Clinical Criteria Algorithm: Wheelchair Prescribing for Medicare Beneficiaries
- By Andria Pritchett
- Apr 21, 2018
What do I need to document for Medicare? This is the number one question asked by countless clinicians when faced with prescribing Mobility Assistive Equipment (MAE) for their clients.
Clinical documentation sets your client’s order up for successful outcomes when completed to Medicare’s documentation standards. This is true across MAE, but in particular with Complex Rehab Technology orders, good, objective and thorough clinical documentation is the key to authorization and payment of your client’s Medicare claim. Authorization denials, claim denials and reworks translate to repeat visits, more documentation time, and ultimately, delays for the client.
What are these standards?
In addition to National and Local Coverage Determinations, Policy Articles and an assortment of other resources, CMS provides a nine-step clinical criteria algorithm for wheelchair prescribing (www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/id143c.pdf) to assist clinicians in determining what type of equipment would be considered medically necessary by Medicare for their patients with mobility deficits.
Not sure what equipment would be considered medically necessary and how to rule out least costly alternatives? Let’s take a brief look into the nine-step clinical criteria algorithm.
1. Mobility Limitation
Does the client have a mobility limitation that significantly 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? Medicare will only cover mobility assistive equipment that is needed for primary use in the home.
If the equipment is needed for outside, or community distances only, Medicare does not consider that to be reasonable and necessary. A mobility limitation is one that:
• Prevents the client from accomplishing the MRADLs entirely; or
• Places the client at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to participate in MRADLs; or
• Prevents the client from completing the MRADLs within a reasonable time frame.
2. Other Limitations
Are there other conditions that limit the client’s ability to participate in MRADLs at home?
• Examples -- significant impairment of cognition or judgment and/or vision.
• If no other limitations are present, skip to step 4.
3. Are other limitations compensated?
If these other limitations exist, can they be compensated sufficiently so that the MAE can be reasonably expected to significantly improve the client’s ability to perform or obtain assistance to participate in MRADLs in the home?
• Example -- a caregiver may be compensatory, if consistently available in the client’s home and willing and able to safely operate the equipment.
• This must be documented, it cannot be inferred.
4. Capable of safe use?
Does the client or caregiver demonstrate the capability and the willingness to consistently operate the MAE safely?
• Safety considerations include personal risk to the client as well as risk to others.
• Documenting that a client and/or caregiver is unwilling to utilize the equipment, even when the equipment is a medical necessity, will still result in a denial.
Can the functional mobility deficit be sufficiently resolved by the prescription of a cane or walker?
• The cane or walker should be appropriately fitted to the client for this evaluation.
• Assess the client’s ability to safely use a cane or walker.
• If yes, then a cane or walker is the least costly alternative.
• If no, then document why, as objectively as possible, (i.e., strength measurements, range of motion, etc.), this equipment is not medically appropriate.
6. Home Environment
Does the client’s typical environment support the use of manual wheelchairs, scooters/power-operated vehicles (POVs) and power wheelchairs?
• Determine whether the client’s environment will support the use of these types of MAE.
• Can the client gain access to the areas of the home necessary to complete or participate in their MRADLs?
• Keep in mind such factors as the home’s physical layout, surfaces, and obstacles, which may render MAE unusable in the client’s home.
7. Manual Wheelchair
Does the client have sufficient upper-extremity function to propel a manual wheelchair in the home to participate in MRADLs during a typical day?
• The manual wheelchair should be optimally configured (seating options, wheelbase, device weight, and other appropriate accessories) for this determination. Limitations of strength, endurance, range of motion, coordination, and absence or deformity in one or both upper extremities are relevant.
• The client’s home should provide adequate access, maneuvering space, and surfaces for the operation of a manual wheelchair.
• Assess the client’s ability to safely use a manual wheelchair.
• If the optimally configured manual wheelchair is not medically appropriate, then document why as objectively as possible -- avoiding subjective, broad statements, such as “Patient cannot self-propel an optimally configured manual wheelchair due to upper-extremity weakness” with no objective findings to support.
Does the client have sufficient strength and postural stability to operate a Power Operated Vehicle (POV) or scooter?
• A POV is a 3-wheeled or 4-wheeled device with tiller steering. The client must be able to safely transfer on and off the POV and maintain stability and position for adequate operation.
• The client’s home should provide adequate access, maneuvering space, and surfaces for the operation of a POV.
• Assess the client’s ability to safely use a POV.
• If they are not a candidate, then document why, as objectively as possible (i.e., strength measurements, range of motion, etc.), this equipment is not medically appropriate.
9. Power Wheelchair
Are the additional features provided by a power wheelchair needed to allow the client to participate in one or more MRADLs?
• The pertinent features of a power wheelchair compared to a POV are typically controlled by a joystick or alternative input device, lower seat height for transfers, and the ability to accommodate a variety of seating and positioning needs.
• The type of wheelchair and options provided should be appropriate for the degree of the client’s functional impairments.
• The client’s home should provide adequate access, maneuvering space, and surfaces for the operation of a power wheelchair.
• Assess the client’s ability to safely use a power wheelchair.
• If the client is unable to independently use a power wheelchair, and if there is a caregiver who is available, willing, and able to provide assistance, a manual wheelchair is appropriate. A caregiver’s documented inability to operate a manual wheelchair can be considered in covering a power wheelchair so that the caregiver can assist the client.
• Paint a picture of your client’s function on a typical day. Medicare doesn’t see your client; they only see your documentation. Be as objectively descriptive as possible.
• Just like you’ve heard thousands of times -- if it’s not documented, it didn’t happen. Medicare’s take on the same principle is that if it’s not documented, it’s not taken into consideration during their review process. Every client is different, each patient presents differently, so Medicare reviewers cannot infer medical need based upon diagnosis...even ALS.
• Medicare is looking for justifications, not definitions. When Medicare reviews documentation, they aren’t looking for what the equipment is -- they want to know how it will impact your client and their function specifically.
• Be on the look-out for conflicting information in your documentation -- this can cause denials and reworks.
Understanding Medicare’s Clinical Criteria Algorithm for Wheelchair Prescribing is a big piece of the complex puzzle of Medicare Funding for Complex Rehabilitation Technology.
As you evaluate your client’s mobility deficits and functional limitations, it can be very helpful to utilize the Clinical Criteria Algorithm as a high-level blueprint for prescribing Medicare-funded mobility assistive equipment with success. Following these nine steps, and prescribing and documenting accordingly, will increase the likelihood of approval with Medicare. This can decrease the time that you spend documenting repeat visits to address denials, and more importantly, approvals translate to decreased wait time for your client, our customer.
CMS: “An Algorithmic Approach to Determine if Mobility Assistive Equipment Is Reasonable and Necessary for Medicare Beneficiaries with a Personal Mobility Deficit (CR3791 - Mobility Assistive Equipment(MAE)”