Posts Tagged ‘LMN’

Example Letter of Medical Neccessitty for Sleepsafe Bed and Wheelchair

Wednesday, October 19th, 2011

2 EXAMPLES of LETTER OF MEDICAL NECESSITY

The following example letter of medical necessity and advice are only intended to assist you in writing your own letter to aid in securing funding for medical equipment. It is in no way implied that if you use this example you will be granted funding for medical equipment. Our only intention is to share information that we have gathered in the past and used by other clients.

The funding agencies that would be in charge of compensation for such medical items, such as your insurance company or a private philanthropic organization, almost always demand a letter of medical necessity from a therapist (physical, occupational, or otherwise) or from a physician to prove your claim that your child’s medical equipment was necessary to his successful treatment. The claim or appeal will be likely be refused if you do not include a letter of medical necessity which includes a detailed explanation of the condition or disability that makes the equipment a necessity for your loved one.

It is possible that your particular physician may not fully be acquainted with the rules of your insurance company which will affect whether or not you are reimbursed for your child’s medical equipment. (Each insurance company or state may have slightly different rules.) To be on the safe side, educate yourself on the rules so that you can be a better advocate for your family. You should become familiar with the bare minimum of information that needs to be included in a letter of medical necessity. Otherwise, the letter may contain insufficient information, which may lead to the funding agency denying your claim.

The following is an example of a thorough and professional letter of medical necessity taken from Dr. Freeman Miller’s Cerebral Palsy: A Complete Guide for Care giving. If you prefer, you can take a copy of this letter to the physician who is writing your child’s letter of medical necessity, and ask that he or she adhere to the example letter below.

“To Whom It May Concern (or, better, to a specific employee of the funding agency):

John Smith is a 5-year-old male with a primary diagnosis of cerebral palsy. He was seen at the Seating Clinic at the John Doe Institute in Anywhere, USA, on June 23, 2007, for the prescription of a bed system to meet his resting needs.

John presents with the following: generally decreased tone in upper and lower extremities, and fair head and trunk control. He is dependent in transfers and mobility. He is cognitively severely delayed. He is incontinent in bowel/bladder. He has frequent respiratory complications and is subject to bronchitis and pneumonia, and he receives chest therapy. He occasionally aspirates, he has increased skin sensitivity, and he has seizures, but they’re generally under control with his medication. He must have safe sleeping environment to eliminate the danger of falls and entrapment with appropriate positioning to provide safety and support, and to facilitate safe sleeping, breathing and feeding.

His current bed is a ___________ that is three years old. It no longer meets his bedding needs because he has outgrown it, and it poses safety concerns because_____________________.

The goals for John’s sleeping and resting is to provide a safe sleeping environment where falls and entrapment no longer pose a threat for harm and to foster a comfortable rest, maintain posture, provide comfort, and enhance function. Upon evaluation, _____________________ has recommended that the following equipment be prescribed for John:

(Be very specific in the bed model, size, and specific safety features)

the following example is for a wheel chair…rewrite this section to detail all of the specific features of the recommended bed system….for example…the Sleep Safe 2 Plus model is prescribed because it offers 22 inches of safety rail height protection above the mattress, eliminating the risk of a fall when he is in a sitting position. The “plus” model frame is prescribed because he is dependant on tube feedings and his head must be elevated during this time….etc)

The ____________________(is prescribed because it is a manual wheelchair for total positioning, and because he is dependent in mobility. The tilt is needed because he is hypotonic in head and trunk. He also has difficulty breathing, and it will help aid in feeding. It will help with low endurance and pressure relief, and it will control seizure reaction. The adjustable height arms are needed to support tray at right height, for upper body support and balance, and for ease of transfers. The I-back will bring side supports close to trunk, but insert will fit the full width of the wheelchair. The laterals will encourage midline trunk position, compensate for lack of trunk control, provide safety, and contour around trunk for better control. The chest harness is needed for safety in transport by providing anterior support, preventing forward flexion, and retracting shoulders. The headrest is needed for poor head control due to low tone, active flexion of head, posterior lateral support, safety in transfers, and to facilitate breathing. The clear tray is needed for functional surface for schoolwork, stimulation, upper arm and trunk support, inability to access tables, computer, and a base for augmentative communication devices. The shoe holders are needed to control increased extension or spasms in lower extremities, excessive internal rotation, and to prevent aggressive behavior for safety. The anti-tippers are needed for safety.

