Adult Complex Rehab Power Wheelchair Medicare Funding Guide

Combining the evaluation and assessment process with the coding, coverage, and payment policies and regulations.

Per Medicare guidelines, the provision of Mobility Assistive Equipment (MAE) is complex and involves multiple components that must be completed in order to qualify a patient for coverage and reimbursement. The National Coverage Determination (NCD) for Mobility Assistive Equipment (MAE) provides the decision algorithm for funding decisions. The algorithm includes the spectrum of technology from walking aids to power wheelchairs and it is necessary to rule out lower levels of technology in order to qualify for the recommended base device.

This guide is intended to assist healthcare providers by providing an overview of those components - coverage, coding, and documentation - as it relates to adult complex rehab power wheelchairs. It is NOT a substitute for the policy itself and should only be relied upon as a quick reference guide. Healthcare providers should familiarize themselves with the Local Coverage Determination (LCD) and related Policy Article for each of the items being recommended in order to obtain a thorough understanding of the Medicare rules and regulations governing mobility assistive equipment.

Basic Funding Elements Specific to Complex Rehab Technology (CRT) Power Mobility Devices (PMDs)

The following provides specific requirements for power mobility devices and CRT wheelchairs in particular:

  • The PMD Local Coverage Determination (LCD) and policy article.
  • A face-to-face evaluation must be completed and a 7-element written order provided to the supplier.
  • The PMD LCD requires a specialty evaluation for power wheelchair bases classified as CRT.
  • The PMD LCD requires a RESNA certified ATP to be "direct and in-person" and actively involved in the selection of the technology.
  • Policy also requires the OT or PT who completes the specialty evaluation to have no financial tie to the supplier of the technology.

PMD Process Timelines

  • Completion of the face-to-face or discharge from a hospital or nursing home stay.
    • Supplier involvement follows face-to-face or referral to PT/OT for completion of the evaluation.
  • 7-element order (7-EO)
    • Supplier must receive the written report of the face-to-face exam within 45 days of completion of the exam or discharge if the examination was performed during a hospital or nursing home stay and prior to delivery of the wheelchair to the beneficiary.
  • On-site home assessment - on or before the date the wheelchair was ordered.

Power Mobility Documentation Checklist

When submitting documentation for funding approval, be sure to include the following:

  • Face-to-face medical evaluation - date stamped
  • 7-element order* - date stamped
  • Detailed product description - date stamped
  • Specialty evaluation
  • Supplier ATP appraisal - demonstrates direct involvement in selection of equipment
    • Copy of RESNA certificate
    • OR
    • Screen-print/printout of credential verification from RESNA website
  • Delivery document
  • On-site home assessment

* 7-EO is required for Power Mobility Devices (WOPD) and a 5-EO is needed for some options and accessories that may be billed at the same time.

Power Base/PMD Performance Characteristics

CHAIR TYPE GROUP 1 GROUP 2 GROUP 3 GROUP 4 GROUP 5
Length PWC 40 inches 48 inches 48 inches 48 inches 48 inches
POV 48 inches 48 inches      
Width PWC 24 inches 34 inches 34 inches 34 inches 28 inches
POV 28 inches 28 inches      
Obstacle Height PWC 20 mm 40 mm 60 mm 75 mm 60 mm
POV 20 mm 50 mm      
Minimum Top End Speed - Flat PWC 3 MPH 3 MPH 4.5 MPH 6 MPH 4.5 MPH
POV 3 MPH 4 MPH      
Range PWC 5 miles 7 miles 12 miles 16 miles 12 miles
POV 5 miles 10 miles      
Dynamic Stability Incline PWC 6 degrees (1:12) 6 degrees (1:12) 7.5 degrees (1:10) 9 degrees (1:8) 7.5 degrees (1:10)
POV 6 degrees (1:12) 7.5 degrees (1:10)      
Fatigue Test on a Level with Slats PWC 200,000 cycles
with 0.5-inch
slats under all
wheels
200,000 cycles
with 0.5-inch
slats under all
wheels
200,000 cycles
with 0.5-inch
slats under all
wheels
200,000 cycles
with 0.5-inch
slats under all
wheels
200,000 cycles
with 0.5-inch
slats under all
wheels
POV
Drop Cycles PWC 6,666 drop cycles 6,666 drop cycles 6,666 drop cycles 6,666 drop cycles 6,666 drop cycles
POV

The listed requirements are the minimums; the actual differences between the minimum requirement and what specific models offer can be significant. In addition, other important performance characteristics, features, and functions are not referenced at all. Understanding how these impact performance for each individual is important.

