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Scooter - Customer Checklist

West Palm Beach: 561-964-6767

Boynton Beach: 561-733-2331

www.AtlanticHP.com

               

 

The checklist below is derived from Medicare’s Coverage criteria for a Scooter (POV). Without the below criteria being fully and legible documented in the physician's chart notes and Rx, Medical justification has not been met.

 

Checklist for Face-to-Face Examination Chart Notes for a Scooter (POV)

 

Do the Medical records relevant to mobility needs 1) indicate and 2) support: 

Reason: ‘Mobility evaluation for a: Powered Mobility Device, PMD, Scooter or POV

▢ Any other reason, or “follow-up” is not acceptable

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

▢ Distance beneficiary can walk without stopping

▢ Pace of ambulation

▢ History of falls, including frequency, circumstances leading to falls

Physical examination relevant to mobility needs:

▢ Height and weight

▢ Cardiopulmonary examination

▢ Arm and leg strength tests and range of motion tests. 

Neurological examination:

▢ Gait

▢ Balance and coordination

Mobility Assessment: 

▢ Description of the mobility limitations and how it 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 -  

▢ prevents the beneficiary from accomplishing an MRADL entirely;  - or - 

▢ places beneficiary at a reasonably determined risk secondary to the attempts to perform an MRADL;  - or – 

▢ prevents beneficiary from completing an MRADL within a reasonable amount of time

▢ Beneficiary’s mobility limitation cannot be sufficiently and safely resolved by use of appropriately fitted cane or walker;

AND -  

▢ Beneficiary does not have sufficient upper extremity function to self-propel an optimally configured manual wheelchair in the home 

- AND -  

▢ Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities; 

- AND -  

▢ Beneficiary’s mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) are sufficient for safe mobility; -- Beneficiary’s weight is less than or equal to weight capacity of scooter provided; 

- AND -  

▢ Beneficiary’s home provides adequate access; or differ to Provider’s Home Assessment  

- AND -  

▢ Use of a Scooter POV will significantly improve the beneficiary's ability to participate in MRADLs and beneficiary will use it in the home.; 

- AND -  

▢ Beneficiary has not expressed an unwillingness to use a PWC in the home.

 

7 Element Order - 

▢ beneficiary's name, 

▢ item of DME ordered “SCooter”, “POV”, or Power Mobility Device 

▢ Length of Need. 

▢ Date of the Face to Face Examination

▢ Date of the order 

▢ Diagnosis or Dx Code

▢ Legible Signature of the ordering practitioner, or signed over printed name. 

 

Statutory Timing Requirements

▢ Did the Supplier Receive within 45 days the 7 Element Order. 

▢ Did the Supplier Receive within 45 days the F2F Examination Report. 

▢ Will Delivery of the Power Wheelchair be before 120 days after the F2F

 

Physicians: We invite you to create the Face to Face Chart note through DMEevalumate.com

Medicare Compliant paperwork the first time!

Please fax your referrals and documentation to 561-290-1434

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