The pieces of the puzzle that make up the Centers for Medicare & Medicaid Services’ (CMS) power wheelchair and scooter policy continue to come together, as CMS’ Durable Medical Equipment Program Safeguard Contractors (DME PSCs) last week issued the new Local Coverage Determination (LCD) for power mobility devices (PMD).
The document includes definitions for the 64 new Healthcare Common Procedure Code System (HCPCS) codes issued earlier this year, as well as information on documentation, orders and funding involving “least costly alternatives.”
The LCD lists “Basic Coverage Criteria” that Medicare beneficiaries must meet to qualify for PMD, then lists additional criteria to determine whether beneficiaries qualify for power-operated vehicles (POVs/scooters) or power wheelchairs. More criteria are listed to then determine the type of scooter or power wheelchair needed.
The most basic coverage criteria requires beneficiaries to have “a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs)” defined as toileting, feeding, dressing, grooming and bathing within “customary locations” in the home. Qualifying beneficiaries must also have mobility limitations that cannot be adequately or safely addressed by using canes or crutches, and must lack the upper-extremity function, strength, range of motion, endurance or freedom from pain needed to use a manual wheelchair to accomplish MRADLs.
To then qualify for a scooter, a beneficiary must be able to transfer on and off a POV safely; be able to operate a tiller-style steering system; be able to maintain posture and position while operating the vehicle; and have the cognitive and physical abilities to operate the POV safely. The home environment must also be able to accommodate a POV, the beneficiary must be willing to use the POV, and the beneficiary’s ability to perform MRADLs must “significantly improve” through use of the POV.
The LCD divides POVs into Group 1 and Group 2, with the latter vehicles having “added capabilities that are not needed for use in the home.” The LCD therefore says, “Payment for a Group 2 POV will be based on the allowance for the least costly medically appropriate alternative.”
To qualify for a power chair, the LCD says a beneficiary must meet the “basic coverage criteria” listed above; must not be able to transfer to/from or use a scooter safely; or must have a home environment not compatible with scooter usage. In addition, the beneficiary must have the cognitive ability to use a power chair or have a caregiver who cannot propel a manual chair, but can operate a power chair; the home environment must be compatible with power chair usage; using the power chair must significantly improve the beneficiary’s ability to accomplish MRADLs; and the beneficiary must be willing to use the power chair.
The LCD also lists coverage criteria for the various power chair groups, from standard to heavy-duty, very heavy-duty and extra heavy-duty. Power chairs are also grouped by their number of power options, such as tilt or recline; performance characteristics; measurements; portability or lack of portability; design construction and ability to accept seating and positioning accessories; adjustability for growth; ability to accommodate a ventilator; and type of controller (expandable vs. non-expandable).
In addition to other previously mentioned criteria, many power chairs also require a patient evaluation by a clinician, such as an occupational or physical therapist or physician specifically trained to perform rehab wheelchair evaluations. The evaluating clinician cannot have financial ties to the wheelchair supplier.
Included in the PMD LCD are criteria required for a beneficiary to be eligible for a power-assist device used on the pushrims of a manual wheelchair. In addition to meeting basic PMD coverage criteria, a beneficiary who wants such a power-assist device must undergo an evaluation by a clinician with rehab wheelchair training and experience and must have self propelled in a manual chair for at least a year.
PMD funding is discussed in the LCD particularly in the context of “least costly alternatives”: “The fact that a PMD meets the coverage criteria specified in this policy does not necessarily mean that the item/code will be paid in full. Coverage and payment are separate determinations.”
The LCD gives several examples of when Medicare may choose to pay for lower-cost equipment, even if the coverage criteria are met. For instance, the LCD states that if a beneficiary meets the coverage criteria to qualify for a POV, but “a PWC (power wheelchair) is less costly than the POV, payment for the POV will be based on the allowance for the PWC.” The LCD states that in some cases, the least costly alternative vehicle may in fact belong to a higher performance group or have additional features the beneficiary hasn’t qualified for.
Portability and power elevating seat are among the PMD options and features that the LCD says are not covered. Backup (secondary) wheelchairs are also deemed in the LCD to be not medically necessary.
Suppliers must receive orders for PMD within 45 days of the completion of the face-to-face examination conducted by the prescribing physician, the LCD says. The order must include the beneficiary’s name; description of the product being ordered; date of the face-to-face exam; diagnoses or conditions related to the need for the PMD; length of time beneficiary will need the PMD; physician’s signature; and date of the physician’s signature. Suppliers need to use a date stamp to document the receipt date.
Specialty evaluations are required for beneficiaries to qualify for Group 2 single power option or multiple power option power chairs, any Group 3 or 4 power chair, or a power-assist device. The supplier or practitioner also must perform a home assessment to ensure the PMD can be maneuvered within the environment, through doorways and over doorway thresholds.
To download a pdf of the LCD and view all the coverage criteria, go to www.tricenturion.com/content/Doc_View.cfm?type=LCDCurr&File=power%20mobility%20devices%20lcd%20aug%202006%2Epdf.