DOCUMENTATION CHECKLIST

Group 3 Power Mobility Devices

No Power Options (K0848 – K0855)

Reference: LCD L23598 and PA A41127

Required Documentation in Supplier’s File

Claims for all Group 3 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
• What ambulatory assistance is currently used
• What has changed to now require a PMD
• Description of home setting and ability to perform ADL in the home

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 DOCUMENTATION CHECKLIST
Group 3 Power Mobility Devices
No Power Options (K0848 – K0855)

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.

‰ 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

‰ 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 3 Power Mobility Devices
No Power Options (K0848 – K0855)

Payment Criteria for Group 3 No Power Option Wheelchairs

‰ 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 weight is less than or equal to weight capacity of power wheelchair 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’s mobility limitation is due to neurological condition, myopathy, or congenital
skeletal deformity; and
‰ Patient had a specialty evaluation performed by a licensed/certified medical
professional with specific training and experience in rehabilitation wheelchair
evaluations and documents medical necessity for the wheelchair and its special
features; and
‰ Wheelchair is provided by supplier employing a RESNA-certified Assistive
Technology Professional (ATP) specializing in wheelchairs and having direct, in-
person involvement in wheelchair selection.

General Information:
‰ Face-to-face examination is done before completing the detailed written order.
‰ 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.

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 DOCUMENTATION CHECKLIST
Group 3 Power Mobility Devices
No Power Options (K0848 – K0855)

Billing Reminders:
‰ Add KX modifier to the code for power mobility device and all accessories only if one of
the following conditions is met:
o If all the coverage criteria specified in LCD have been met for the product provided;
or
o If there is an affirmative Advance Determination of Medicare Coverage (ADMC) for
the product provided; or
o If a Group 4 PWC is provided and all coverage criteria for a comparable Group 3
PWC 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 2/4/2009