Power Mobility Devices (such as power-operated vehicles and power wheelchairs)

We cover these devices if the treating practitioner and supplier meet these basic coverage criteria:

• The treating practitioner (a physician or non-physician practitioner) submits a standard written order (SWO) prior to delivery.
• The practitioner sees the patient face-to-face. See Step 1: See the Patient Face-to-Face for more information.
• Both the practitioner and the DMEPOS supplier accept Medicare.

In addition, the patient:

• Has a mobility limitation that significantly impairs their ability to participate in 1 or more mobility-related activities of daily living (MRADLs), such as:
  • Using the toilet
  • Eating
  • Getting dressed
  • Grooming
  • Bathing in a bathroom
• Has a mobility limitation that can’t be sufficiently and safely resolved using a cane or walker.
• Doesn’t have the upper extremity function needed to self-propel an optimally configured manual wheelchair in their home to perform MRADLs (and there’s no caregiver available who’s willing and able to push them in a manual wheelchair). The patient may have 1 of these:
• Limitation of strength, endurance, range of motion, or coordination
• Presence of pain
• Deformity or absence of 1 or both upper extremities
• Must be able to safely operate and get on and off the device.

Regulatory Requirements

Review the criteria in Local Coverage Determination (LCD): Power Mobility Devices (L33789) and National Coverage Determination (NCD): Mobility Assistive Equipment (MAE) (280.3) and the specific conditions for the chosen device (POV or power wheelchair).

The Master List contains all the DMEPOS items that may be included on the Required Face-to-Face Encounter and Written Order Prior to Delivery List or the Required Prior Authorization List.

The patient:

• Can get in and out of the POV safely
• Can operate the POV’s tiller steering system
• Can maintain postural stability and position while operating the POV in their home
• Is mentally and physically able (including having the necessary cognitive function, judgment, and vision) to safely operate the POV in their home
• Lives in a home that has adequate access between rooms, maneuvering space, and surfaces for the POV’s operation
• Can use the POV to significantly improve their ability to participate in MRADLs at home, like using the bathroom or eating
• Hasn’t expressed that they’re unwilling to use the POV at home
• Meets both of these weight requirements:
  • Their weight is less than or equal to the maximum weight capacity of the POV provided
  • Their weight is greater than or equal to 95% of the weight capacity of the next lower POV weight class
• Meets all LCD L33789 criteria

The patient:

• Is mentally and physically able to operate the power wheelchair, or they have a caregiver who’s available, willing, and able to safely operate a power wheelchair but can’t push an optimally configured manual wheelchair in a safe or effective way
• Lives in a home that has adequate access between rooms, maneuvering space, and surfaces for the power wheelchair’s operation
• Can use the power wheelchair to significantly improve their ability to participate in MRADLs at home
• Hasn’t expressed that they’re unwilling to use a power wheelchair at home
• Meets both of these weight requirements:
  • Their weight is less than or equal to the maximum weight capacity of the power wheelchair provided
  • Their weight is greater than or equal to 95% of the weight capacity of the next lower power wheelchair weight class
• Doesn’t meet all the criteria for a POV
• Meets all LCD L33789 criteria

A face-to-face visit is an in-person visit or telehealth visit between you and the patient. If you use telehealth for the visit, you must meet telehealth services requirements to get paid.

You must conduct and document the encounter for us to cover a PMD. Be sure to gather all information about diagnosing, treating, or managing the patient’s condition that requires the PMD. This visit must happen within the 6 months before ordering a device.

During the visit:

• Evaluate and treat the patient for their medical conditions
• Tailor your evaluation to the patient’s conditions
• Determine if a PMD is necessary for their treatment plan
• Document that a mobility exam was a major reason for the visit
• Perform a mobility exam, including a physical exam and assessment of their MRADLs
• Answer these questions about the patient:
  1. What’s their mobility limitation?
  2. How does their mobility interfere with them performing MRADLs?
  3. Why won’t a cane or walker meet their needs at home?
  4. Why won’t a manual wheelchair meet their needs at home?
  5. Why won’t a POV, if applicable, meet their needs at home?
  6. Are they physically and mentally able to operate a power wheelchair safely in the home?

