DOCUMENTATION CHECKLIST

Group 1 Power Wheelchairs (K0813 – K0816)

Group 2 Power Wheelchairs, No Power Options (K0820 – K0829)

Reference: LCD L23598 and PA A41127

Required Documentation in Supplier’s File

Claims for All 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.

‰ 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

‰ 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

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 DOCUMENTATION CHECKLIST
Group 1 Power Wheelchair (K0813 – K0816)
Group 2 Power Wheelchair, No Power Options (K0820 – K0829)

• 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

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.

‰ 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

Payment Criteria for Group 1 and No Power Option Group 2 PWCs:

‰ 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

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 DOCUNTATION CHECKLIST
Group 1 Power Wheelchair (K0813 – K0816)
Group 2 Power Wheelchair, No Power Options (K0820 – K0829)

‰ Patient does not meet coverage criteria for a power operated vehicle (POV); and
‰ Patient’s home provides adequate access; and
‰ Patient’s weight is less than or equal to weight capacity of wheelchair provided; and
‰ Patient’s mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g.,
vision) are sufficient for safe mobility; and
‰ Use of a power wheelchair will significantly improve patient’s ability to participate in
MRADLs and patient will use it in the home. For patients with severe cognitive and/or
physical impairments, participation in MRADLs may require the assistance of a
caregiver; and
‰ PWC is appropriate for the patient’s weight.

General Information:
‰ Detailed written order must be date stamped 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.
‰ This category of PWCs is not capable of accommodating a power tilt, recline, seat
elevation, or standing system.
‰ PWC capable of accepting only power elevating legrests is considered to be a No
Power Option chair.

Billing Reminder:
‰ 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