Physician's Resources

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 patients. 

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

Definitions - A cheat sheet for many of Medicare's new acronyms for mobility equipment

9 Step Algorithm - The foundation of Medicare's new criteria

Interactive Algorithm - 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.

Documentation - An overview of  documentation requirements

Face to Face Evaluation - An overview of the face to face exam requirement for power mobility devices

Reimbursement - Billing for your time to prepare documentation

Supplier Responsibilities - New supplier requirements

Canes & Walkers - An overview of requirements for prescribing canes and walkers

Manual Wheelchairs - 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 sources

The Old Rules - They No Longer Apply

• No more "Bed or Chair Confined" rule

• No more Certificates of Medical Necessity (CMN's) for Mobility Assistive Equipment (MAE)

• No longer necessary to require a specialist in physical medicine, orthopedic surgery, neurology, or rheumatology to provide a written order for Power Operated Vehicles (scooters).

The New Rules - Basic Principles

• Mobility Assistive 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

• The patient's 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

Medicare has 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)

• MAE: 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)

The 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 beneficiary’s ability to participate in MRADL’s in customary locations in the home.  Additionally, Medicare expects the patient’s medical record will document the need for the prescribed MAE using this algorithm.  It is critical for your patient’s 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 patient.

 Here is the 9-Step Algorithm as published by Medicare.

1. Does the beneficiary have a mobility limitation that significantly impairs his/her ability to participate in one or more MRADLs in the home?

A mobility limitation is one that:

• Prevents the beneficiary from accomplishing the MRADLs entirely; or

• Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts  to participate in MRADLs; or

• Prevents the 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.

2. Are there other conditions that limit the beneficiary’s ability to participate in MRADL’s at home?

• Some examples are significant impairment of cognition or judgment and/or vision.

• For these 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.

3. 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 beneficiary’s ability to perform or obtain assistance to participate in MRADLs in the home?

• A caregiver, 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 caregiver’s need to use a wheelchair to assist the beneficiary in the MRADLs is to be considered in this determination.

• If the 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.

4. Does the beneficiary or caregiver demonstrate the capability and the willingness to consistently operate the MAE safely?

• Safety considerations include personal risk to the beneficiary as well as risk to others.

• The 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.

5. Can the functional mobility deficit be sufficiently resolved by the prescription of a cane or walker?

• The cane or walker should be appropriately fitted to the beneficiary for this evaluation.

• Assess the beneficiary’s ability to safely use a cane or walker.

6. Does the beneficiary’s typical environment support the use of wheelchairs, including scooters/power-operated vehicles (POVs)?

• Determine whether the beneficiary’s home environment will support the use of these types of MAE.

• Keep in mind such factors as the home’s physical layout, surfaces, and obstacles, which may render MAE unusable in the beneficiary’s home.

7. Does the beneficiary have sufficient upper extremity function to propel a manual wheelchair in the home to participate in MRADLs during a typical day?

• The manual 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.

• A beneficiary 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 beneficiary’s physical characteristics and anticipated intensity of use.

• The beneficiary’s home should provide adequate access, maneuvering space, and surfaces for the operation of a manual wheelchair.

• Assess the beneficiary’s 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. 

8. 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 operation.

   • The beneficiary’s home should provide adequate access, maneuvering space, and surfaces for the operation of a POV.

   • Assess the beneficiary’s ability to safely use a POV/scooter.

    

9. Are the additional features provided by a power wheelchair needed to allow the beneficiary to participate in one or more MRADLs?

• The pertinent 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 beneficiary’s functional impairments.

• The beneficiary’s home should provide adequate access, maneuvering space, and surfaces for the operation of a power wheelchair.

•  Assess the beneficiary’s ability to safely use a power wheelchair.

Documentation - It's The Key

Thorough documentation 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

• The patient's 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 MS

• Documentation should be a detailed narrative in the same format as other chart entries.  ie: No canned forms

• The equipment 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.

Face 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 patient’s 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 patient.

• Document just those elements that are pertinent to the need for the Power Mobility Device.

• The amount of detail required depends on the nature of your patient’s condition.

• Paint a picture of your patient’s functional abilities and limitations on a typical day.

• Be as quantitative as possible

The report of your face-to-face examination should provide information relating to the following questions:

• What is this patient’s mobility limitation and how does it interfere with the performance of activities of daily living?

• Why can’t a cane or walker meet this patient’s mobility needs in the home?

• Why can’t a manual wheelchair meet this patient’s 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 can’t a POV (scooter) meet this patient’s 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?

The report should provide pertinent information about the following elements, but may include other details. Each element would not have to be addressed in every evaluation.

• Symptoms · Related diagnoses

• History · How long the condition has been present

• Clinical progression · Interventions that have been tried and the results

• Weight · Physical exam

• Past use of walker, manual wheelchair, POV, or power wheelchair and the results

• Impairment of strength, range of motion, sensation, or coordination of arms and legs

• Sitting and standing balance · Neck, trunk, and pelvic posture and flexibility

• Presence of abnormal tone or deformity of arms, legs, or trunk

• Functional assessment – any problems with performing the following activities including the need to use a cane, walker, or the assistance of another person

• Transferring between a bed, chair, and PMD 

• Walking around the home – to bathroom, kitchen, living room, etc. – 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/OT’s written report you must see the patient (if you did not do so prior to the referral) and perform any additional examination necessary.

• 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.

• Medicare’s coverage of a wheelchair is determined solely by the patient’s mobility needs within the home, the examination must clearly distinguish the patient’s abilities and needs within the home from any additional needs for use outside the home.

It 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 physician’s examination can be before or after the LCMP’s examination.

Reimbursement - 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.

Supplier Responsibilities - New Requirements

• For power mobility devices, the supplier must prepare a “Detailed Product Description” 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.

• The supplier 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.

•  If 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.

•  The supplier must also perform an assessment of the home to verify the home will support the use of a wheelchair or power mobility device.