Should you have any questions regarding these recommendations, please do not hesitate to call me at (555) 555-5555. We hope that you will be able to accommodate these needs in an expedient manner. Thank you for your cooperation and assistance in this manner.

Sincerely,

John Doe

Be sure to take note of when your child’s letter was sent to the funding agency, and if three or four weeks pass without word from them, you might want to call the agency to inquire about the status of your claim. Always keep a record of when you call and with whom you speak to, and always try to remain calm and collected when dealing with the insurance company. If, however, you are unable to obtain a straightforward response as to when your claim will be processed, do not hesitate to enlist the help of your physician.

Sample Justification Letter of Medical Neccessitty for ALS Group 3 Power Wheelchair and Accessories

Wednesday, October 19th, 2011

Date:

To: Medicare

Re: ————————
DOB: 00-00-0000
HICN: ———————–

Diagnosis/problems: ALS

Subject: prescription for power wheelchair and seating/positioning equipment

To Whom It May Concern,

——————- is a 74 year old male patient of mine who was diagnosed with ALS in January of 2006. He has presented with signiciant functional decline over the past few months such that he was ambulating 1 mile a day in December of 2005 and now cannot stand independently. He is unable to ambulate or propel a manual wheelchair of any type secondary to his diagnosis. Therefore, it is recommended that he be provided a power wheelchair with power seat functions to support his functional independence and safety at home.

———— lives with his wife in a single family home that is accessible to a power wheelchair. He has been provided a loaner power wheelchair to use in his home and is demonstrating safe operation and maneuvering of the power wheelchair throughout his home. He requires moderate assistance with ADL’s and continues to be able to feed himself orally although he is reporting occasional coughing with swallowing. He is using a thickener for his liquids to facilitate safe swallowing. His sitting posture and trunk control are significantly influenced by gravity and he frequently collapses into flexed postures a as a result increasing his risks for contractures/deformity as well as compromising his position for respiration and/or swallowing. —————— is unable to independently perform pressure relief and/or re-position himself resulting in increased risks for skin breakdown and/or development of contractures. In addition, he is experiencing urinary incontinence which further increases his risks for skin breakdown.

In order to provide safe supported sitting, facilitate independent postural changes, facilitate independent functional mobility, support postural changes for cardio-pulmonary function and accommodate for postural abnormalities, reduce risks for development of skin breakdown and contractures as well as provide for positioning options to reduce risks for aspiration, the following equipment is recommended and is considered medically necessary:

1) Quantum Q-600 Group 3 Power wheelchair with Tru-Comfort Seating and 45 degree power tilt and 150 degree power recline with 8 inch power seat elevation and power elevating leg supports with leg length extension kit to facilitate pressure relief, re-positioning, lower extremity venous flow, accommodation for hamstring tightness, independent postural/positional control to reduce risks for skin breakdown, contractures and aspiration; group 34 batteries(2) and charger

Page 2/————————

to provide power to drive and seat functions; flat-free tire inserts to reduce maintenance
concerns; Q Logic joystick with swing-away mount and Multiple Seat Function kit to allow
operation of seat functions thru joystick; 18w x 21h Ergo Back Recline; Tru Comfort Seat 17w x
20d with Ergonomic seat cushion; 4 x 14 adjustable height arm supports; removable head
support to reduce risks for hyper-extension cervical injuries; swing-away lateral trunk supports
to facilitate trunk alignment when seated and to reduce risks for development of trunk
deformity; long thigh supports with dual adjustable mounting bracket to provide for lower
extremity alignment when seated; safety positioning belt.

