PMDs DOING IT RIGHT
The Rules are still the same just make sure you understand
them
Presented for GAMES
2/4/2014
Peggy Walker, RN
US Rehab/VGM
800-401-3643
803-754-2091fax
877 907 3862 V-fax
peggy.walker@usrehab.com
UPD AND REVIEWED 01/27/2014
Do I have to have it?
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Yes – A good order with the 7 elements
Patient information – name
Date of F2F (can be date seen by physician (for basic
eq. Or has to be date clinical evaluation reviewed by
physician for complex rehab.
(this is the date of the “completion of” the F2F) and
when the time frame starts.
Length of need
Diagnosis
Item being ordered
Physician signature --- date --- NPI
Supplier needs to have this “prior” to completing the
detailed product description.
**** Suggest adding NPI after July 1, 2013****
1. Ordering practitioner sees client and completes all 9 areas of F2F
general notes in his normal charting format. (SOAP notes)
{F2F date would be this date}
2. Physician does an evaluation and refers to clinician for mobility eval –
The clinician sends back to physician for review and signature.
{F2F date would be date he signs off on clinical notes}
3. Physician Refers to OT/PT first and then “completes” his part of the
evaluation and reviews PT/OT notes –
{F2F date would be date he sees client his part of the evaluation
and signs off on OT/PT notes}
4. If in seating clinic – the physician, the therapist, and the ATP can be in
attendance at the same time.
REMEMBER the seating evaluation by the clinician is “in addition to” not
“in lieu of” or “instead of” the physicians evaluation per the LCD policy.
In the hospital setting the F2F date would be the date of discharge from
the hospital but mobility needs would have to be noted in hospital chart
notes/PT/OT notes etc.
Written Orders CMS response per Dr. Hoover.
{5/27/2009}
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“I have received clarification from CMS on the form in
which the 7-element order may take. As you recall, there
was some debate regarding whether or not the 7-element
order was required to be “handwritten” by the physician or
whether or not it could be computer-generated as part of
an electronic medical record/electronic order.
As noted in the PIM Chapters 3.4.1.1,B and 5.2.3, written
orders can be in the form of photocopy, facsimile image,
electronically maintained or original pen and ink
document. The treating physician must still complete all 7
elements him/herself. Suppliers may provide a form with
“BLANK” spaces for the “7 ELEMENTS” but MUST NOT
complete any of the elements.
No Stamped Signatures
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NO STAMPED SIGNATURES
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CR 5971 Clarification - Signature Requirements
Reference: MLN: SE0829
Published Online: 7/31/2008
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Provider Types Affected
Physicians and other providers who bill Medicare
Contractors (Carriers, Fiscal Intermediaries, Regional
Home Health Intermediaries, Part A/B Medicare
Administrative Contractors, including Durable Medical
Equipment Medicare Administrative Contractors) for care
provided to Medicare beneficiaries.
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What You Need to Know
The purpose of this notice is to provide guidance to
providers/suppliers and Medicare contractors on the use
of stamped signatures. Note that stamped signatures are
not acceptable on any medical record.
7 element order
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1. Patient name _____________
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5.
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Date of completion of face to face _________
Diagnosis related to mobility impairment ____________
Length of Need _____________
Item being ordered: ____________
Physicians Signature ____________
(print name) ______________
NPI _________
7. Date: _________________
NOTE denials received using 2 dates in all jurisdictions 3/2013
NPI required on F2F items implemented 7/1/13 suggest adding
to the 7 element order to prevent denials from auditors.
7 element order
Patient name __________
 Date of COMPLETION of F2F __ __ ____
 Diagnosis
___________
 Item ordered ___________
 Length of Need
___________
 Physicians Signature ________ NPI _____
 Print signature: ______________
 Date _____
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Denial reasons seen for 7 element order
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none received
left off bene name
left off F2F date
left off description of item ordered
left off Length of need
left off diagnosis
No physicians signature or signature not legible
Physician did not personally complete all elements of order
Date stamp or equivalent missing
Order dated BEFORE completion of F2F
Supplier did not receive within 45 days of completion of F2F
Ordering physician was a podiatrist(DPM) or Chiropractor (DC)
7 element on form with item preprinted or check boxes or other prompts
that may be leading physician as to what to order
7 element order combined with detailed written order.
What do I do to educate the
ordering practitioner?
Keep it simple
Tell them why & who {not me} CMS
When it became effective & how they can get paid
(not just the G0372 code)
99211 –99212 for E & M billing according to time spent
Outline the “good order” for them
Talk only briefly about the algorithm in progress format
using “SOAP” note format (H & P) History & physical
 {subjective/objective/assessment/plan}
Face to Face Progress Notes Must Include
in normal charting format {H & P /SOAP Notes}
History of the present condition(s) and past medical history that is relevant to mobility
needs: *** NOTE __ this can be a combination of physicians’ and clinical evalution***
Symptoms that limit ambulation
Diagnoses that are responsible for these symptoms
Medications or other treatment for these symptoms
Progression of ambulation difficulty over time
Other diagnoses that may relate to ambulatory problems
How far the patient can walk without stopping
Pace of ambulation
What ambulatory assistance (cane, walker, wheelchair, caregiver) is currently used
What has changed to now require use of a power mobility device
Ability to stand up from a seated position without assistance
Description of the home setting and the ability to perform activities of daily living in
the home
•Physical examination that is relevant to mobility needs
Weight and height
Cardiopulmonary examination
Musculoskeletal examination
oArm and leg strength and range of motion
Neurological examination
oGait
oBalance and coordination
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 contain as much objective data as possible. The
physical examination should be focused on the body systems that are
responsible for the patient’s ambulatory difficulty or impact on the patient’s
ambulatory ability.
