medicare's new acronyms for mobility equipment
9 Step Algorithm
- The foundation of Medicare's new criteria
- A step by step guide to help you select and prescribe the most appropriate
mobility device. This is an interactive guide that goes through
Medicare's algorithm to determine what mobility device Medicare believes is
appropriate. It also offers tips and guidelines for documenting and
prescribing the equipment.
- An overview of documentation requirements
Face to Face Evaluation
- An overview of the face to face exam requirement for power mobility
- Billing for your time to prepare documentation
- New supplier requirements
Canes & Walkers
- An overview of requirements for prescribing canes and walkers
- An overview of requirements for prescribing manual wheelchairs
Scooters - An overview of
requirements for prescribing scooters
Power Wheelchairs -An overview
of requirements for prescribing power wheelchairs
Medicare - Information from Medicare
on the algorithmic process in prescribing mobility equipment
Medicare - Information from Medicare
on prescribing power mobility devices
Other Info - Information from other
Old Rules - They No Longer Apply
New Rules - Basic Principles
Equipment (MAE) coverage is
based the patient's ability to perform Mobility Related Activities to
Daily Living (MRADL's) in the home.
Medicare does not
cover any MAE for use outside the home.
The appropriate type
of MAE is determined by an algorithmic process that sequentially considers
the patient's need and ability to use all types of MAE in his or her home
medical record must document and justify the prescribed MAE. Without
this justification, Medicare will deny the equipment.
There are specific
requirements for the written prescription
A face to face exam
is required prior to prescribing any Power Mobility Device (PMD).
Part of the face to face exam can be referred to a PT or OT
Physicians can bill
under a new G code for time required to prepare necessary documentation
Definitions - Acronyms Galore
created a slew of new acronyms related to mobility equipment. Here's a
little cheat sheet to help you decipher many of them.
MRADL: Mobility Related Activity to
Daily Living (ie: toileting, feeding, dressing, grooming, and bathing)
Mobility Assistive Equipment (ie: cane, crutch, walker, manual
wheelchair, scooter or Power Wheelchair)
PMD: Power Mobility Device (ie: Scooter or Power Wheelchair)
POV: Power Operated Vehicl (ie: Scooter)
PWC: Power Wheelchair
LCMP: Licensed or Certified Medical
Professional (ie: PT/OT)
9 Step Algorithm - Cornerstone Of Medicare's Policy
Medicare has issued
a 9 step algorithmic process to provide clinical guidance in determining
what type of MAE is reasonable and necessary for beneficiaries who have a
mobility related deficit. This algorithm covers all MAE from canes and
walkers to power mobility such as scooters and power wheelchairs. When
prescribing MAE, you should sequentially consider the specific questions in
the algorithm that provide clinical guidance for the coverage of equipment
to restore the beneficiaryís ability to participate in MRADLís in customary
locations in the home.
expects the patientís medical record will document the need for the
prescribed MAE using this algorithm. It is critical for your patientís
current and future access to MAE that you document their mobility status and
related deficiencies on an on going basis.
Not sure which MAE is best? Here is
a step by step guide to help you choose the most appropriate MAE for your
is the 9-Step Algorithm as published by Medicare.
Does the beneficiary have a mobility
limitation that significantly impairs his/her ability to participate in
one or more MRADLs in the home?
limitation is one that:
beneficiary from accomplishing the MRADLs entirely; or
beneficiary at reasonably determined heightened risk of morbidity or
mortality secondary to the attempts to participate in MRADLs; or
beneficiary from completing the MRADLs within a reasonable time frame.
NOTE: Medicare will only cover MAE
for IN HOME USE. MAE that is needed for use outside the home is not
considered reasonable and necessary.
Are there other conditions that limit the
beneficiaryís ability to participate in MRADLís at home?
are significant impairment of cognition or judgment and/or vision.
beneficiaries, the provision of MAE might not enable them to participate
in MRADLs if the comorbidity prevents effective use of the wheelchair or
reasonable completion of the tasks even with MAE.