Thank you for your attention in this matter.

Sincerely,

—————————-, MD
UPIN:

This copy is provided by Active American Mobility and Medical Supply. No restrictions on distribution.
Contact Patrick Boardman 281-495-4400

Sample Letter of Medical Neccessity (LMN) for Kaye Walker Gait Trainer

Wednesday, October 19th, 2011

March 30, 2006

To: ——————-

Re: ————-
DOB: 00-00-0000
ID#: ——————–

Diagnosis/Problems: Muscular Dystrophy; Gait Disturbance

Subject: prescription for posture reverse walker

To Whom It May Concern,

—————– is a 9 year old male patient of mine whose ability to independently ambulate has deteriorated over the past several months. He is now frequently falling at home and at school and he is demonstrating significant fatigue and respiratory stress with minimal exertion. He is experiencing increased difficulty getting up from the floor after falling due to increasing lower extremity and trunk weakness. He is now frequently complaining of pain in his lower extremities with standing and walking even short distances. As a result, he is unable to participate in activities with his peers at school, home, or in his community.

In discussing mobility assistance options with his mother and his therapists, it was determined that at his home, classroom at school, or in the community, —-, currently, would do well with a postural rolling walker that offered a seat for him to sit and rest on when needed. It would provide a supportive means for him to participate in normal daily activities without excessive fatigue and pain.

In order to facilitate safe independent functional mobility and accommodate for physical limitations/restrictions, the following equipment is recommended and is considered medically necessary:

1) Kaye Posture Control/PostureRest 4 wheel walker with flip-down seat; pelvic stabilizer and
extensor pad; and swivel limiters.

Thank you for your attention in this matter.

Sincerely,

——————, MD

Ehlers Danlos Syndrome Letter of Medical Neccessity for K0005 Manual Wheelchair

Wednesday, October 19th, 2011

April 18, 2010
To: Medicare (or other insurance carrier)

Re: ————-
DOB: 00-00-0000
HICN: ————-
Diagnosis/Problems: Ehlers Danlos Syndrome; Osteoporosis; HTN; Multiple Hematomas;
Gait Dysfunction; Scoliosis; Chronic pain; History of Tendon Rupture;
Left hip replacement(10/04); wrist subluxation bilaterally;
Decubitus Ulcer

Subject: prescription for ultra-lightweight manual wheelchair and seating equipment

To Whom It May Concern,

—————— is a 40 year old male with multiple medical problems secondary to his Ehlers Danlos syndrome which effects the integrity of his connective tissues throughout his body. As a result of this condition, he is unable to ambulate secondary to inadequate connective tissue in his feet to support the weight of his body. When he attempts to stand/ambulate he is loading his weight directly onto the bones in his feet which can result in tearing of the skin across planter surface and severe pain throughout lower extremities. His ambulation is also inhibited by restricted active range of motion at ankles secondary to surgical fusion of ankles due to hyper-mobility as a result of loss of connective tissues in lower extremities. In addition, with the loss of connective tissue, his joint stability and lower extremity strength is significantly impaired and inadequate for safe ambulation.

————– is dependent upon a wheelchair for independent functional mobility at home, work and in the community but his ability to propel is restricted by loss of connective tissue in upper extremities which results in skin tears in hands. His upper extremity strength/endurance is fair but the task of propelling a standard/lightweight manual wheelchair is significantly difficult for him and he is unable to safely load the wheelchair in/out of vehicles as needed due his risks for skin damage which is further complicated when having to lift a heavy object such as a wheelchair. In addition, upper extremity function and prehensile patterns are inhibited by wrist subluxation bilaterally. He has also required multiple tendon repairs in hands/wrists bilaterally resulting in either restricted or hyper range of movement at joints.

Approximately 3 weeks ago, ————— received a new wheelchair as recommended. It was projected that by the time he received this equipment that he would no longer require elevation of his legs/feet. However, he continues to experience restricted range of movement at times in knee flexion bilaterally that inhibits his ability to position his lower extremities on 70 degree leg rests provided with the wheelchair. In addition, he has become more comfortable with his legs in variable positions of elevation taking the physical stress off of his knees and reducing his risks for further skin tears.