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The home environmental evaluation should
address what CMS has outlined
Make it brief –if the one you have covers this
than continue to use it. Do what you are
comfortable with.
If it is 2 pages make sure if you send it in to
ADMC that you number all pages
Make sure if you have a line to complete that
you either complete or put N/A
Have the patient/caregiver sign & date (not
required but safer so you can prove you did do
it)
**Should come “after” receiving the 7 element
order from physician**
LEGIBLE _ SIGNATURES AND NOTES
Environmental Assessment
ABC Company
Patient name:____________________________________ Date of Assessment: ___________
Address: ____________________________________________________________________
____________________________________________________________________
Completed by: __________________________________________________________
Housing Type: Apartment Single story house  Two story house  Mobile home
 Independent living  Group home  Other ______________________
Comments: _________________________________________________________________
Surfaces:  Carpet Linoleum  Hardwood  Other
Comments: _________________________________________________________________
Space:
 Cluttered  Open  Small rooms  Narrow hallways
Comments: __________________________________________________________________
Accessibility:
Bedroom:  Yes  No
Bathroom:  Yes  No Kitchen:  Yes  No
Living/family room:  Yes  No Dining room:  Yes  No Other:  Yes  No
Comments: __________________________________________________________________
Ramps or steps within the home:  Yes  No
____________________________________________________________________________
Measurements (indicate widths): Entry doors _____ Bathroom _____ Kitchen _____
Bedroom ______ Living/family room ______ Hallways ______ Other ______________
Entrance:
 Ramp
 Steps (how many) _______
 Low threshold  Sliding glass door
Comments: __________________________________________________________________
Outside access:
 Paved  Gravel  Dirt  Flagstone  Other ______________
Recommendations: ____________________________________________________________
____________________________________________________________________________
Patient and/or caregiver/family member is willing and able to use the mobility device safely and
adequately to assist with MRADLs in the home  Yes  No
Patient / Caregiver signature __________________________________ Date __________
Why patient unable to sign if caregiver signs: ________________________________________
Supplier’s signature/ATP _____________ (print name)______________
Date _________
Required on any grp 2 (single power option) or greater
that requires specialty controls or seating
 {ALL group 3s ; 4s; and MWCs with power assist device}
 K0005s & E1161s --- March 1, 2013
 Required on all custom seating
 THE SUPPLIER must do an attestation statement of no
financial relationship with PT/OT completing the evaluation
– for each patient – hospital owned DMEs exempt.
 PTs/OTs have different codes they can bill 97001 for PT –
97003 for OT plus they can bill 97755 for time (1 U =s 15
min) they need to check their region for clarification on
allowable. NOT all states are the same & some areas do
not even pay for these.
 A clinical evaluation does not take the place of a F2F by
ordering practitioner (in conjunction with but does not take
place of)
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Company Letterhead
Attestation Statement:
This is to attest that ABC company has no financial
relation ship with (name, PT/OT) completing the
evaluation for (patient name) on (date).
Signature:
Date:
Title:
(Can be completed and signed by supplier or therapist)
HAS TO BE A SEPARATE FORM – AUDITORS ARE DENYING
Must contain:
* Patient information
* Brief description of item (name/model)
****** DATE of FACE to FACE completion****
* HCPCs Code (DESCRIPTION OF) ie:grp2pwc M41
INV
EACH accessory must have complete description
* * Must be signed and dated prior to delivery
* If all or part changes a new order would be
required.
**** MUST come “AFTER” the 7 element order****
**** Must be completed prior to delivery of
equipment****
{medical necessity for each accessory required}
NO LONGER REQUIRES PRICING retroactive to
October 2009 - Q & As Jurisdiction C July 25, 2011
ABCD Company
Anywhere Street
Any Town – USA 55555
555-555-5555
Beneficiary Name:
Address:
Date of F2F __ __ ____
(this is initial / start date)
Dear Doctor ________)
This is a detailed order for wheelchair base and all accessories that
are required for your patient to maintain mobility – please review
and if you agree sign and date below.
Code
Description
Your charge**
Medicare Allowable**
(base and all accessories)
UPGRADES USE BOTH CODES AND CLEARLY IDENTIFY WHAT THEY ARE
Physician _____________________ Date ___
Print Name: ___________________
Note*This can be completed by supplier for ordering practitioner to
review and sign off & should include all items being billed.
Medical necessity for “in the home” must be documented in clinical
format for the base and each accessory billed.
**Pricing No longer required June 1, 2011**
•
Denial Reasons Seen
Not received or was within the therapist notes not separate
 Did not have separate listing for base and each
option/accessory to be billed
 Does not provide enough detail information to determine the
item was properly coded (manf name and product number)
 DPD was combined with 7 element order (by policy the DPD
can’t be completed until the supplier has received the 7
element order.
