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DOCUMENTATION CHECKLIST

Group 2 Single Power Option Wheelchairs (K0835 – K0840)


Group 2 Multiple Power Option Wheelchairs (K0841 – K0843)

Reference: LCD L23598 and PA A41127

Required Documentation in Supplier’s File

Claims for All Single and Multiple Group 2 Power Mobility Devices (PMDs)
‰ Valid written order that contains:
o Beneficiary’s name
o Description of item ordered (may be general, e.g., “power operated vehicle,”
“power wheelchair” or “power mobility device” or may be more specific)
o Date of face-to-face examination
o Pertinent diagnoses/conditions that relate to need for power wheelchair
o Length of need
o Physician’s signature
o Date of physician signature

NOTE: In order for Medicare to cover a PMD, the supplier must obtain the written order within
45 days of a face-to-face examination by the treating physician and prior to delivery. A PMD
cannot be delivered based on a verbal order. If the supplier delivers the item prior to receipt of a
written order, it will be denied as noncovered. If the written order is not obtained prior to
delivery, payment will not be made even if a written order is subsequently obtained.

‰ Face-to-face examination that is relevant to mobility needs. For example:


o History of present condition and relevant past medical history
• Symptoms that limit ambulation
• Diagnoses that are responsible for symptoms
• Medications or other treatment for symptoms
• Progression of ambulation difficulty over time
• Other diagnoses that may relate to ambulatory problems
• Distance patient can walk without stopping
• Pace of ambulation
• What ambulatory assistance is currently used
• What has changed to now require a PMD
• Description of home setting and ability to perform ADLs (activities of daily
living) in the home
o Physical examination relevant to mobility needs
• Height and weight
• Cardiopulmonary examination
• Arm and leg strength and range of motion
o Neurological examination
• Gait
• Balance and coordination

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DOCUMENTATION CHECKLIST
Group 2 Single Power Option Wheelchairs (K0835 – K0840)
Group 2 Multiple Power Option Wheelchairs (K0841 – K0843)

NOTE: The physician may refer the patient to a licensed/certified medical professional (LCMP),
such as a physical therapist (PT) or occupational therapist (OT), who has experience and training
in mobility evaluations to perform part of the face-to-face examination. The physician then
reviews the written report of this examination and performs any additional examination that is
needed. The report of the physician’s visit shall state concurrence or disagreement with the
LCMP examination.

‰ Specialty assessment:
o Performed by licensed/certified medical profession having specific training and
experience in rehabilitation wheelchair evaluations
o Provides detailed information explaining need for each specific option or accessory
– i.e.
• Power seating system
• Alternate drive control interface
• Elevating leg rests
o Done in addition to the requirement for a face-to-face examination

‰ Attestation statement
o Affirms the medical professional performing the specialty assessment has no
financial relationship with the supplier

‰ Detailed product description


o Specific base HCPCS code
o All options and accessories that will be separately billed
o Supplier’s charge for each item
o Medicare’s fee schedule allowance for each item
• If no allowance, list “not applicable”
o Physician signature and date signed
o Date stamp to document receipt date

‰ Home assessment:
o Verifies patient can adequately maneuver the device considering:
• Physical layout
• Doorway width
• Doorway thresholds
• Surface
o Documented in a written report

‰ Beneficiary authorization

‰ Proof of delivery

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DOCUMENTATION CHECKLIST
Group 2 Single Power Option Wheelchairs (K0835 – K0840)
Group 2 Multiple Power Option Wheelchairs (K0841 – K0843)

Payment Criteria for Group 2 Single Power Option Wheelchairs (K0835 –


K0840):