Page 2/—————

In order to provide for safe supported positioning of lower extremities, accommodation of restricted knee flexion and to reduce risks for furhter injury to knees and/or skin damage in lower extremities, the following equipment is recommended and is considered medically necessary:

1) Ki Catalyst V wheelchair with articulating elevating leg rests with adjustable angle footplates to accommodate ________________
2) Natural Fit handrims to accommodate tensile strength and grip in hands and to allow client to propel chair manually.
3) Other accessories (Insert here and add medical justification)

Thank you for your attention in this matter.

SCI/Quadriplegia C7; Osteoarthritis; Sample Letter of Medical Neccessity for Quantum Power Chair and Seating

Wednesday, October 19th, 2011

Date:

To: Medicare

Re: ———————-
DOB: 00-00-0000
HICN: ———————

Diagnosis/Problems: SCI/Quadriplegia C7; Osteoarthritis

Subject: prescription for power wheelchair and seating equipment

To Whom It may Concern,

——————— is a 45 year old male patient of mine who suffered a C7 level spinal cord injury secondary to a MVA over 30 years ago. As a result he is quadriplegic, unable to ambulate, and dependent upon a wheelchair for mobility. Without a wheelchair he would be bed and/or room confined. Currently, he is using a manual wheelchair that was loaned to him by a friend. It is a lightweight frame but is significant disrepair. —————- is having increasing difficulty with propelling any type of manual wheelchair up/down ramps or across unfinished/uneven surfaces secondary to debilitation of shoulder function and loss of strength/endurance as a result of multiple decades of manual wheelchair propulsion.

————- lives in a rural setting in a mobile home that requires him to traverse rough/unfinished terrain daily and to be able to manage propelling himself up/down a 30-40 foot ramp daily to enter/exit his home. He lives on a farm with other family members living in homes that are adjacent to his so he must propel himself in/out of his home several times a day. ————— is reporting increasing shoulder and back pain with manual wheelchair propulsion within his home and on level surfaces as well. He reports taking 40mg of Vicodin per day for pain. He recently severed the skin on several fingers of his right hand and is unable to propel himself up/down his ramp secondary to pain in his hand. It is recommended that he be provided a power wheelchair that will meet his functional mobility needs and support his daily independence.

Due to the nature of his diagnosis, the following postural abnormalities and physical problems will need to be addressed in his wheelchair and seating equipment:

1) Moderate right pelvic obliquity(fixed) with secondary right scoliotic curvature of spine resulting in increased risks for skin breakdown on right IT’s/buttocks and/or increased risks for development of fixed contractures in spine/trunk.

2) Mild kyphotic curvature/deformity in upper thoracic spine.

3) Fair bilateral shoulder strength with poor bilateral wrist extension/flexion, MCP and IP flexion/extension impaired bilaterally. Poor endurance with available upper extremity movement(s).
Page 2/——————

4) Moderate to High risk for skin breakdown secondary to constant sitting, inability to perform adequate pressure relief in current equipment, loss of sensation below mid level of back, and a history of pressure breakdown(10 years ago).

In order to provide for safe supported sitting, facilitate independent functional mobility, accommodate for postural/physical abnormalities and reduce risks for secondary complications such as skin breakdown, the following equipment is recommended and is considered medically necessary:

1) Quantum 600 power wheelchair base with Tru-Balance power seat tilt is recommended to facilitate independent functional mobility and to provide for independent weight-shifting/pressure relief to reduce risks for skin breakdown. A PG 70 amp joystick with thru controller operation of drive/seat functions is recommended; 14 inch flat-free tires are needed since —————- cannot independently maintain tire pressure/repair flats; 50 amp gel batteries are required for drive/seat function power; Solution cushion is recommended for needed pressure relief when not tilted to reduce risks for skin breakdown; high mount foot platform to facilitate foot support when in tilted positions; solid curved seat back with Stealth head support to reduce risks for hyper-extension injuries/fatigue when in tilted postures; 2-post flip back arm supports with desk length pads;

Thank you for your consideration in this matter.