 Documentation does not support that the supplier received,
prior to delivery, a DPD that was signed and dated by physician
 Missing Date Stamp or equivalent
 Corrections/changes made without physicians’ initials and dated
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November 12, 2009
Power Mobility Devices
Detailed Product Description – Clarification
In a revision of the Power Mobility Devices Local Coverage
Determination that became effective on 10/1/09, the requirements for the
detailed product description were revised. The LCD states:
For the wheelchair base and each option/accessory, the supplier must
enter all of the following:
HCPCS code
Narrative description of the HCPCS code
Manufacturer name and model name/number
Supplier's charge **** no longer required (June 2011)
Medicare fee schedule allowance ****revised and removed June 2011
retroactive to 2009 BUT even the ADMC nurses are denying if not
there***
2011 CB Modifier updates// note date here (this is not what they are
using) -- KT is still used for traveling / KE & KY for accessories 2013
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MLN SE1035 January 1/17/2010
KE – use on accessories billed on a manual wheelchair K0001
through K0009 that could be billed on a competitive bid power
wheelchair *** USE even if in non CB area***
KG modifier is on accessories billed with standard power chairs
K0813 through K0829 for beneficiary who permanently lives in a
CB area ( If not in CBA area do NOT use KE or KG)
KK modifier is to be used on accessories billed with Complex Rehab
power wheelchairs in Group 2 (K0835 – K0843) if beneficiary lives
in a CBA area – KK used for CB area for complex rehab ELRs in CB
Complex Rehab Group 3 K0848 thru K0864 do not use any of the
CB modifiers ( KE/KG or KE) ***KE****
The CB modifiers (KG/KK/KU/KW) are only used on beneficiaries
who live in a CBA (**KT **use if traveling out of CBA)
These modifiers are to be used in CBA by CB winners.
KY is temporary modifier for grandfathered suppliers to use in
CBAs which will change in future (October 1, 2011) no longer use
KG KK KL CB Modifiers for power accessories
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Competitive Bid Modifiers for power wheelchairs KG/KK ** not using**
The denial s/rejections will happen if not used correctly in the CB areas.
K0195 or E0990 for ELRs (& any other accessories) should have the KG when billing
for standard power chair (such as K0822; K0823 or K0825) * anything in the K0813
through K0831 group) but the KK if billed for the complex rehab bases. Group 3s or
any other Group 2 bases that is not in the CB range.
Accessories that can be billed on both the CB bases and the Non CB bases will
require these modifiers.
List of common codes where the modifiers are left off are:
E0990KK (purchase ELRS for complex) K0195KG (rental ELRs for basic power
E0973 (adj hgt arm rests) E2361 (batteries) E2365 (batteries) E0951 (heel loops)
E0955 (head rest)
E1028 (swing away hardware) ---Anti tips should not be billed with power chairs –
If a fully reclining back is billed (and is truly a “fully” {greater than 80 degrees}
reclining back E1226 would require these modifiers as well.
NOTE these are not being used in 2013 just for reference –
KE for accessories for complex rehab manual (E1161/K0005s/ and manual
tilt in spaces even pediatric.
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PMD Revisions June 1, 2011
K0822 – will deny -For patients who do not have special skin protection or positioning
needs, a power wheelchair with Captain’s Chair provides appropriate support.
Therefore, if a general use cushion is provided with a power wheelchair with a
sling/solid seat/back instead of Captain’s Chair, the wheelchair and the cushion(s)
will be covered only if either criterion 1 or criterion 2 is met:
The cushion is provided with a covered power wheelchair base that is not available in
a Captain’s Chair model – i.e., codes K0839, K0840, K0843, K0860 – K0864, K0870,
K0871, K0879, K0880, K0886, K0890, K0891; or A skin protection and/or positioning
seat or back cushion that meets coverage criteria is provided.
If one of these criteria is not met, both the power wheelchair with a sling/solid seat
and the general use cushion will be denied as not reasonable and necessary.
ABNs seat elevator bases updates revised JUNE 1, 2011
Not reasonable and necessary means you can now use ABNs again for chairs with
seat elevator.
If a Group 2 Single Power Option PWC is provided and if criterion II(A) or II(B) is not
met (including but not limited to situations in which it is only provided to
accommodate a power seat elevation feature, a power standing feature, or power
elevating leg rests), it will be denied as not reasonable and necessary.
Group 4 also same revision with effective date of June 1, 2011.
These are effective as of June 1, 2011 and this basically means that an ABN can be
used for the Group 2 bases that the patient “Wants” a seat elevator as well as the
Group 4 that patient wants but meets for a group 3 or lower.
Revisions June 1, 2011
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Not reasonable and necessary denial means you can now use ABNs
again for chairs with seat elevator.
If a Group 2 Single Power Option PWC is provided and if criterion
II(A) or II(B) is not met (including but not limited to situations in
which it is only provided to accommodate a power seat elevation
feature, a power standing feature, or power elevating leg rests), it
will be denied as not reasonable and necessary.
Group 4 also same revision with effective date of June 1, 2011.
These are effective as of June 1, 2011 and this basically means that
an ABN can be used for the Group 2 bases that the patient “Wants”
a seat elevator either billable or free upgrades
Group 4 that patient wants but meets for a group 3 can now accept
ABNs or free upgrades.
Can do the K0831 to the K0823 again.
K0822 and general use cushion and backs – US Rehab/VGM and
other industry experts are requesting revision of this policy to
allow the rehab seat and general use cushion /less cost to
Medicare trust fund & increases beneficiary access to Rehab
seating backs heights and widths can’t get with captains’ seats.
PWK additional documentation
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NOTE- Medicare now has the PWK segment which allows a supplier
to submit paper documentation by fax or mail along with your
electronic claim BEFORE it is requested by the DME MAC. To submit
PWK documentation with your claim, you must complete the PWK
segment with a value of either BM (if mailing documentation) FX
(if faxing). AFTER the claim has been accepted by CEDI, complete
the PWK Fax/Mail cover Sheet and mail or fax the cover sheet
along with your documentation
This became available beginning Oct 1, 2012 in all
jurisdictions – copy of A, B, C and D forms attached.
