Medicare Requirements for wheelchairs/power wheelchairs

What documentation is needed to get a wheelchair covered through Medicare?

 

Many are surprised when informed that a prescription for a wheelchair from their physician is not enough documentation to get Medicare to pay for this type of equipment.  So what is all needed?  Hopefully the following information will help.

 

First of all, Medicare will only pay for the least costly piece of equipment medically necessary to get you around inside your home.   For example, if a wheelchair is being requested, medical documentation will have to state why a cane or walker would not be sufficient to meet your mobility needs within the home.  If the equipment is only needed outside the home or in the community for traveling greater distances, Medicare does not consider that to be reasonable and necessary and would deny coverage.  If this is the case, you do, however, have the option to purchase such equipment yourself if you would prefer.

 

Clinical documentation is a key factor in getting Medicare to pay for the equipment necessary to allow you independence in your residence.  This is true for any medical device billed to Medicare but is critical when it comes to mobility devices such as wheelchairs and power wheelchairs.  Lack of thorough clinical documentation will result in authorization and claim denials and will translate into repeat office visits and ultimately delay the delivery of the equipment needed.

 

So where to start?  The first step in this process is to be seen for a face-to-face evaluation by your treating physician specifically for a wheelchair assessment.  The physician’s office notes must state this is the primary purpose of the visit as well as paint a very clear picture of your mobility deficits and determine what type of equipment will be considered medically necessary by Medicare.  Not sure how to determine what would be considered medically necessary and how to rule out least costly alternatives?  Let’s review what Medicare requires to be documented.

 

MOBILITY DEFICITS:

What mobility limitations significantly impair the client’s ability to perform their activities of daily living including toileting, feeding, dressing, grooming and bathing within their home?

 

A mobility limitation is anything that prevents someone from accomplishing their activities of daily living entirely, places them at an increased risk of injury, or prevents them from completing them within a reasonable timeframe.  These deficits will need to be described in great detail including any diagnoses responsible for them.  Medicare doesn’t assume anything and if it isn’t documented, “it doesn’t exist”.

 

OTHER LIMTING FACTORS:

Are there any other conditions that restrict the individual from completing their activities in the home setting safely?  Things that could fall under this are significant cognitive impairment or lack of good judgment and/or vision but certainly not limited to these.

 

If there are other limitations that do exist, evaluator will need to describe how these can be compensated for to improve the individual’s ability to use the assistive device while performing their daily activities in a safe manner.

 

For example, someone may not be able to propel themselves in a wheelchair but may have a caregiver available to them who is willing and able to push them to where they need to go.  Again, this must be documented and not inferred.

 

SAFETY CONCERNS:

Medicare requires that documentation include information regarding if the individual or caregiver demonstrates the ability and willingness to use the equipment in a safe manner.  Considerations should include personal risk to the user as well as risk to others.  If records fail to contain this information or state that there is unwillingness on the part of the user or caregiver to use the equipment in a safe manner, even if the equipment is medically necessary, Medicare will still deny payment for such equipment.

 

LESS COSTLY EQUIPMENT:

The medical records must contain information as to why a less costly option such as a cane or walker will not sufficiently resolve the mobility deficits.  These items should be appropriately fitted to the client and trialed.  If either of these items is sufficient to allow the client to perform their activities of daily living within the home, then that item is what Medicare will pay for.  If these items do not allow the client to complete these activities safely or within a timely manner, it must be documented why this equipment would not be medically appropriate using objective measurements (i.e. strength, range of motion, etc.

 

HOME ENVIRONMENT:

The client’s home will need to be evaluated to ensure the proposed equipment will be operable within the home.  Documentation should include information stating whether the home supports the use of the equipment such as wide enough doorways and hallways and whether the bathroom is accessible while using the equipment.  Flooring surface is another thing to take into account, particularly when determining whether a client will be able to propel a manual wheelchair through the home.  Oftentimes carpeting with padding underneath proposes a problem for someone propelling a manual wheelchair and this needs to be considered as well.  Attention also needs to be given to whether the client will be able to enter and exit the home safely or if there needs to be some type of modification such as a ramp.  If there are areas of the home the client needs to access but are not accessible with the equipment, note should be made as to alternative options for the client.  It is important to realize that Medicare will deny coverage if there is not documentation stating that the home supports the equipment being provided.

