CMS Publishes Face-to-Face Exam Checklist

A new Medicare Learning Network (MLN) article seeks to improve compliance with Medicare power mobility device (PMD) documentation requirements.

Specifically, the article gives physicians and other power wheelchair and scooter prescribers a checklist that can be used during Medicare's required face-to-face examinations. But the MLN article also says use of the checklist is voluntary "and does not ensure Medicare payment for a PMD, even if signed and dated."

A face-to-face examination between the physician or other prescribing healthcare professional and the Medicare beneficiary is mandatory as part of Medicare's PMD policy. As the article states, "An in-person visit between the ordering physician and the beneficiary must occur. This visit must document the decision to prescribe a PMD."

The prescribing physician must also perform a medical evaluation. "The evaluation," the article says, "must clearly document the patient's functional status with attention to conditions affecting the beneficiary's mobility and their ability to perform activities of daily living within the home. This may be done all or in part by the ordering physician."

After the face-to-face exam is completed, the article says, the prescribing physician can write the PMD prescription.

The new MLN article includes a number of tips for PMD providers, including two examples of medical record documentation - one example that "may result in a claim denied" and the other with significantly more "detail and support."

An attachment, called "Sample Checklist for the PMD Examination," suggests a list of details that could be included in the patient's medical history and documentation, including:

  • Signs/symptoms that limit ambulation
  • Diagnoses that are responsible for these signs/symptoms
  • Medications or other treatment for these signs/symptoms
  • Progression of ambulation difficulty over time
  • Other diagnoses that may relate to ambulatory problems
  • How far the patient can ambulate without stopping and with what assistive device
  • Pace of ambulation
  • What has changed in the patient's condition that now requires the use of a PMD
  • Reason for inability to use a manual wheelchair, such as assessment of upper body strength
  • Description of the home setting, including the ability to perform activities of daily living in the home

To download the MLN article and checklist, click HERE.

About the Author

Laurie Watanabe is the editor of Mobility Management. She can be reached at lwatanabe@1105media.com.

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