 Each Jurisdiction has a form to be attached to the
additional documentation submission that you can find
on their web site under forms. B is very difficult to find
and is titled Medicare DMEC fax Medicare cover sheet
instead of PWK cover sheet
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Prior Authorization Demo project
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Starts : (September 4, 2012) for any order received on or after this date
PMDs and POVs in group 1, 2,3,4 and 5
 All povs K0800-K0805 and K0809-K0812
 All standard power grp 1 & 2 K0813 – K0829
 All grp 2 complex K0835 – K0843 *** NOTE*** these can also
go to ADMC so make sure you do PA or you will lose 25%
 All grp 3 complex without power options K0848 –K0855
 All Ped and grp 4 pwcs K0887 – K0891
 (NOTE does not mean grp 4s are covered may help with going
to a secondary payer source.
 Miscellaneous pwcs K0898
 EXCLUDED are grp 3s (K0856-K0864) but these can still go to
ADMC in all jurisdictions.
 Pademo@cms.hhs.gov for more information for documentation
help go to usrehab.com and PMD help from Peggy
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CMS PMD Demo (submit)
F2F documentation
 7 element order
 Detailed Product Description
 Any other relevant documentation if
necessary
 Suggest sending any relevant
documentation that shows continued
progression of disease state especially for
cardio / pulmonary disease / conditions.
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Keep a check off sheet for what is required
Make sure all staff are aware of changes and dates
The 45 days is how long the “ordering practitioner”
has to get the information to your office.
You must have date stamp/or similar for receipt
Have 120 days from F2F to deliver chair
Timing starts at original F2F or when ordering
practitioner reviews the PT/OT evaluation
PT evaluation does not exempt F2F ****
Make sure any changes/updates are relayed to all
staff
To do a “free” upgrade use the code the patient meets criteria
for than and than put RRKHKXGL in the narrative field and
explain what you are doing
Bill code provided: K0816RRKHKXGL then in narrative state
K0823 provided because this is all we had in stock on this
date (why gave free upgrade)
Beneficiary Requested upgrade:
RRKHGA (1st line) and narrative explaining this is the base pt.
{WANTS}- will denyRRKHKXGK (2nd line) narrative field note this is the item the
patient meets criteria for {NEEDS}
KB is the overflow modifier when using an ABN –
99 if you need greater than 4 modifiers and no ABN being used.
(most often used for purchased replacement bases or
accessories with RTLT modifiers)
BOTH CODES CAN BE PUT ON DPD AND CLEARLY IDENTIFY
EACH CODE (MORE IS SOMETIMES BETTER)
IMPORTANT LCA
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(least costly alternative)
February 4, 2011 the LCA became affective --- March 14th – items
Group 2 (K0806/K0807(POVs***) & K0830/K0831(PWCs) &
Group 4 PMDs*** fell into statutorily non covered in the LCA and
***** CHANGED Back on June 1, 2011 with July Revision to LCD
POLICY****
This meant basically that if you tried to do an upgrade with an ABN
these items would deny with an ANSI 96 so there would be no
reimbursement from Medicare for a base with a seat elevator.
The ansi denial would be on both lines because you could not use a
GA and would have to use a GY modifier on first line.
This is a rule that the 4 jurisdictions have no control over. Industry
associations are aware and are working along with US
Rehab/VGM/NCART/AAH/ to try to address this through
regulatory channels.*** SUCCESS*** Corrected as of 6/1/2011
The PMD LCD will be revised as of June 1, 2011 to allow for an
upgrade for Grp 4 to Grp 3 PMDs and
CAUTION – Grp 2 POVs to Grp 1 POVs – remember has to be
needed (for use) within the home – VERY rarely that a grp 2 POV
could actually go throughout someone’s entire home
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1. 5/5/2005 – MAE was published by CMS with implementation July 5, 2005
2. MAE relates to MRADL (mobility related activities of daily living)
3. August 24, 2005 – CMS issues regulations that CMNs no longer required for Power w/cs and POVs
4. September 14, 2005 – Evidence of Medical necessity – PMD claims
5. **No CMN required for Manual Sept 23**
6. transitional CMNs 10/01/05till {4/1/06}
Face 2 Face - 10/25/05 (45d grace existing pts.)
3/10/06 // 30ds – detailed order(7 element order) (1/1/06-4/1/06)not req. (F 2 F still)
3/31/06 IFR fact sheet *45d* - NOTE date
Federal Register 4/5/06–will be final in 60days*6/05/06* implementation
Date STAMP/or equivalent doc. MD --- 6/5/06
7/11/06 updates – 120 days (p F2F) deliver chair (8/24/06)
Detailed order must include brief description of base, options to be billed – your charge and Medicare
allow / or N/A *8/24/06* (HCPCs Code) **DATE – AFTER 7 element order**
Sign attestation that you have no financial involvement with PT/OT 8-10-06
April 1, 2008 – ATS / ATP must be “employed by” supplier completing evaluation on the patient –
(ATP requirement for clinician eval. removed from policy (12/07) – The ATS must be personally
involved in actual eval and not just review paper work – Qualified technician for repairs in new Quality
Standards --- Keep copy of ATS Resna exam letter on file & Rehab contact “form” or statement
showing direct involvement
KX modifier required date of service on or after 11/15//2006
NUKHBPKX – if >4 mods. Req. NUKHBPKB (if ABN used) 99 if replacement modifier needed and put
extra modifiers in HAO record & explain use
October 1, 2009 – must detail out each accessory on detailed order (make/model)
MUST have legible signatures ---October 2009 – physicians name can be printed below/typed
November 5 2009 – 7 element order –no reference to PMD/PWC/Scooter within body of the order
(may be “leading” physicians to order power mobility)
1/1/2011 – pwcs K0813-K0831 and K0898 go into capped rental / accessories bill same as before
Competitive bid started on 1/1/2011 (group 2 standard power /grp. 2 complex rehab are part of)
Time lines and revisions 2011 (2)
2012 big is PA change
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February 4, 2011 the LCA became effective --- March 14th –
items Group 2 (K0806/K0807(POVs***) &
K0830/K0831(PWCs) & Group 4 PMDs*** fell into
statutorily non covered in the LCA and ***** CHANGED
Back on June 1, 2011 with July Revision to LCD
POLICY****
Manf chair that has both a captain seat code and rehab seat
code such as K0822 – can’t bill essential cushion and back –
both chair and cushion will deny since CMS states that if
they need rehab seating it would be specialty seating only.