 

MANUAL WHEELCHAIR:

Determination will need to be made as to whether or not the client has sufficient upper extremity function to propel a manual wheelchair throughout the home setting and allow them the ability to perform the activities of daily living during a typical day.

 

An optimally configured wheelchair (correct base, seating, weight and accessories) should be trialed in the client’s home to determine whether this is the appropriate equipment.  Deciding factors should include whether the client has appropriate strength, endurance, range of motion and coordination to propel the wheelchair.  Is there a deformity or absence of one or both upper extremities that creates a challenge to independently maneuver the equipment?  Is the client’s home designed to adequately access and maneuver in all areas necessary with surfaces compatible for wheelchair use?  Does the client have the ability to safely use the wheelchair?

 

If an optimally configured wheelchair is not medically appropriate, the documentation must state why in as much detail as possible using measurements and objective statements and not broad statements such as upper extremity weakness with no supporting findings.

 

SCOOTER/POWER OPERATED VEHCILE:

If a cane, walker, rollator or optimally configured wheelchair is not enough to meet the client’s mobility requirements, the next step to consider is whether a scooter will assist with this.  Consideration will also need to be given to whether or not the client has sufficient strength and postural stability to operate a scooter.

 

A scooter is a 3-wheeled or 4-wheeled device operated with tiller steering instead of a joystick.  Medicare will require documentation as to if the client can safely transfer on and off the scooter and maintain stability and position to adequately operate the device.  In addition, note will need to be made regarding whether the client’s home allows for adequate access to maneuver the device throughout all areas and if not how this issue will be solved.  Furthermore, the client’s ability to safely use the scooter will need to be established and recorded.

 

If the client is not a good candidate for a scooter, records will need to state why the equipment is not appropriate in as much detail as possible including strength measurements, range of motion, home environment, etc.

 

POWER WHEELCHAIR:

If all the above least-costly items are considered and ruled out as being sufficient options for the client to meet their mobility needs within the home, Medicare will then consider coverage for a power wheelchair.  A power wheelchair is operated with a joystick or alternative device and can be maneuvered in much tighter spaces than a scooter.

 

A power wheelchair can be configured to accommodate the client’s medical limitations much better than a scooter including proper seat width and height to allow for safe transfers as well as numerous seating and positioning options.  The type of power wheelchair and options should directly correlate to the client’s functional impairments.  Medicare will only provide coverage for items that are justified medically as being necessary for the client to perform their activities of daily living within the home.

 

Again, the client’s home will need to be assessed to determine whether it allows adequate access to maneuver the power wheelchair and records must contain this information.  Mention will also need to be made to whether or not the client has the ability to operate the equipment safely.

 

If the client is unable to safely and/or independently use any of the above-mentioned equipment but has a caregiver who is willing and able to provide assistance, Medicare will consider coverage for the device but only if documented in medical notes.  Typically a manual wheelchair is appropriate in this type of situation, unless the caregiver has documented limitations that doesn’t provide adequate access for the client.  However, proper documentation is key in getting any type of mobility equipment covered by Medicare.  If medical records do not contain any of the supporting information, they will deny coverage for the equipment as they will not assume anything.  The more detailed information obtained from the physician/therapist, the better chance of Medicare allowing coverage for the equipment.

 

It is very important that the physician/therapist paint a very clear picture of the client’s function.  Medicare doesn’t know anything about the client and only sees the documentation.  Information provided must be supported with objective statements including measurements.  Medicare’s philosophy is if it is not documented, it isn’t an issue.  Every client is different and a diagnosis is not enough for reviewers to determine medical need.  Medicare is looking for justification of every mobility device as well as all accessories/options with any least-costly items ruled out.  They want to know what the client’s limitations are and how the equipment will improve the mobility concern.

 

Oftentimes a doctor will not provide enough information to support medical need and a physical or occupational therapist will be necessary to provide additional clinical data.  If this is the case, be sure the information provided by the physician does not conflict with anything documented by the therapist.  This will be a cause for a denial.  The therapist’s documentation will then need to be reviewed and concurred with by the physician or will not be recognized by Medicare.

 

Medicare’s requirements for providing funding for a wheelchair or power mobility device are complex, but if proper documentation is obtained which supports the medical need for the equipment, they will cover these devices.  However, as stated many times throughout this article, documentation is critical in this process.

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