Coverage

• Mobility Assistive Equipment (MAE) (280.3) National Coverage Determination (NCD)
• Power Mobility Devices (PMD) Local Coverage Determination (LCD) and Policy Article [PDF]
• Wheelchair Options/Accessories LCD and Policy Article [PDF]
• Wheelchair Seating LCD and Policy Article [PDF]

Documentation

• Changing a 7-Element Order for PMDs - It is recommended that when the need for a correction to a 7-element-order for a PMD is identified, the supplier should request that the physician who completed the original 7-element order complete and submit a new 7-element order
• Group 1 / Group 2, No Power Options Documentation Checklist [PDF] - Checklist to ensure suppliers gather all required documentation for HCPCS K0813 - K0816 and K0820 - K0829
• Group 2 Single / Multiple Power Options Documentation Checklist [PDF] - Checklist to ensure suppliers gather all required documentation for HCPCS K0835 - K0840 and K0841 - K0843
• Group 3 Single / Multiple Power Options Documentation Checklist [PDF] - Checklist to ensure suppliers gather all required documentation for HCPCS K0856 - K0860 and K0861 - K0864
• Group 3 No Power Options Documentation Checklist [PDF] - Checklist to ensure suppliers gather all required documentation for HCPCS K0848 - K0855
• POV and Push-Rim Activated Power Assist Device Documentation Checklist [PDF] - Checklist to ensure suppliers gather all required documentation for HCPCS K0800 - K0808, K0812 and E0986
• Physician Letter - Power Wheelchairs and Power Operated Vehicles [PDF] - Letter may be sent to physicians to assist in obtaining documentation

Reviews/Audits

• Advance Determination of Medicare Coverage (ADMC)
  • ADMC Overview
  • Eligible HCPCS List
  • Request Form
  • Preventing Duplicate ADMC Requests
• Medical Review - View notifications/findings of pre/post claim reviews completed by Noridian Medical Review
• Prior Authorization Demonstration - View eligible HCPCS codes, CMS resources, and all applicable publications

Reminders

Topic	Reminder
Billing Reminder for Mounting Hardware - HCPCS E1028	Guidelines for appropriate billing of wheelchair mounting hardware are provided
Discontinued Use	If a beneficiary discontinues use of a rental PMD, supplier may not continue to bill Medicare for that item. Although Medicare does not have specific guidelines on how a supplier should monitor and document use, each claim submitted may be subject to review. Supplier records must clearly demonstrate ongoing monitoring and use of rental item by beneficiary, if audited
Group 3 Power Wheelchair Requirements	Requirements and coverage criteria for Group 3 Power Wheelchairs, HCPCS K0848-K0864, are provided
Home Assessment	There is no requirement for a supplier to perform a new PMD home evaluation to reassess a beneficiary's home in event that a beneficiary changes residence. Medicare would not start a new capped rental period if new residence will not accommodate PMD beneficiary is currently renting and a different base (same HCPCS code) is required. If supplier elects to provide a different wheelchair base (different HCPCS code), a new signed and dated detailed product description (DPD) is required but a new face-to-face examination (F2F) or 7-element order (7EO) is not needed. If a beneficiary with a PMD moves and his/her new home will no longer accommodate PMD, Medicare will not pay for a new wheelchair. Medicare covers a replacement only if an item is lost, stolen, irreparably damaged, or reaches five year reasonable useful lifetime. Medicare covers a different item only if there is a change in beneficiary's medical condition
Hospital, Skilled Nursing Facility	During a PMD capped rental period, if beneficiary goes into a hospital or skilled nursing facility for an extended stay, supplier may elect to pick up PMD. Upon returning home, if supplier chooses to provide a different model PMD within same HCPCS code, a new DPD must be obtained. A F2F examination 7EO is not needed in this situation. If beneficiary is receiving same type of PMD (same HCPCS code) on discharge that they previously had, then rental period resumes where it left off. If beneficiary qualifies for a different type of PMD on discharge because of a change in his/her medical condition, all requirements for a new PMD must be met (i.e., F2F exam, 7EO, etc.). A new capped rental period will begin only if there has been a break in medical necessity of at least 60 days plus days remaining in last paid rental month
Power Wheelchair Electronics Clarification	DMEPOS suppliers may ensure appropriate billing of power wheelchair electronics, such as motors, controllers, harnesses and interfaces by considering clarifications provided in this article
Repair of Rented Items	There is no payment for repair of rented items under any circumstances during a PMD capped rental period. Reimbursement for repairs is included in rental payments. If supplier believes that a repair is required because of malicious damage or culpable neglect by beneficiary, supplier can present information to DME MAC for investigation. If DME MAC, in consultation with CMS, agrees that beneficiary is responsible for damage, supplier can charge him/her. Supplier can call the Contact Center to address this issue. When a PMD has a service issue, supplier is required to provide a loaner item that meets beneficiary's medical needs. Monthly billing would continue while rental PMD is being repaired. There should be no separate billing and/or payment for loaner wheelchair during 13 month capped rental period
Supplier Assistive Technology Professional Involvement	Supplier of a rehab PMD must employ a RESNA-certified Assistive Technology Professional who specializes in wheelchairs and who has direct, in-person involvement in wheelchair selection for patient