‰ Patient has mobility limitation that significantly impairs his/her ability to


participate in one or more mobility-related activities of daily living (MRADLs)
such as toileting, feeding, dressing, grooming, and bathing in customary locations
in the home; and
‰ Patient’s mobility limitation cannot be sufficiently and safely resolved by use of
appropriately fitted cane or walker; and
‰ Patient does not have sufficient upper extremity function to self-propel an
optimally-configured manual wheelchair in the home; and
‰ Patient does not meet coverage criteria for a power operated vehicle (POV); and
‰ Patient’s mental capabilities (e.g., cognition, judgment) and physical capabilities
(e.g., vision) are sufficient for safe mobility; or
‰ Patient has a caregiver who is unable to adequately propel an optimally-configured
manual wheelchair but is available, willing and able to safely operate the power
wheelchair that is provided; and
‰ Patient’s home provides adequate access; and
‰ Use of a power wheelchair will significantly improve patient’s ability to participate
in MRADLs and patient will use it in the home; and
‰ Patient requires a drive control interface other than a hand or chin-operated
standard proportional joystick; or
‰ Patient meets coverage criteria for a power tilt or a power recline system and the
system is being used on the wheelchair; and
‰ Patient had a specialty evaluation, as described above; and
‰ Wheelchair is provided by a supplier employing a RESNA-certified Assistive
Technology Professional (ATP) specializing in wheelchairs who has direct, in-
person involvement with wheelchair selection for the patient.

Payment Criteria for Group 2 Multiple Power Option Wheelchairs (K0841 –


K0843):
‰ Patient has mobility limitation that significantly impairs his/her ability to
participate in one or more mobility-related activities of daily living (MRADLs)
such as toileting, feeding, dressing, grooming, and bathing in customary locations
in the home; and
‰ Patient’s mobility limitation cannot be sufficiently and safely resolved by use of
appropriately fitted cane or walker; and
‰ Patient does not have sufficient upper extremity function to self-propel an
optimally-configured manual wheelchair in the home; and
‰ Patient does not meet coverage criteria for a power operated vehicle (POV); and

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DOCUMENTATION CHECKLIST
Group 2 Single Power Option Wheelchairs (K0835 – K0840)
Group 2 Multiple Power Option Wheelchairs (K0841 – K0843)

‰ Patient’s mental capabilities (e.g., cognition, judgment) and physical capabilities


(e.g., vision) are sufficient for safe mobility; or
‰ Patient has a caregiver who is unable to adequately propel an optimally-configured
manual wheelchair but is available, willing and able to safely operate the power
wheelchair that is provided; and
‰ Patient’s home provides adequate access; and
‰ Use of a power wheelchair will significantly improve patient’s ability to participate
in MRADLs and patient will use it in the home; and
‰ Patient meets coverage criteria for a power tilt and recline seating system and system
is being used on the wheelchair; or
‰ Patient uses a wheelchair mounted ventilator; and
‰ Patient had a specialty evaluation as described above; and
‰ Wheelchair is provided by a supplier employing a RESNA-certified Assistive
Technology Professional (ATP) specializing in wheelchairs who has direct, in-person
involvement with wheelchair selection for the patient.

General Information:
‰ Detailed written order, detailed product description and face-to-face examination
must be date stamped (or equivalent) to document date of receipt.
‰ Delivery of the PMD must be within 120 days following completion of the face-to-
face examination.
‰ PMD will be denied as not medically necessary if the underlying condition is
reversible and length of need is less than three months.
‰ Upgrades that are beneficial primarily in allowing the patient to perform leisure or
recreational activities are noncovered.

Billing Reminders:
‰ Append the KX modifier to the code for the PMD and all accessories if the coverage
criteria for the PMD provided have been met.
‰ Accessories must be billed on the same claim as the wheelchair base.

* NOTE: It is expected that the patient’s medical records will reflect the need for the care
provided. These records are not routinely submitted but must be available upon request.
Therefore, while it is not a requirement, it is a recommendation that suppliers obtain and review
the appropriate medical records and maintain a copy in the beneficiary’s file.
DISCLAIMER
The content of this document was prepared as an educational tool and is not intended to grant
rights or impose obligations. Use of this document is not intended to take the place of either
written law or regulations.

Updated 2/10/2009