Sincerely,

———————————, MD
UPIN:

This copy is provided by Active American Mobility and Medical Supply. No restrictions on distribution. For more information contact us.
Contact Patrick Boardman 281-495-4400

Muscular Dystrophy Sample Letter of Medical Neccessity for Power Wheelchair and Seating

Wednesday, October 19th, 2011

Date:

To: Humana

Re: ————————–
DOB: 00-00-0000
SS#: ————————-
policy#: —————————

Diagnosis: Muscular Dystrophy

Subject: prescription for power wheelchair and seating equipment

To Whom It May Concern,

——————— is a 19 year old male patient of mine with the above diagnosis who is non-ambulatory and is unable to propel any type of manual wheelchair. He is dependent upon a power wheelchair for all functional mobility at home and in the community. He has recently graduated from highschool and is preparing for enrollment in a college later this year. He requires a new power wheelchair base with upgraded electronics and custom fitted seating and drive controls to support his independent functional mobility at home, in the community and to support his independent access on his college campus.

Currently, ——- is using an Invacare power wheelchair (serial# 00000000) that is several years old. There have been several repairs made to this wheelchair in the past few months and there is current concern over needing to replace drive motor(s) and/or gear boxes. All 4 tires are severely worn and in need of replacement as well. ——-also reports having increased difficulty driving this power wheelchair up inclines and maintaining the position of his right upper extremity to allow for joystick access with right hand. He is unable to utilize the foot supports on this chair because of the overall length of the power wheelchair with them attached. His access/mobility is restricted in turning thru doorways at home as well as maneuvering thru his van, hallways and other spaces at home and in the community. The seat back on the current power wheelchair provides no contact or support when ——– is seated upright or in moderate tilted angles and only provides minimal support when he is in full tilted postures. There is no accommodation designed in the current seating or power seat functions for the significantly hyper-lordotic spine/trunk posture that dominates ——– sitting position/posture. Consequently, he sits unsupported the majority of the day resulting in significant motor and respiratory fatigue. Finally, the current power wheelchair does not provide the electronic interface modules to environmental access controls or remote computer access controls which ——- desires and will need to further facilitate his independence at home, school and in the community/work environment(s).

Due to the nature of his diagnosis, ——–is dependent for all transitional mobility, transfers, bed mobility, re-positioning, and ADL’s including feeding. He is unable to stand or bear weight on lower extremities and he is unable to sit unsupported. He recently began using a bi-pap machine Page 2/————————-

at night due to respiratory compromise. He also has a cardiomyopathy that is being treated medically. His upper extremity functional mobility is significantly limited by his progressive loss of motor function. Currently, he can operate the power wheelchair using his right hand when the forearm is supported on a padded trough. He grasps the extended joystick between his first and second fingers with his wrist in extension and ulnar deviation and his forearm in neutral or slightly supinated. He primarily uses gross motor movements at shoulder to push or pull hand in controlling the joystick. Alternative drive controls were explored with —— but did not appear to support his independent control of the joystick as well as his current method. However, he is having increased difficulty moving his forearm across the arm trough surface material due to excessive friction but also reports being unable to support his forearm/hand in position when tilted if forearm trough becomes wet/slippery from his perspiration.

———- presents with an anteriorly rotated pelvis and hyper-lordotic spine/trunk that has been stabilized with rods in 2000. His head control is good when he is in upright seated postures but he requires posterior and lateral support of his head when he moves into tilted postures. As indicated, ——- cannot seat upright without support including lateral trunk supports, anterior chest support and posterior back support. His righting reactions and protective reflexes are delayed and/or impaired and he is unable to perform independent pressure relief techniques due to upper extremity weakness. Therefore, he is at significantly increased risks for skin breakdown.