Selecting the Base - Beyond the Diagnosis

The Medicare policy for Group 3 power wheelchairs is diagnosis driven, but not ICD-10 driven. In addition, it isn't as simple as having a qualifying diagnosis. You will need to understand all routinely encountered environments (home and community) to help determine the drive-wheel configuration:

Front-Wheel Drive Base
Front-Wheel
Mid-Wheel Drive Base
Mid-Wheel
Rear-Wheel Drive Base
Rear-Wheel
Red filled circle

Center of rotation of the chair

Red dashed circle

Arc described by the head as the chair rotates

Blue dashed circle

Turning radius of the chair

Understanding routine activities, roles, and responsibilities will help define necessary wheelchair performance and influence selection. Don't automatically rule out Group 4 devices; many people may be eligible for Medicaid where community access is a mandate. Also understanding needs and trade-offs will influence final selection, e.g., outdoor performance versus indoor maneuverability.

Characteristics Influencing Base Selection

There are several characteristics that influence base selection. When choosing a base, keep the following in mind:

  • Sling or solid base (also known as the rehab seat) - requires additional seat or back cushion. The client must also have a documented medical need for the seating, including the selected seat and/or back cushion. This wheelchair seating policy is ICD-10 driven. Even if the person qualifies for the power wheelchair base, if they do not have one of the listed qualifying ICD-10 diagnoses, the seat or back will be denied.
  • Captain seat style - no additional seat or back cushion will be covered.
  • Power seating: tilt, recline, elevate, standing
    • Single-power
    • Multi-power
Tilt Power Seating
Tilt
Recline Power Seating
Recline
Elevation Power Seating
Elevation

Wheelchair Options, Accessories, and Seating

Important features required to ensure the power wheelchair can meet the person's medical and functional needs will require understanding the wheelchair options and accessories, and wheelchair seating LCDs and associated Policy Articles.

Features to keep in mind:

  • Power seating
  • Electronics
  • Alternative drive inputs
  • Wheelchair components related to upper and lower extremity positioning
  • Wheelchair seating (prefabricated or custom fabricated)
  • Seat and back cushions
    • Skin protection
    • Positioning
    • Combination
  • Positioning components
    • Headrests
    • Lateral pads
    • Thigh or knee pads
    • Medial thigh pads
    • Arm troughs
Seat Cushion
Seat Cushion
Arm Trough
Arm Trough
Lateral
Lateral
Headrest
Headrest
Electronics
Electronics

Included in the Initial Payment Group 3 and 4 PWCs

E0971
anti-tip

E0978
positioning/safety belt

E0981
seat upholstery

E0982
tube for pneumatic drive wheel tire

 

E0995
calf rest pad

E1225
manual semi-reclining back

E2366
battery charger single-mode

E2367
battery charger dual-mode

 

E2368
drive wheel motor

E2369
drive wheel gearbox

E2370
integrated drive wheel motor and gearbox combination

E2374
remote joystick replacement

 

E2375
non-expandable controller

E2376
expandable controller

E2378
actuator

E2381
pneumatic drive wheel tire

 

E2382
tube for pneumatic drive wheel tire

E2383
tube for pneumatic drive wheel

E2384
pneumatic caster tire

E2385
tube for pneumatic caster tire

 

E2386
foam filled drive wheel tire

E2388
foam drive wheel tire

E2389
foam caster tire

E2390
solid rubber drive wheel tire

 

E2391
solid caster tire

E2392
solid caster tire with integrated wheel

E2394
drive wheel excludes tire

E2395
caster wheel excludes tire

 

E2396
caster fork any size

K0015
non-adjustable height armrest

K0017
adjustable height armrest base

K0018
adjustable height arm - upper portion

 

K0019
arm pad

K0020
fixed adjustable height armrest pair

K0037
high mount flip up footrest

K0041
large size footplate

 

K0042
standard size footplate

K0043
footrest, lower extension tube

K0044
footrest, upper hanger bracket

K0045
footrest complete assembly

 

K0046
elevating leg rest lower extension tube

K0047
elevating leg rest, upper hanger bracket

K0051
can release assembly footrest or leg rest

K0052
swing-away, detachable footrest

 

K0077
front caster assembly

K0098
drive belt

 

Coverage and Conditions for Coverage

In order to qualify for power mobility the following conditions must be met:

  • Mobility limitation that impairs ability to participate in at least one mobility related activity of daily living. For more details refer to the MAE algorithm.
  • The mobility limitation cannot be resolved by the use of a cane, crutches, or walker.
  • A manual wheelchair is not an option due to limitations of strength, endurance, range of motion, coordination, presence of pain, deformity, or the absence of both upper extremities and is relevant to the upper extremity function. Even an optimally-configured manual wheelchair is not sufficient to allow the person to perform mobility-related activities of daily living during their typical day.
  • Lower level equipment should be trialed or ruled out and documentation should provide specific reasons why they don't meet the person's needs.

