In May 2022, the OIG conducted a nationwide audit of Power Mobility Device (PMD) repairs for Medicare beneficiaries. The findings were not favorable; the audit revealed CMS paid 20% of durable medical suppliers incorrectly during the audit period of October 01, 2018- September 30, 2019. This was a total of $8 million in device repairs out of $40 million paid by CMS. The finding stated these claims did not comply with federal requirements, specifically documentation for repairs, labor time associated with the repair, and other compliance issues that may not have been reasonable and necessary.

These errors also cost Medicare beneficiaries; submitted charges that may not have been reasonable and necessary resulted in $20,692 in questionable Medicare payments and $5,278 in associated beneficiary coinsurance payments. Several providers may have been issued a demand for payment from Medicare. We gathered information in this article to assist providers and suppliers in keeping the payments received, protecting beneficiaries, and remaining compliant.   

What is Mobility Assistive Equipment
Mobility Assistive Equipment includes most power mobility devices such as power-operated vehicles (scooters and power wheelchairs, see Types of Devices with options and accessories for more information.) This article will cover the basic coverage criteria required by CMS.

If the accumulative cost to repair a patient’s power mobility device exceeds 60% of the cost to replace the device, provide a new device.

The Power Mobility Devices booklet explains how to properly document and bill for power mobility devices (PMDs); we have added the steps here. 

Required Face-to-Face Encounter
Step 1: See the Patient Face-to-Face.  A face-to-face visit is an in-person visit or telehealth visit between you and the patient. If you use telehealth for the visit, you must meet telehealth service requirements to get paid. You must conduct and document the encounter for us to cover a power mobility device. Be sure to gather all information about diagnosing, treating, or managing the patient’s condition that requires the power mobility device. This visit must happen within 6 months prior to ordering a device.

During the visit:

• Evaluate and treat the patient for their medical conditions
• Tailor your evaluation to the patient’s conditions
• Determine if a power mobility device is a necessary part of their treatment plan
• Document that a mobility exam was a major reason for the visit

Perform a mobility exam, including a physical exam and assessment of their mobility-related activities of daily life.

Answer these questions about the patient:

1. What’s their mobility limitation?
2. Does their mobility interfere with them performing activities of daily living?
3. Why won’t a cane or walker meet their needs at home?
4. Why won’t a manual wheelchair meet their needs at home?
5. Why won’t a power-operated vehicle, if applicable, meet their needs at home?
6. Are they physically and mentally able to operate a power wheelchair safely in the home?

You don’t need to do a new face-to-face visit in these limited cases:

• The power mobility device is replaced during the 5-year useful lifetime of the item, and it’s in the same Medicare Performance Group previously covered.
• You’re ordering power mobility device accessories that aren’t included in the required face-to-face encounter and written order prior to delivery lists. See Types of Devices for more information.

Step 2: Update their medical record. After the face-to-face visit, create a detailed narrative that includes all relevant information about the items below. Try to paint a picture of the patient’s functional abilities and limitations on a typical day. Include as much objective information as possible.  You don’t need to include elements if they don’t apply (for example, don’t include respiratory information if a patient doesn’t have a respiratory illness or injury). Consider including these details about the patient:

Present and past medical history of mobility needs, including:

• Symptoms and diagnoses that make it difficult for them to move
• Medications or other treatments
• Increased difficulty moving over time
• Other related ambulatory problems
• Description of their home
• Confirmation that the patient can do activities of daily living at home
• How far and fast they can walk without stopping
• If they need help standing up from a seat without help
• What they currently use to help them get around
• Any changes that now require them to use a power mobility device

Physical exam that focuses on the patient’s body systems that are responsible for ambulatory difficulty or impact their ambulatory ability, including:

• Height
• Weight
• Cardiopulmonary exam results
• Musculoskeletal exam results
• Neurological exam results, like balance
• Respiratory, cardiovascular, or neuromusculoskeletal information
• Other medical conditions, you can include other relevant details, even if they aren’t on this list.

In addition to the detailed narrative, be sure that the patient’s medical record supports the medical need of a power mobility device in their home. Include lab tests, X-rays, and any other diagnostic tests that show their mobility needs.

