Professional Documents
Culture Documents
Claims for All Single and Multiple Group 2 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.
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DOCUMENTATION CHECKLIST
Group 2 Single Power Option Wheelchairs (K0835 – K0840)
Group 2 Multiple Power Option Wheelchairs (K0841 – K0843)
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 2 Single Power Option Wheelchairs (K0835 – K0840)
Group 2 Multiple Power Option Wheelchairs (K0841 – K0843)
3
DOCUMENTATION CHECKLIST
Group 2 Single Power Option Wheelchairs (K0835 – K0840)
Group 2 Multiple Power Option Wheelchairs (K0841 – K0843)
General Information:
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.
Billing Reminders:
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