In order to provide safe supported seating, accommodate for postural abnormalities, facilitate independent functional mobility and reduce risks for secondary complications such as skin breakdown, contractures and deformity as well as facilitate environmental access and functional independence at home, school and in the community, the following equipment is recommended and is considered medically necessary:

1) Invacare TDX-SP power base (short) with MARK VI electronics; transport
brackets; 8 inch casters with shock forks; 14 x 3 inch foam filled tires; compact 1812 joystick with display; Gatlin adjustable joystick mount; straight handle flexible joystick extension; Communication Module 1 &2 for environmental/computer access thru power wheelchair electronics.

2) Motion Concepts Ultra-Low TRx-CG power seating system for Invacare Storm Arrow base with 55 degrees power seat tilt; 174 degrees power seat recline/30 degrees power seat pre-cline; TRx elevating seat module; 16w/18d seat pan with 2 inch narrower seat back; 19 inch back height with 22 inch tall back canes and standard Rehab back pan and pad; reclining height adjustable arm supports; TRx elbow blocks; 2 pairs of TWB lateral supports for trunk and hip guide alignment/support; fixed 90 degree center mount interface bracket with flip-up footplatform 11in x 10 inch; enhanced 2-5 function electronics to allow control of drive/seat functions thru joystick with standard scan mode select upgrade; Trx M16 splitter and accessory port power supply to accommodate environmental/computer access thru power wheelchair electronics. The power pre-cline function is needed to facilitate back support and accommodate for ———– abnormal structural trunk/spinal posture; power pre-cline is not Page 3/——————–

available without power recline function; power tilt is needed for pressure relief and to facilitate trunk posture/alignment improving head control and supporting respiration, communication and swallowing; the footplatform is required for lower extremity support.

3) AEL chest support strap to fit between lateral trunk supports to prevent forward trunk collapse.

4) AEL arm troughs with adjustable hardware mounts and wrist straps to facilitate positionijng of upper extremities and reduce risks for injury to upper extremities from falling off of arm supports when in tilted postures or when operating power wheelchair drive function.

5) Freedom Design custom headrest with removable cover to support head when in tilted positions and when driving power wheelchair.

6) Freedom Design mild contour seat insert to accommodate for pelvic and lower extremity positioning and to reduce risks for contractures, deformity and skin breakdown.

Thank you for your attention in this matter.

Sincerely,

————————–, MD
UPIN:

This copy is provided by Active American Mobility and Medical Supply. No restrictions on distribution.
Contact Patrick Boardman 281-495-4400

Evaluate your Evaluations: Catching Critical Data for Seating Evaluations

Wednesday, October 19th, 2011

By Jeff McDaniel ATP
Active American Mobility

“I have a patient that needs a foam cushion, can you send one over?” This is a recent phone call I received from a case manager, she had heard about Active American Mobility through another case manager and needed some help with her patient. I probed a little further asking why she was requesting the cushion. “I’m not sure; the daughter called me and said that she needed one.” I asked her to send over the demographics for the client and told her that I would bring one out but that I would like to call the daughter first. After speaking with the daughter, it was revealed that her mom had a stage II and III pressure wound, one on each ischial. I informed the daughter of the seriousness of a pressure wound and setup an appointment to meet her mom’s therapist at the house.

This is a very common occurrence and for those of us in the mobility industry, it is an opportunity. It is an opportunity to educate and gain the trust of our client and our referral. Ultimately, as an ATP, this is our goal. If I had had fulfilled my referral’s original request, the foam cushion could have easily been delivered and maybe would have helped as the client was sitting directly on the wheelchair sling. But I see my job as more than just providing equipment. Actually, as an ATP, it is my job to scrutinize, interrogate, investigate, and then to help provide solutions. Evaluating the client for his or her needs is inarguably the most important step in the process of providing assistive technology. Whether it is a cushion, a wheelchair, or a stander we must utilize our knowledge to provide recommendations and equipment that truly helps our client with their needs. So, I would like to share a brief summary of my processes in performing an evaluation and ultimately providing appropriate equipment.