Additional coverage criteria for Group 3 PWCs:

  • The mobility limitation is due to:
    • A neurological condition
    • Myopathy
    • Congenital skeletal deformity
  • Requires a drive control interface other than a hand or chin operated standard joystick.
  • OR
  • Meets coverage criteria for power tilt or power recline (single-power option) or both (multi-power option) and the system(s) is being used on the wheelchair.
  • The person must be willing and have the mental and physical ability to safely use the device or has a caregiver who cannot push an optimally configured manual wheelchair, but is available and able to safely operate the power wheelchair that is provided.

Evaluation and Documentation

The Medicare coverage policy may not include use outside the home, however other funding sources may. For example, Medicaid has a community access mandate.

Document the numerous technology decisions made during the evaluation and technology assessment. Documenting what influenced the decision and how each recommended item impacts the function of the individual is critical for:

  • Assisting the individual in understanding the trade-offs related to the final technology decision and in determining whether alternative sources of funding should be sought
  • Medical review - without clear and full details, medical review staff may not approve all of the necessary technology
  • Appeals
  • Legal challenges

Documenting Medical Need

It is necessary to paint a full and detailed picture of the individual's specific needs. Therefore, it is important to include the following types of information in the documentation:

  • Physical evaluation and findings, specifically as they relate to the technology recommendation
  • Description of any trials or simulations; failings and successes
  • Functional needs
  • Daily tasks, roles, and responsibilities
  • Environments routinely encountered
  • Current technology details:
    • What worked and what didn't
    • Why is replacement necessary; provide details

Start and End with Why

The best way to assess the clarity and sufficiency of the documentation is to ask "why?" Continue to ask "why?" until the answer and details are clear and concise.

Ensure that the final documentation clearly states why the technology choices are necessary, is written objectively, and allows the medical review staff to have a complete and clear picture of the person's needs and how the specific technology recommendations address them.

Start (Why) -> Finish (Why)

Replace Subjective and Canned Language with Objective Measures and Details

The importance of the language used in documentation cannot be overstated. Subjective language is open to interpretation and value judgment. There is no guarantee that the medical reviewer, who has not seen the person, will have the same value judgment. Objective language consists of information that is measured and quantified.

Examples of Subjective vs. Objective

Subjective

"The patient is not a functional ambulator."

Objective
  1. "The patient is unable to ambulate and requires maximal assistance to transfer."
  2. "The patient is able to ambulate 15' maximum with a walker, which is insufficient for safely moving from the bedroom to the kitchen or to the bathroom in a timely manner."
  3. "Severe ataxia causes a balance dysfunction for Mr. Jones such that he requires maximal assistance and his wife reports he has fallen twice this month."

Comparing Medical Justification

Example 1
Subjective

"Angle adjustable footrests are required to support lower extremities in a functional position."

Objective

"Mrs. Smith has ankle contractures (supported by measurement of degrees in the evaluation) requiring angle adjustable footplates."

Example 2
Subjective

"A WHITMYER® headrest is needed to maintain neutral alignment and provide support for the head."

Objective

"A WHITMYER Heads Up® with LINX2 hardware is required to inhibit Mr. Jones's asymmetrical tonic neck reflex posturing and to maintain head alignment needed for driving his power wheelchair and other routine activities due to high-tone and spasticity (noted in evaluation)."

Roles in Documentation

Person/caregiver

  • Describe daily or routine activities as clearly and as detailed as possible and how the technology will resolve or ameliorate difficulties in performing them.
  • Clearly describe current equipment and detail what does or does not meet daily needs.
  • Provide details about the various environments/surfaces encountered routinely.
  • Provide details regarding transportation, public and private.

Therapist/treating physician

  • Document medical and functional limitations and deficiencies.
  • Provide details that describe the specific person. Avoid vague generalities or repeating the language in the coverage policy.
  • Through words, paint a vibrant and detail picture of the person and their needs.
  • Help the reviewer understand the person's daily activities and routine environments and how the recommended technology addresses their needs.
  • Document and justify all options, components, and seating being billed to a third party.