A captain seat would be comparable to an essential seat
and essential back. Used to have medical necessity
reasoning now has statutorily non-covered reasoning so will
cause both the base and cushion to deny.
WATCH for updates and changes on these. --- Hopefully
2012 update -- Prior authorization demo project started in
CA-FL-NY-NC-MI-IL and TX October 2012
Timelines and revisions 2013
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KY modifier for accessories for NON-CB complex group 3
accessories
KE for mwc accessories for complex manual tilts and
ultra light weights (K0005 and E1161)
Effective/revision dates 7/1/2013 change request 8181
dated 2/8/2014
K0005/ E1161 –ATP and clinician required 3/1/2013
JULY 1, 2013 F2F IMPLEMENTED FOR OTHER DME
ITEMS PMD RULES AND ORDERS REMAIN THE SAME
Basic Equipment Package
Belts(E0978)
Battery chargers(E2366)
Complete set of tires and casters (any type)
Controller & input devices***NOTE*** if a
code specifies an expandable controller as an
option (but not a requirement) at the time of
initial issue, it may be billed separately (if
medically necessary)
 Leg rests (ELRs separate)
 Fixed/swing away detachable foot
rests/include ang. Adj.
 Weight specific components according to sub
division
 Armrests (hgt. adj. will still be separate) **
except part of tilt recline code for high end
pwcs)
 Upholstery
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Basic Equipment Package
Shoulder harness/straps/vest may be billed separately
 Seat width/depth exceptions : grp 3 & 4 pwcs with a
sling/solid/back can bill separately for:
*standard –seat w/d > 20 inches
*heavy duty – w/d > 22 inches
*Very HD – w/d > 24 inches
*Extra HD – no separate billing
* Back width exceptions: grp 3 & 4 pwcs with sling/solid
seat/back can bill separately for:
*standard – width > 20 inches
*HD – width > 22 inches
*VHD – width > 24 inches
*Extra heavy duty – no separate billing
K0108 is code to use for width/depth making sure you give
name, make, model and MSRP in narrative.
Adj angle foot plates can be billed on grp 3-4 & 5 on initial
issue.
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All power will have to be coded by the SADMERC
10/01/2006 (NOW DMEPDAC)
64 codes 6 groups
Groups are broken out by performance
Sub divisions based on wgt capacity & power
seating capability
Manufacturers will submit bases for codes
****NOTE**** SADMERC was no longer contracted
by PGBA after August 18, 2008 – Noridian took over
this contract {www.dmepdac.com} they are to
maintain a DMECs site.
Is exactly the same as previous SADMERC site with
same search features etc.
 PDAC - Pricing Data Analysis Contractor
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PT/OT Evaluation Example p1
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Evaluation – Mobility Assist Equipment
HISTORY/DIAGNOSIS/PROGNOSIS:
_______ is a ____ yr old male/female with a diagnosis of ____. Pertinent Medical
history includes ________. He/she is ___tall & weight _____. Prognosis poor,
good, fair etc.
Assistance:
He/she lives in a w/c accessible/non-accessible (will remodel) house/apartment
alone/with____. He/she has assistance/no assistance. Caregiver is able/unable to assist
with ____
HOW NEEDS ARE MET TO DATE:
Presently using a ______ that is ____ years old & in (fair, poor, good)
condition. A change is needed because: _____________________________.
MOBILITY:
___ is (non-ambulatory - ambulates short distances with assistance of - etc.)
high risk of falls?
STRENGTH, FUNCTIONAL LEVEL & ADLS: Patient is
dependent/independent/requires minimal/maximal assist with bathing,
dressing, toileting, preparing simple meals etc. Upper extremity strength is
____ Lower extremity strength ___. Movement of extremities _____. Passive
range of motion _____ upper & lower extremities. Sitting balance is _____
static & ____ dynamic. Circulation ___ .
COGNITIVE ABILITY: Alert - oriented - MR - decreased cognitive status etc.
Compliance with use of equipment?
Safety Awareness / in home trial with MAE – must be completed for all power
chairs. *** manual can be a verbal/telephone interview with patient or family
member/caregiver but should be followed up*** If the manual chair being
provided is needed specifically as related to environment than an actual visual
evaluation would have to be completed by suppler***
PREDOMINANT TONAL PATTERNS: Spasticity lower extremities - etc.
POSTURAL IMPAIRMENT: Mr./Mrs. /Ms sits with fixed kyphosis, scoliosis,
wind swept etc. – Contractures of _____ etc.
SKIN CONDITION: History of decubi rt. ischeal - no break down - etc.
VISUAL/HEARING: Presents with limited vision - WNL - Hearing WNL etc.