You don’t need to do a new face-to-face visit in these limited cases:

• The PMD is replaced during the 5-year useful lifetime of the item, and it’s in the same performance group previously covered.
• You’re ordering PMD accessories that aren’t included in the Required Face-to-Face Encounter and Written Order Prior to Delivery List. See Types of Devices for more information.

After the face-to-face visit, document in the patient’s chart a detailed narrative note that describes the patient’s functional abilities and limitations on a typical day. Include as much objective information as possible. You don’t need to address each element in every evaluation.

Consider including these details about the patient:

• Present and past medical history of mobility needs, including:
  • Symptoms and diagnoses that make it difficult for them to move
  • Medications or other treatments
  • Increased difficulty moving over time
  • Other diagnoses that may relate to ambulatory problems
  • Description of their home
  • Their ability to perform MRADLs at home
  • How far and fast they can walk without stopping
  • If they need help standing up from a seat
  • What they currently use to help them get around
  • Any changes that now require them to use a PMD
• Physical exam, which focuses on the patient’s body systems that are responsible for ambulatory difficulty or affect their ambulatory ability, including:
  • Height
  • Weight
  • Cardiopulmonary exam results
  • Musculoskeletal exam results
  • Arm and leg strength and range of motion
  • Neurological exam results, like gait and balance
  • Other medical conditions

The evaluation should be tailored to the individual patient’s conditions. The history should paint a picture of the patient’s functional abilities and limitations on a typical day. It should have as much objective data as possible.

Along with providing the detailed narrative, make sure the patient’s medical record supports the medical need for a PMD in their home. Include lab tests, X-rays, and other diagnostic tests that show their mobility needs.

Write an SWO, which is a prescription for a PMD. Send this to the DMEPOS supplier within 6 months of the face-to-face visit. When the DMEPOS supplier gets the SWO, they can render the item and submit the claim. For some items, like power wheelchairs, the practitioner must send the SWO to the DMEPOS supplier before they deliver the item.

The SWO must include:

• The patient’s name or MBI
• A general description of the item, like the brand name or model number, HCPCS code, or HCPCS code narrative
• The quantity, if applicable
• The order date
• Your name or NPI
• Your signature

PMDs require approval before delivery to the patient. A Medicare Administrative Contractor (MAC) will review the prior authorization request and then tell you if the item is approved (“affirmation”) or not approved (“non-affirmation”). If you don’t get prior authorization before delivery, we deny the claim. Either you or the DMEPOS supplier can complete this request—but not both.

Voluntary prior authorization is available for some options and accessories.

Either before or during delivery of the PMD, you or the DMEPOS supplier must perform an on-site patient home assessment and write a report. The report must show that the patient can safely use the PMD, considering these home details:

• Physical layout
• Doorway width
• Doorway threshold
• Surfaces

It’s important to work together with DMEPOS suppliers to avoid improper payments. Be sure to:

• Complete steps 1–5 above
• Double check the patient’s medical record and all necessary documents

PMDs and related options, accessories, and repairs have a high improper payment rate. To avoid improper payments for PMDs, make sure:

• Medical records are complete
• Medical records show the devices are medically necessary
• No information or documents are missing, including your signature on the SWO

To avoid improper payments on accessories, repairs, and replacements, be sure to:

• Show that a device replacement is necessary.
• Show that repairs are reasonable and necessary and meet the requirements.
• Show that suppliers document labor time adequately.
• Show that reasonable and necessary repairs don’t include parts and labor covered under a manufacturer’s or supplier’s warranty.
• Specify that if cumulative device repair costs exceed a certain amount over a device’s 5-year lifetime, the original supplier of the device must replace it free of charge.
• Show that we don’t allow replacement of a durable power wheelchair accessory, such as a power seating system, before the end of the 5-year lifetime for the durable accessory. An option or accessory added onto a wheelchair base isn’t a part of the wheelchair base and can’t be billed for as repairs to the wheelchair base. The durable wheelchair option or accessory is an item of DME and must last for the entire 5-year reasonable useful lifetime.

Make sure there’s a signed and dated SWO for all items, including options, accessories, and seating. Be sure the SWO was written within 6 months of the face-to-face encounter.

