CMS requires that for Specified Covered Items payment may only be made if a physician has communicated to the supplier a written order for the item before the delivery of the item.
For many items of DME, a physician must document that a physician, a physician assistant (PA), a nurse practitioner (NP), or a clinical nurse specialist (CNS) has had a face-to-face encounter with the beneficiary pursuant to that order. The encounter must occur during the six months prior to the written order for each item.
The patient’s medical record must contain sufficient documentation of the patient’s medical condition to substantiate the necessity for the type and quantity of item ordered and must be signed by the ordering physician.
- Duration of patient’s condition
- Clinical course
- Nature and extent of functional limitations
- Other Therapeutic interventions and results
Key Items to Address
- Why does the patient require the
- Do the physical examination findings support the need for the item?
- Signs and symptoms that indicate the need for the item.
- Diagnoses that are responsible for these signs and symptoms.
- Other diagnoses that may relate to the need for the item.
- The information must not be re-corded in vague and subjective terms.
- The information must provide ob-jective measures, tests or observa-tions.
- Each medical record is expected to be individualized to the unique patient.
General Coverage Criteria
- A manual wheelchair for use inside the home is covered if the following criteria are met and documented in the patient’s medical record:The patient has a mobility limitation that significantly impairs his/her abil-ity to participate in one or more mo-bility-related activities of daily living (MRADL). A mobility limitation is one that:
- Prevents the patient from ac-complishing an MRADL en-tirely
- Places the patient at reasona-bly determined heighten risk of morbidity or mortality sec-ondary to the attempts to perform an MRADL;
- Prevents the patient from completing an MRADL within a reasonable time frame
- The patient’s mobility limitation can not be sufficiently resolved by the use of a cane or walker.
- The patient’s home provides adequate access between rooms, maneuvering space, and surfaces for the use of the manual wheelchair.
- Use of the manual wheelchair will significantly improve the patient’s ability to participate in MRADLs.
- The patient has not expressed an unwillingness to use the manual wheelchair.
In addition to the forgoing, two of the following criteria must be met and documented in the patient’s medical record:
- The patient has sufficient upper extremity function and other physical and mental capabilities needed to safely propel the manual wheelchair.
- The patient has a caregiver who is available, willing, and able to provide assistance with the wheelchair.
Additional Coverage Criteria for Spe-cific Manual Wheelchairs
In addition to the general manual wheel-chair criteria noted, the s criteria for each of the following specific wheelchairs must be met and documented in the patient’s medical record:
- Standard hemi-wheelchair – The patient requires a lower seat height because of short stature or to enable the patient to place his/her feet on the ground for propulsion.
- Lightweight wheelchair – The patient cannot self-propel I a standard wheel-chair in the home and can and does proper in a lightweight wheelchair.
- High strength lightweight wheelchair -The patient meets one of the following criteria:
- The patient self-propels the wheelchair while engaging in frequent activities in the home that cannot be performed in a standard or lightweight wheel-chair, or
- The patient requires a seat width, depth, or height that cannot be accommodated in a standard, lightweight or hemi-wheelchair, and spends at least two hours per day in the wheelchair.
- Heavy duty wheelchair – The patient weighs more than 250 pounds or the patient has sever spasticity.
- Extra heavy duty wheelchair – The pa-tient weighs more than 30 pounds.