PLANNED USE FOR CHAIR: What are patients daily activities that they require this level of
chair? This is specific as related to MRADLs.
CAREGIVERS’S CONCERNS: Who was involved in evaluation? What do they see as needs for
their family member, patient, friend? How available are they? Time spent with patient
_______. Are they available & willing to assist patient with care of base being provided?
Risk to patient (injury) – history of frequent falls (be specific) One fall a year would not be
something that would be acceptable.
ESTIMATED NUMBER OF YEARS CHAIR WILL BE USED/ FUTURE NEEDS ADDRESSED:
Permanently / will they need an add on at a later date? Prognosis is very important when
choosing specific bases because of need for future changes to meet functional decline.
Evaluators’ names & titles. --- PT/OT/ATPS etc.
The next part is to be completed with ATP assistance as needed. It is important that all
accessories that are required for the seating and positioning needs of the client have the
functional needs documented
EVALUTION for specific equipment & Accessories (example)
Equipment (base) & explanation of need for specific accessories.
Base - Name, make, model no. - Why this base is needed above any lower level chair for
functional mobility within the home.
Tilt/Recline: Name, Make, Model no - What is the condition that requires this specialty item.
What was used in past? Why is change needed?
Seat - Special width/depth (name, make, model of base & why this special sizing was
needed).
Leg rests : If power Name, make, model & why needed - If manual why needed over regular
leg rests. (edema, fixed hip angle, cast etc.)
Armrests: Adjustable height, arm troughs etc. - Why needed over standard.
Other Special Considerations: Make sure you always give the name, make, model, of the
specialty item and the condition which requires the item as related to medical necessity &
not convenience.
** Past history of use of same or similar equipment must always be addressed***
If you are using a special item and the standard item has an
existing code for any accessory you must state why the
standard item would not meet the needs of this particular
patient as related to Medical Necessity & not convenience.
The item must address the needs of the patient both
present and future & not care givers specifically.
MEDICAID --- Additional Information
Make sure that you give other options/bases (with pricing)
tried and why the other option/base did not meet the
needs/goals for the particular client/patient. Use Medicaid
codes as required. (This is good to use with Medicare as
well.)
In many states Medicaid wants more detailed information on
products such as breaking out the hardware from specific
items and giving Medical Necessity for this as well. ie:
Laterals – Hardware to attach laterals. (why
detachable/swing away needed over fixed hardware)
NOTE Check off sheets are OK IF the answer is explained
within the notes or beside the check off. E.g. (weak UE Y
NO) should explain what weakness is related to.
 What is “intended” as a meaning and what is actually documented is
a difference in actual coverage.
 The algorithm states that physician must address why cane – walker manual chair will not meet needs. This needs to be addressed in
all categories (even Quads) and replacement bases with the
completion of the F2F (includes therapists evaluation)
 F2F date means F2F date and not “appointment date” date seen etc.
 The progress notes must address that patient is in for an evaluation
for mobility (not follow up of multiple medical problems; for
surgery etc.) *NO supplier generated FORMS*
 7 element order must be dated prior to the detailed product
description (suppler must receive this order before they can
complete the detailed product description)
 HTTP://www.dmepdac.com Coding information
A Group 2 single power option or multiple
power option PWC, any Group 3 or Group 4
PWC, or a push rim activated power assist
device for a manual wheelchair must be
provided by a supplier that employs a
RESNA-certified Assistive Technology
Practitioner (ATP) who specializes in
wheelchairs and who has direct, in-person
involvement in the wheelchair selection for
the patient.
*** K0005 /E1161 & any pediatric tilts as
well March 1, 2011
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ATP Resna Certified – you have a certification letter that states you have passed the exam – that will
become part of the process of a request for documentation on an audit situation.
The person who works directly with the client in either a wheel chair “team” clinic situation/ does the
equipment evaluation and documents what he/she does during the process would meet the policy
statement.
The key is “documents” how he/she is involved with the selection of the particular equipment for the
particular patient.
Most /ATP have a format that they use for documenting how they decide the specific base and
accessories for the individual patient. The patients’ physical limitations, as described by the clinical
(LCMP) evaluation, will drive the need for specific accessories and the base which, with complex
rehab equipment, is a requirement.
*** The KX modifier on the claim indicates that all criteria in policy has been met so this would not be
requested for billing purposes.***
Send in a copy of the ATP/RESNA certification letter for the ATS completing the evaluation on the client.
Send in the specification/evaluation summary that the ATP completes in whatever format you use to
document how the specific base and accessories were chosen for the particular patient and why.
The documentation that “clearly outlines the ATP’s direct involvement with the equipment selection
process” is what they are looking for. The purpose of having an ATS is to ensure that the patient
receives the proper equipment to meet their needs for mobility and seating within their usual
environment. So the home evaluation would also be an important part of the ATPs’ documentation.
Make sure that the signatures are legible & identify the person as an ATP. ****All documentation
should be legible.****
I do not advise any types of “cookie cutter” formatting; if you have a line to complete you should
complete it or put N/A; “if” you have blocks that have to be checked off than make sure these are
addressed. Just something that says YES ____ NO _____ for a specific item should fully define
why.
Example: laterals needed YES X NO ______ -- Why needed ___________
Do not leave it for a reviewer/auditor to have to search for the reason.
EVALUTION / SPECIFICATION
Base - Name, make, model no. - Why this base is needed above any lower
level chair for functional mobility within the home. Why was this base
chosen over other bases?
Tilt and/or Recline: Name, Make, Model no - What is the condition that
requires this specialty item. What was used in past? Why is change
needed? Make sure you clearly indicate why the specific item was
chosen. Why both tilt and recline and why just the tilt or recline would
not meet needs. Reference the LCMPs evaluation for additional clinical
documentation.
