Power Mobility Devices - 7-Element Order

Original Effective Date: 11/05/2009
Revision Effective Date: 11/01/2013

Medicare national and local policy specify that following completion of the face-to-face examination, the physician or treating practitioner must complete a written order containing seven specified elements. Suppliers have the option of providing physicians with a form that lists the seven elements, but which requires the physician to provide all of the requested information. One example of such a form is:

Question Answer
Beneficiary Name  
Item Ordered  
Date of Face-to-Face Examination  
Diagnosis/Condition Relating to Need for Item  
Length of Need  
Physician Signature  
Signature Date  


It is not permissible for the supplier to "lead" the physician as to the type of equipment that is ordered. Some examples, not all-inclusive, of unacceptable 7-element orders are:

  • A form with "power mobility device" already entered in Item Ordered field.
  • A form with check-off boxes for various types of mobility assistive equipment.

A 7-element order with these or similar elements will be considered invalid and the claim for the power mobility device will be denied.

Refer to the Power Mobility Devices Local Coverage Determination and Policy Article for additional information on coverage and documentation.

            Last Updated Mon, 08 Jan 2018 13:32:04 +0000