If these other limitations exist, can they
be ameliorated or compensated sufficiently such that the additional
provision of MAE will be reasonably expected to significantly improve the
beneficiaryís ability to perform or obtain assistance to participate in
MRADLs in the home?
for example a family member, may be compensatory, if consistently
available in the beneficiary's home and willing and able to safely operate
and transfer the beneficiary to and from the wheelchair and to transport
the beneficiary using the wheelchair. The caregiverís need to use a
wheelchair to assist the beneficiary in the MRADLs is to be considered in
amelioration or compensation requires the beneficiary's compliance with
treatment, for example medications or therapy, substantive non-compliance,
whether willing or involuntary, can be grounds for denial of wheelchair
coverage if it results in the beneficiary continuing to have a significant
limitation. It may be determined that partial compliance results in
adequate amelioration or compensation for the appropriate use of MAE.
Does the beneficiary or caregiver
demonstrate the capability and the willingness to consistently operate the
considerations include personal risk to the beneficiary as well as risk to
determination of safety may need to occur several times during the process
as the consideration focuses on a specific device.
A history of
unsafe behavior in other venues may be considered.
Can the functional mobility deficit be sufficiently
resolved by the prescription of a cane or walker?
Does the beneficiaryís typical environment
support the use of wheelchairs, including scooters/power-operated vehicles
whether the beneficiaryís home environment will support the use of these
types of MAE.
Keep in mind
such factors as the homeís physical layout, surfaces, and obstacles, which
may render MAE unusable in the beneficiaryís home.
Does the beneficiary have sufficient upper
extremity function to propel a manual wheelchair in the home to
participate in MRADLs during a typical day?
wheelchair should be optimally configured (seating options, wheelbase,
device weight, and other appropriate accessories) for this determination.
Limitations of strength, endurance, range of motion, coordination, and
absence or deformity in one or both upper extremities are relevant.
with sufficient upper extremity function may qualify for a manual
wheelchair. The appropriate type of manual wheelchair, i.e. lightweight,
etc., should be determined based on the beneficiaryís physical
characteristics and anticipated intensity of use.
beneficiaryís home should provide adequate access, maneuvering space, and
surfaces for the operation of a manual wheelchair.
beneficiaryís ability to safely use a manual wheelchair.
Note: If the
beneficiary is unable to self-propel a manual wheelchair, and if there is a
caregiver who is available, willing, and able to provide assistance, a
manual wheelchair may be appropriate.
Does the beneficiary have sufficient strength and postural
stability to operate a POV/scooter?
A POV is a 3- or 4-wheeled device with
tiller steering and limited seat modification capabilities. The
beneficiary must be able to maintain stability and position for adequate
The beneficiaryís home should provide
adequate access, maneuvering space, and surfaces for the operation of a
Assess the beneficiaryís ability to
safely use a POV/scooter.
Are the additional features provided by a
power wheelchair needed to allow the beneficiary to participate in one or
features of a power wheelchair compared to a POV are typically control by
a joystick or alternative input device, lower seat height for slide
transfers, and the ability to accommodate a variety of seating needs.
The type of
wheelchair and options provided should be appropriate for the degree of
the beneficiaryís functional impairments.
beneficiaryís home should provide adequate access, maneuvering space, and
surfaces for the operation of a power wheelchair.
the beneficiaryís ability to safely use a power wheelchair.
Documentation - It's The Key
of your patient's mobility status is essential to securing Medicare coverage
for any present or future MAE you prescribe. Here are a few basic
things things to
keep in mind when charting your patient's condition with regard to mobility.
CMN's are no longer
used to justify the need for MAE
medical record must document the need for MAE
The Medical record
should address all points in the algorithmic formula
Try to be as
quantitative as possible in documenting your patient's mobility condition
The level of
documentation detail depends on the patient's diagnosis. ie: A
diagnosis of COPD needs more evidence to justify need than a diagnosis of
be a detailed narrative in the same format as other chart entries.
ie: No canned forms
supplier is required to obtain copies of pertinent parts of the patient's
medical record for manual wheelchairs, POV's and PWC's.