Seating - Special width/depth (name, make, model of base & why special
sizing was needed). Need height and weight – specific measurements,
which is already part of your specification sheet. {Back – Cushions –
Laterals}
Leg rests : If power Name, make, model & why needed - If manual why
needed over regular leg rests. (edema, fixed hip angle, cast etc.)
Armrests: Adjustable height, arm troughs etc. - Why needed over
standard.
Other Special Considerations: Custom foot boxes/ specialty items -- Make
sure you always give the name, make, model, of the specialty item and
the condition which requires the item as related to medical necessity &
not convenience.
****Any accessories MUST address medical necessity.****
***Just signing off on the LCMP is not adequate unless the actual
documentation within the LCMP states that (specific name, ATS) was
present and involved with the selection of the specified equipment and
accessories for the client.***
The critical part of any audit is legible documentation relating to the
specific detailed involvement of the ATS/CRTS/ATP in the “selection of
the equipment”.
K0856- K0864 & related accessories.
MEMO from : CMS dated 19 May 2008
COMPETETIVE Delayed 18 months but 9.5% decrease in allowable
for all round one products to start 1/1/2009 – even though complex
Rehab did get the exempt from the CB we did not get it exempted
from the cut. You can’t use the KE modifier on accessories in Group
3 products -Industry is attempting to change this.
REPAIRS – the codes that are part of the CB will have to be
replaced / repaired by a CB contracted supplier.
(this has been updated to state any one can repair but only receive CB
pricing for the item) THESE are denying -ISSUES STILL EXIST WITH REPAIRS OCTOBER 2013
Bid winners will continue to be able to purchase group 2 standard
PWCs BUT ONLY IN ROUND 1 ROUND 2 THEY ARE NOW
RENTAL FOR THE BID WINNERS AS WELL
“For any DMEPOS item to be covered by Medicare,
the patient’s medical record must contain sufficient
documentation of the patient’s medical condition to
substantiate the necessity for the type & quantity of
items ordered & for the frequency of use or
replacement (if applicable). -- However, neither a
physician’s order nor a CMN nor a DIF nor a
physician attestation statement by itself provides
sufficient documentation of medical necessity, even
though it is signed by the treating physician or
supplier. --
Clinical Review Judgment
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This clinical review judgment involves two steps:
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1. The synthesis of all submitted medical record information (e.g.
progress notes, diagnostic findings, medications, nursing notes,
etc.) to create a longitudinal clinical picture of the patient; and
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2. The application of this clinical picture to the review criteria to
determine whether the clinical requirements in the relevant policy
have been met.
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NOTE: Clinical review judgment does not replace poor or
inadequate medical record documentation, nor is it a process that
review contractors can use to override, supersede or disregard a
policy requirement (policies include laws, regulations, Centers for
Medicare & Medicaid (CMS) rulings, manual instructions, policy
articles, national coverage decisions, and local coverage
determinations).
Date:________________
Facility / Therapist:
___________________________
Last Name:_____________________
First Name:________________________
D.O.B. ____________Family Members / Caretaker Present__________________
Reason(s) for Visit:
(Circle One)
(Circle One)
Secure New Wheelchair
Power / Manual Primary / Back up
Evaluate Chair for Repair
Power / Manual Primary / Back up
Secure Other Rehab
Device
_______________________________
Evaluate Other Rehab Device for Repair _______________________________
 Visit Included: (check all that apply)Initial Needs Assessment
 Physical / Mat Evaluation
 Simulation
 Demo Equipment
 Order Written
 Review Insurance Guidelines and Process
 Equipment Fitting
 Training On Use
 Delivery
 Follow-up on Recently Delivered Equipment
 Repair/ Adjustment to Wheelchair
 Install New Parts
 Adjustment for Growth
 Time Spent: ___________ hours.
 Signature: _______________________Title:____________ Date:_____________
 RESNA ID # {if applicable}______________________________
 I certify that I am a RESNA Certified ATP who specializes in wheelchairs;
 I am employed by ________ and I have had direct in person involvement in the
wheelchair selection for the above patient.
***Using this does not mean an ATP does not have to complete his/her equipment
evaluation***
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Summary of Documentation Required
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Good Order which must include: Date of F2F – Diagnosis relating to mobility deficit –
length of need -- Item being ordered (POV or Power wheelchair) *** must clearly
indicate that a major reason for visit was for mobility evaluation***
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Copy of progress notes on date of F2F and any ***additional notes*** that may be
required to show progression of disease process. *** Especially on cardio pulmonary
disease or conditions.***
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Date stamped/or equal documentation which was received from the
physician within 45 days of F2F (discharge from hospital, rehab facility, SNF etc.)
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Home evaluation by supplier.
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Detailed written order which is a brief description of each item ordered, HCPCs code,
this does not require pricing as of July 1, 2010 retroactive to October 2009
and signed by the physician prior providing the chair. Date stamp required (8/24/06)
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Attestation statement (8/10/06) if a PT or OT did an evaluation and it is being included in
F2F documentation ** stating supplier has no financial relationship with them** If
supplier is hospital owned and evaluation was completed by PT/OT employed by the
hospital this is not required.
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Note: the 45 days starts on date of actual F2F or when the physician has reviewed the
PT/OT evaluation and signed off. The physician does not have to see the patient a second
time if there was a complete F2F prior to PT/OT evaluation, but if the PT/OT evaluation
was completed prior to physician seeing patient than there has to be a F2F with an
eval confirming what the PT/OT evaluation states. This would become the date of F2F.