PMDs require approval before delivery to the patient. A MAC will review the prior authorization request and then tell you if the item is approved (“affirmation”) or not approved (“non-affirmation”). Either you or the practitioner can complete this request—but not both.

Voluntary prior authorization is available for some options and accessories.

Either before or during delivery of the PMD, you or the ordering practitioner must perform an on-site patient home assessment and write a report. The report must show the patient can safely use the PMD, considering these home details:

• Physical layout
• Doorway width
• Doorway threshold
• Surfaces

Keep these documents and be able to provide them, if requested:

• SWO
• Face-to-face visit supporting documents
• Written home assessment report
• Proof of delivery
• Written order prior to delivery, which must be completed before delivering the item to the patient
• Records describing repairs, including a detailed explanation that justifies the placement of components or parts and the labor time needed to fix the item
• Licensed/certified medical professional specialty evaluation or assistive technology professional evaluation, if required

It’s important to work together with practitioners to avoid improper payments. Be sure to:

• Complete steps 1–4 above
• Double check the patient’s medical record and all necessary documents before you submit a claim

PMDs and related options, accessories, and repairs have a high improper payment rate. To avoid improper payments for PMDs, make sure:

• Medical records are complete
• Medical records show the devices are medically necessary
• No information or documents are missing, including the practitioner’s signature on the SWO

To avoid improper payments on accessories, repairs, and replacements, be sure to:

• Show that a device replacement is necessary.
• Show that repairs are reasonable and necessary and meet the requirements.
• Document labor time adequately.
• Show that you didn’t charge for repairs covered under a manufacturer or supplier warranty.
• Show that the repair charges don’t exceed the cost of replacing the item being repaired.
• Show that your repair charges don’t include charges for replacement of a durable power wheelchair accessory, such as a power seating system, before the end of the durable equipment’s 5-year lifetime. An option or accessory added onto a wheelchair base isn’t a part of the wheelchair base and can’t be billed for as a repair part for the wheelchair base. The durable wheelchair option or accessory is an item of DME and must last for the entire 5-year reasonable useful lifetime just like the wheelchair base. If the durable power wheelchair option or accessory needs to be replaced before the end of the equipment’s 5-year reasonable useful lifetime, the original supplier of the equipment (in this example, the power seating system) is responsible for replacing the item free of charge under 42 CFR 414.210(e)(4).

We cover options and accessories if both these apply:

• The patient has a PMD that meets our coverage criteria
• The medical record supports the medical necessity of the options and accessories

Covered items include, but aren’t limited to:

• Basic Components: Arm of chair, foot or leg rests, and seat or back cushions
• Seating Systems: Non-standard seat frames and power tilt and recline seating systems
• Power Components: Batteries, chargers, and drive control systems
• Specialized Equipment: Power seat elevation equipment for certain power wheelchairs

Compliance Notes: We don’t cover all options and accessories. See LCD: Wheelchair Options/Accessories (L33792) and NCD: Seat Elevation Equipment (Power Operated) on Power Wheelchairs (280.16) for more information.

Durable wheelchair options and accessories are items of DME, and payment for these items can’t be made before the end of the 5-year reasonable useful lifetime for the item under 42 CFR 414.210(f). We don’t consider durable wheelchair options and accessories to be parts of the wheelchair base they’re added onto, so they can’t be billed as repair parts.

We cover repairs (including parts and labor) and replacements of patient-owned PMDs if they’re reasonable and necessary.

• Supplier Requirements: To ensure payment and avoid improper payments, suppliers must:
  • Document labor time adequately.
  • Honor repair warranties.
  • Ensure that each individual repair charge doesn’t exceed the cost of replacing the item being repaired. If the PMD doesn’t last for the device’s 5-year lifetime, the original supplier of the device is required to replace it free of charge in accordance with 42 CFR 414.210(e)(4).
• Replacements: Documentation must show that a device replacement is necessary (meaning the device has reached its 5-year useful lifetime or is lost, stolen, or irreparably damaged, which doesn’t mean irreparably worn)
• Regulatory Reference: View 42 CFR 414.210 for more information