Step 3: Send a Standard Written Order (Prescription). Send a prescription, known as a standard written order or SWO, that shows the patient’s need for a power mobility device. Send this to the DMEPOS supplier within 6 months of the face-to-face visit. When the DMEPOS supplier gets the order, they can submit the claim. For some items, like power wheelchairs, you must send the order to the DMEPOS supplier before they deliver the item. Tip: You must do the face-to-face visit and the SWO. You can’t write the SWO if another practitioner sees the patient for the face-to-face visit.

The SWO must include:

• The patient’s name or MBI
• A general description of the item, like brand name or model number, HCPCS code, or HCPCS code narrative
• Quantity if applicable
• Order date
• Your name or NPI
• Your signature

Step 4: Make a Prior Authorization Request.  Power wheelchairs require an item review before delivery to the patient. A Medicare Administrative Contractor (MAC) will review the prior authorization request, then tell you if the item is approved (“affirmation”) or not approved (“non-affirmation”). If you don’t get prior authorization before delivery, Medicare will deny the claim. This request can be completed by either you or the DMEPOS supplier, not both. If a power mobility device isn’t on the prior authorization list, submit the order to the DMEPOS supplier before you submit a claim. Don’t submit it before delivery.

Step 5: Complete a Home Assessment. Perform an on-site patient home assessment and write a report. The report must show the patient can safely use the power mobility device, considering these home details: physical layout, doorway width, doorway threshold, and surfaces. You or the DMEPOS supplier must complete the on-site visit. This can happen either before or during the delivery of the power mobility device.

Step 6: Review all Information to Avoid Improper Payments. It’s important to work together with DMEPOS suppliers to avoid improper payments.

Be sure to:

• Complete steps 1–5 above
• Double-check each patient’s medical record and all necessary documents
• Know the common causes of improper payments to avoid spending time and money to correct and resubmit the information. Power mobility devices, related options, accessories, and repairs have a high, improper payment rate.

To avoid improper payments for power mobility devices, be sure that:

• Medical records are complete
• Medical records show the devices are medically necessary
• No information or documents are missing, including your signature on the DMEPOS supplier form

To avoid improper payments on accessories, repairs, and replacements, be sure to:

• Show a device replacement is necessary
• Show repairs are reasonable, necessary, or meet the requirements
• Document labor time adequately
• Show that DMEPOS suppliers must provide repair warranties
• Specify that wheelchair repair costs can’t exceed a certain amount over a device’s 5-year lifetime

What DMEPOS Suppliers Need to Do

Step 1: Check the Standard Written Order. Be sure you have a written, signed, and dated standard written order (SWO) before you deliver a power mobility device.

Step 2: Make a Prior Authorization Request. Power wheelchairs require an item review before delivery to the patient. A Medicare Administrative Contractor (MAC) will review the prior authorization request, then tell you if the item is approved (“affirmation”) or not approved (“non-affirmation”). This request can be completed by either you or the practitioner, not both.

Step 3: Complete a Home Assessment. Perform an on-site patient home assessment and write a report. The report must show the patient can safely use the power mobility device, considering these home details: physical layout, doorway width, doorway threshold, and surfaces. You or the ordering practitioner must complete the on-site visit. This can happen either before or during delivery of the power mobility device.

Step 4: Keep Documents. Keep these documents and be able to provide them if requested:

• SWO
• Face-to-face visit supporting documents
• Written home assessment report
• Proof of delivery
• Records describing repairs, including a detailed explanation that justifies components or parts replaced and labor time to fix the item

. Follow these steps to bill for PMDs:

• Obtain the Standard Written Order (SWO)
• Make a prior authorization request
• Complete a home assessment
• Keep the following documents: SWO, face-to-face visit supporting documents, written home assessment report, and proof of delivery
• Review all information to avoid improper payments
  
  

Billing 
Physicians submitting claims on and after April 1, 2006, must bill the E/M and the G0372 code on the same claim.

• G0372- Physician service required to establish and document the need for a power mobility device