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The supplier has 120 days from the date of F2F to deliver the equipment
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April 1, 2008 supplier must have an ATP on staff for any group 2 single or multi power
option; any group 3 or 4 and any manual with power assist and the ATP must be directly
involved in the evaluation process for the equipment being provided (as of March 1. 2013 must
have ATP with any K0005 or E1161s.
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**** Don’t forget “routine” information – purchase option letter/delivery
ticket/AOB/ etc.**** Explanation of capped rental for K0813 through K0831s
PMD Team Responsibilities
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Physician/ordering practitioner:
Face to face evaluation of patient functional needs for power either a scooter or power wheelchair:
{Must include basic information relating to ability to perform MRADLs within the home environment}Basically establish need by ruling out use of a cane, walker, manual wheelchair and when going to a
power wheelchair (why a scooter/POV will not meet needs) Both cognitive and functional abilities need
to be addressed. ***MUST*** state that the reason for visit was for mobility evaluation.
Write order: which includes the date of the face to face; length of need; diagnosis relating to impaired
mobility & item being ordered which can simply state power mobility device / power wheelchair or
scooter/POV sign and date /
Make sure the supplier receives the progress notes from the date of the face to face and the good order
within 45 days of “completion of” face to face.
If a PT/OT evaluation is completed – review and sign off & concur with
Review and sign off on suppliers “detailed product description”
*** The key here is that the face to face needs to specifically be for an evaluation for power
mobility*** There is no need for completing “forms/CMNs” Just write the information in a narrative
description (SOAP notes) fax a copy of the progress notes along with the good order to the supplier &
review and sign off on the detailed product description and PT/OT evaluation if one is ordered.
Physical Therapist – Occupational Therapist
Complete: A functional mobility assessment which address patients’ “functional” needs within the
home. It is OK to mention what they complete outside the home. The key is what is needed within the
home to complete basic adls daily that could not be completed without the use of a power mobility
device. This needs to be a step by step approach ruling out least costly alternative from a cane –
walker- manual w/c (all levels) to a scooter to a power wheelchair.
Make sure this is detailed and legible. Keep it basic and simple
Detail out each accessory and why it is Medically necessary ie: adjustable height arm rests needed
because patient is 6’3” and requires higher arm rests for upper extremity support etc. lateral supports
to maintain upright position {stroke pt etc.}
The patient cognitive awareness needs to be addressed as well.
Supplier –
Home Environmental Evaluation
Education of patient/caregiver – safe use & care of equipment
Attestation statement (if PT/OT involved)
Higher end needs ATP evaluation and documentation of personal involvement
Completing Detailed product description for review & signature
Date stamp documentation when it comes in
All follow up and processing of paper work flow
Make sure ABNs – purchase option letter is also completed accurately
Capped Rental PMDs
Effective for items provided on or after January 1, 2011, standard power wheelchairs
(K0813 – K0831, K0898) must be furnished on a monthly rental basis like other
capped rental durable medical equipment (DME).
 The capped rental policy will follow the same rules as all other capped rentals.
 Break in service vs break in need rules remain the same.
 Standard capped rental rules for beginning a new rental period will apply to power
wheelchairs.
 Look back periods – continued need will still have to be documented if requested.
EVEN on Capped rental items.
 If pt moves and pwc will not fit in new home would new pwc be allowed ___ NO –
based on medical change in condition only.
 If lost, stolen, or irreparably damaged a new replacement pwc will follow same rules
as any other DME (one incident –not “worn out”
 If malicious damage/culpable neglect during CR period is noted the supplier can
present information to DME MAC for investigation /if the DME MAC (in consultation
with CMS) agrees that beneficiary is responsible for the damage, the supplier can
charge the beneficiary.
 NOTE – after the 13th month has been reached there is an old CFR discussion
capped rental s and suppliers responsibility to replace within the 5 years if the item
needs replacement ***
 If patient abuse is proven the provider would not be held responsible.
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Physicians Progress Note (EXAMPLE format)SOAP NOTE Subjective / Objective / Assessment/Plan
Client:
Date:
Reason for visit: (evaluation for mobility)
Subjective : General information from patient/caregiver/family member/case worker etc.
ie: patient states has become weaker in past few months/was using a cane and a walker but has had
several falls – lives alone without any assistance etc. -_________
Diagnosis & Symptoms:
Objective: Height, weight – ROM – Upper and lower extremity strengths – vision – cognitive status
(This needs to focus on the issue of ambulation difficulties & mobility needs within the home.) Inability to
use a cane, walker, manual wheelchair –
can he use a scooter within his home? Does he have the ability to transfer on an off a scooter – will he
need specialty seating?
This can be basic information and if the physician feels the client needs a complete clinical evaluation he
/she can then refer to a seating clinic / PT or OT.
Mobility – patient unable to ambulate without assistance – “was pushed into office by daughter” unable
to transfer to table without assist of two etc. – objective measurements PLAN : Refer to therapist – order scooter or basic power wheelchair
Than sign and date legibly – and refer to DME / HME supplier
Complete 7 element order that includes – patient name – date of face to face – item being ordered (can
simply state power chair or scooter) length of need and diagnosis related to mobility impairment –
signature and date (print name below signature)
This information needs to be received by the supplier within 45 days of completion of the Face to Face.
The completion of the Face to Face date would change if a therapist evaluation was ordered and the
physician then reviewed and signed off on the evaluation.
This would then become the “completion” of the face to face and the physician would write the 7 element
order with that date as the Face to Face date.