First, it is important to identify the needs and goals for the client. Interviewing the client, the caregiver, and the therapist can readily identify these needs and goals. What are the health concerns? Are there any changes foreseen in the near future? What are the needs of the caregiver? What concerns does the therapist have? Is the client experiencing any pain or discomfort while using the current equipment? What goals are not being met? I also find it useful to ask what is good about the current equipment and does it need to be duplicated with the new equipment? It is important to LISTEN. It is easy to do “what is best for the client” but often times what is best for the client is what is best for the caregiver. For example, a cushion that meets all of the client’s needs doesn’t really meet all of the client’s needs if the caregiver is unable to maintain and care for the recommended equipment. Anyone that has been providing assistive technology has fallen into this trap, myself included.

Additionally, a mat exam is essential. It is not possible to provide proper equipment without knowing pain thresholds, range of motion, and strength. This information is imperative to provide proper equipment and adjustments. A thorough mat exam will provide this information and will often prevent common mistakes when recommending equipment. Keep in mind that the mat exam is both time consuming as well as physically taxing for the client so be sure to prepare the therapist, client, and caregiver of this before your evaluation.

Finally, be prepared. Bring demo equipment, tools, and literature. It is important that the process be efficient, as this will benefit your referral, the therapist and you. For example, if your client has a history or current pressure ulcers, you may want to show up with multiple cushions and a pressure mapping device. Being prepared is essential to our job will save you time, money, and future grief.

I have found that a thorough evaluation and asking the right questions will usually provide appropriate equipment for my clients. This typically results in a happy client, a happy therapist, and an impressed referral source. And hopefully, it will result in future referrals.

Jeff McDaniel, ATP

Power Wheelchairs and Power Operated Vehicles Documentation Requirements

Wednesday, October 19th, 2011

Dear Physician,

In order for Medicare to provide reimbursement for a power wheelchair (PWC) or power operated vehicle (POV) (scooter), there are several statutory requirements that must be met:
1. There must be an in-person visit with a physician specifically addressing the patient»s mobility needs.
2. There must be a history and physical examination by the physician or other medical professional (see below) focusing on an assessment of the patient»s mobility limitation and needs. The results of this evaluation must be recorded in the patient»s medical record.
3. A prescription must be written AFTER the in-person visit has occurred and the medical evaluation is completed. This prescription has seven required elements (see below).
4. The prescription and medical records documenting the in-person visit and evaluation must be sent to the equipment supplier within 45 days after the completion of the evaluation.
The in-person visit and mobility evaluation together are often referred to as the ≈face-to-face examinationΔ.
The complete history and physical examination typically includes:
• History of the present condition(s) and past medical history that are relevant to the patient»s mobility needs in the home:
• Symptoms that limit ambulation
• Diagnoses that are responsible for these symptoms
• Medications or other treatment for these symptoms
• Progression of ambulation difficulty over time
• Other diagnoses that may relate to ambulatory problems
• How far the patient can walk without stopping and with what assistive device, such as a cane or walker
• Pace of ambulation
• History of falls, including frequency, circumstances leading to falls, and why a walker isn»t sufficient
• What ambulatory assistance (cane, walker, wheelchair) is currently used and why it isn»t sufficient
• What has changed to now require use of a power mobility device
• Ability to use a manual wheelchair
• Reasons why a power operated vehicle (scooter) would not be sufficient for this patient»s needs in the home
• Description of the home setting and the ability to perform activities of daily living in the home
• Physical examination that is relevant to the patient»s mobility needs
• Weight and height
• Cardiopulmonary examination
• Musculoskeletal examination
Also:

Arm and leg strength and range of motion
Neurological examination
Gait
Balance and coordination

If the patient is capable of walking, the report should include documented observation of ambulation (with use of a cane or walker, if appropriate)
Examples of vague or subjective descriptions of the patient’s mobility limitations include:

• upper extremity weakness
• poor endurance
• gait instability
• weakness
• abnormality of gait
• difficulty walking
• SOB on exertion
• pain
• fatigue
• deconditioned

These types of statements are insufficient and do not objectively address the mobility limitation or provide a clear picture of the patient’s mobility deficits. Objective measurements should be provided.