Supplier ATP

  • List the manufacturer/model name or number for each recommended component on the claim.
  • list the technological reasons for choices where applicable (i.e.):
    • "Confirmed that LINX2 hardware provides the multi-plane adjustment needed for the intimate fit of the head support pads to adequately position Mr. Jones' head."
    • "A center mount Elevated Leg Rest (ELR) is the only style available on the base Mr. Jones needs."
    • "Due to high tone and reduced range of motion in knees and hips, traditional 2-sided ELRs are not usable by Mr. Jones. A center mount ELR positions Mr. Jones's feet inside the front asters and therefore allows the knee bend angle and hip angle he requires (supported by the therapist's evaluation)."
  • Record all measurements for the wheelchair, seating, and components in the supplier's assessment documentation.
  • Document the home or environmental considerations that are limiting choices in technology and why.
  • Create and follow a clear process for reviewing documentation and ensuring all required elements are present before submitting. Minimize submission of unnecessary information; it only complicates the review process. Using the checklist provided by the DME MACs is useful.
Download this article as a printable PDF

Power Mobility Resources

  1. Dear Physician Letter: Power Wheelchairs and Power Operated Vehicles - Documentation Requirements (PDF)
    https://www.cgsmedicare.com/jc/pubs/news/2010/0910/cope12954.pdf
  2. Local Coverage Determination and Policy Article
    https://www.cgsmedicare.com/jc/coverage/lcdinfo.html
  3. Medicare Claim Review Programs: MR, NCCI Edits, MUEs, CERT and Recovery Audit Program (PDF)
    http://garnerhealth.com/wp-content/uploads/2014/02/MCRP_Booklet.pdf
  4. Medical Review Power Mobility FAQs
    https://www.cgsmedicare.com/jc/help/faqs/current/cope14455.html
  5. Mobility Assistive Equipment (MAE)
    https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=219&ncdver=2&bc=AgAAgAAAAAAA&
  6. National Coverage Determination (NCD)
    https://www.cms.gov/medicare-coverage-database/indexes/ncd-alphabetical-index.aspx?bc=BAAAAAAAAAAA
  7. Power Mobility Devices - 7 Element Order
    https://www.cgsmedicare.com/jc/pubs/news/2009/1109/cope10978.html
  8. Power Mobility Devices - Indicating Receipt Date of Documentation
    https://www.cgsmedicare.com/jc/pubs/news/2009/1009/cope10812.html
  9. Reminder - Replacement of Power Mobility Devices
    https://www.cgsmedicare.com/jc/pubs/news/2009/1109/cope10983.html
  10. Final Rule - Power Mobility Devices (PDF)
    https://www.cgsmedicare.com/jc/mr/pdf/mr_power_mobility_final_rule.pdf
  11. Power Mobility Documentation Requirements
    https://www.cgsmedicare.com/jc/pubs/news/2008/0708/cope7962.html

Documentation Checklists

  1. Power Mobility: Group 3 No Power Option PWCs (K0848 - K0855), Group 3 Single Power Option PWCs (K0856 - K0860), & Group 3 Multiple Power Option PWCs (K0861 - K0864)
    https://www.cgsmedicare.com/pdf/dme_checklists/pmd_3_2018re.pdf
  2. Power Mobility: Group 5 (Pediatric) PWCs with Single (K0890) or Multiple (K0891) Power Options & Push-Rim Activated Power Assist Device (E0986) for a Manual Wheelchair (PDF)
    https://www.cgsmedicare.com/pdf/dme_checklists/pmd_5_2018re.pdf

Date: 2/15/2019


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DISCLAIMER: FOR PROFESSIONAL USE ONLY. THIS WEBSITE (AND THE DOCUMENTS REFERENCED HEREIN) DO NOT PROVIDE MEDICAL ADVICE. Sunrise Medical (US) LLC (“Sunrise”) does not provide clinician services. The information contained on this website (and the documents referenced herein), including, but not limited to, the text, graphics, images, and descriptions, are for informational purposes only and should be utilized as a general resource for clinicians and suppliers to then use clinical reasoning skills to determine optimal seating and mobility solutions for individual patients. No material on this website (or any document referenced herein) is intended to be used as (or a substitute for) professional medical advice, diagnosis or treatment. Never disregard your professional medical training when providing medical advice or treatment because of something you have read on this website (or any document referenced herein). Clinicians should review this (and any other materials) carefully and confirm information contained herein with other sources. Reliance on this website (and the information contained herein) is solely at your own risk.

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