Prior to prescribing
any power mobility device, you must conduct a fact to face examination of
your patient. See below for more details.
to Face Exam - More Details
Medicare law now
requires that beneficiaries have a face to face examination by their
physician in order to determine if a Power Mobility Device (PMD), such as a
power wheelchair or POV/scooter is reasonable and necessary. The face to
face exam should address and document in the patientís clinical record all
of the points in the 9 step algorithm outlined above.
Keep in mind
the following points when performing and documenting your examination of the
those elements that are pertinent to the need for the Power Mobility
The amount of
detail required depends on the nature of your patientís condition.
Paint a picture
of your patientís functional abilities and limitations on a typical day.
quantitative as possible
The report of
your face-to-face examination should provide information relating to the
What is this
patientís mobility limitation and how does it interfere with the
performance of activities of daily living?
Why canít a cane
or walker meet this patientís mobility needs in the home?
Why canít a
manual wheelchair meet this patientís mobility needs in the home?
If a POV is to
be ordered, does this patient have the physical and mental abilities to
transfer into a POV and to operate it safely in the home?
If a power
wheelchair is to be ordered, why canít a POV (scooter) meet this patientís
mobility needs in the home?
If a power
wheelchair is to be ordered, does this patient have the physical and
mental abilities to operate a power wheelchair safely in the home?
should provide pertinent information about the following elements, but may
include other details. Each element would not have to be addressed in every
History ∑ How
long the condition has been present
progression ∑ Interventions that have been tried and the results
Past use of
walker, manual wheelchair, POV, or power wheelchair and the results
strength, range of motion, sensation, or coordination of arms and legs
standing balance ∑ Neck, trunk, and pelvic posture and flexibility
abnormal tone or deformity of arms, legs, or trunk
assessment Ė any problems with performing the following activities
including the need to use a cane, walker, or the assistance of another
between a bed, chair, and PMD
the home Ė to bathroom, kitchen, living room, etc. Ė provide information
on distance walked, speed, and balance
You may choose
to refer your patient to a licensed/certified medical professional (LCMP) (ie:
PT/OT) to perform part of this examination.
Once you have
received and reviewed the PT/OTís written report you must see the patient
(if you did not do so prior to the referral) and perform any additional
The report of
your visit should state your concurrence or any disagreement with the
PT/OT examination. If you saw the patient prior to referral to the PT/OT,
you should note agreement, sign, and date the report but are not required
to see the patient again.
coverage of a wheelchair is determined solely by the patientís mobility
needs within the home, the examination must clearly distinguish the
patientís abilities and needs within the home from any additional needs
for use outside the home.
is important to emphasize that even if an LCMP performs a major part of the
mobility evaluation, there still must be a face to face examination by the
physician. The physicianís examination can be before or after the LCMPís
- Billing For Your Time
You may bill the appropriate E&M code
for the face-to-face examination as well as the new G code (G0372) for the
work and resources involved in compiling and submitting the required
documentation from the medical record.
- New Requirements
mobility devices, the supplier must prepare a ďDetailed Product
DescriptionĒ that lists the specific wheelchair base and all options and
accessories including the supplier charge and the Medicare allowable. The
physician must sign and date the Detailed Product Description and return
it to the supplier prior to delivery of the power wheelchair or POV.
must deliver the power mobility device within 120 days of the face to face
examination. Exception to this is if part of the face to face examination
is performed by a licensed/certified medical professional (LCMP) (ie:
PT/OT) the 120 days does not begin until the treating physician signs the
evaluation performed by the LCMP.
part of the face to face examination is performed by a licensed/certified
medical professional (LCMP) (ie: PT/OT), there must be a signed and dated
attestation by the supplier that the LCMP has no financial relationship
with the supplier.
supplier must also perform an assessment of the home to verify the home
will support the use of a wheelchair or power mobility device.