The evaluation should be tailored to the individual patient»s conditions. The history should paint a picture of your 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.

It is important to keep in mind that because of the way that the Social Security Act defines durable medical equipment, a power mobility device is covered by Medicare only if the beneficiary has a mobility limitation that significantly impairs his/her ability to perform activities of daily living within the home. If the wheelchair/POV is needed in the home, the beneficiary may also use it outside the home. However, in your evaluation you must clearly distinguish your patient»s mobility needs within the home from their needs outside the home.
You may elect to refer the patient to another medical professional, such as a physical
therapist or occupational therapist, to perform part of the evaluation √ as long as that individual has no financial relationship with the wheelchair supplier. However, you do have to personally see the patient before or after the PT/OT evaluation. You must review the report, indicate your agreement in writing on the report, and sign and date the report. If you do not see the patient after the PT/OT evaluation, the date that you sign the report is considered to be the date of completion of the face-to-face examination.
You should record the visit and mobility evaluation in your usual medical record-keeping format. Many suppliers provide forms for you to complete. Suppliers often try to create the impression that these documents are a sufficient record of the in-person visit and medical evaluation. Based upon our auditing experience, most of them are not. That is because they typically contain check-off boxes or space for only brief answers and thus do not provide enough detailed information about the patient»s ambulatory abilities and limitations to allow the Medicare contractor to determine if coverage criteria have been met . Forms such as those developed by the Texas or Florida Academy of Family Physicians are designed to gather selected bits of information and are almost always insufficient. What is required is a thorough narrative description of your patient»s current condition, past history, and pertinent physical examination that clearly describes their mobility needs in the home and why a cane, walker, or optimally configured manual wheelchair is not sufficient to meet those needs.
You may write a prescription for a power mobility device ONLY after the visit and examination are complete. This prescription must contain the following seven elements:
1)Beneficiary»s name
2) Description of the item that is ordered. This may be general √ e.g., ≈power operated vehicleΔ, ≈power wheelchairΔ, or ≈power mobility deviceΔ√ or may be more specific.
3) Date of completion 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

You must forward a copy of the face-to-face evaluation and your seven-element prescription to the supplier within 45 days from the completion of the face-to-face mobility exam. You should also include copies of previous notes, consultations with other physicians, and reports of pertinent laboratory, x-ray, or other diagnostic tests if they will help to document the severity of your patient»s ambulatory problems.
After the supplier receives your order and the face-to-face information, they will prepare a detailed product description that describes the item(s) being provided including all options and accessories. You should review it and, if you agree with what is being provided, sign, date and return it to the supplier. If you do not agree with any part of the detailed product description, you should contact the supplier to clarify what you want the beneficiary to receive.
This information is not intended to serve as a substitute for the complete DME MAC
local coverage determination on Power Mobility Devices. It is only a synopsis detailing the highlights of documentation. Refer to the complete LCD and Policy Article on the CMS Web site at www.cms.hhs.gov/mcd/overview.asp for additional information.
Medicare does provide you additional reimbursement (HCPCS code G0372) to recognize the additional time and effort that are required to provide this documentation to the supplier. This code is payable in addition to the reimbursement for your E&M visit code.
Your participation in this process and cooperation with the supplier will allow your patient to receive the most appropriate type of mobility equipment. We appreciate all your efforts in providing quality services to your Medicare patients.

Sincerely,
Paul J. Hughes, M.D.
Medical Director, DME MAC, Jurisdiction A
Robert D. Hoover, Jr., MD, MPH, FACP Medical Director, DME MAC, Jurisdiction C
Adrian M. Oleck, M.D.
Medical Director, DME MAC, Jurisdiction B
Richard W. Whitten, MD, MBA, FACP
Medical Director, DME MAC, Jurisdiction D

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