FAQ for Power Wheelchairs
What is Mobility Assistive Equipment (MAE)?
MAE includes all durable medical equipment devices that assist individuals by augmenting or restoring mobility skills within their home. For example: canes, crutches, walkers, all manual wheelchairs, and power mobility devices (PMD).
What are Power Mobility Devices (PMD’s)?
This includes power scooters (power operated vehicles or POVs) and power wheelchairs.
Why is an evaluation by a licensed/certified medical professional (such as an OT or PT who holds specific training and experience) needed for certain power wheelchairs?
Individuals who need complex rehab mobility and seating devices often have some type of neurological disease or impairments related to an injury (e.g. cerebral palsy, stroke, spinal cord injury, multiple sclerosis). Their mobility and seating needs often require “high end” or “complex rehab” devices that aren’t part of common clinical practice for all therapists. Therefore, specific education and training are required for therapists who want to become wheelchair specialists. Knowing how to match an individual’s functional skills to the appropriate equipment requires an advanced level of knowledge. Having specific training and experience ensure therapists will make the appropriate equipment recommendations to meet an individual’s needs.
What are MRADLs? Are they different from ADLs and IADLs?
Mobility Related Activities of Daily Living or MRADLs are defined as any activities of daily living that require a mobility device to augment or restore an individual’s independence. They’re no different than ADLs or IADLs defined by the therapy profession including, feeding, grooming, dressing, bathing, toileting, meal preparation, laundry, etc. These activities must be performed within the home if the mobility device is to be covered by Medicare, under its “in the home” requirement.
What is an ATP?
An ATP or assistive technology professional, who is also a clinician, is one that is involved in the clinical analysis, evaluation and recommendation of an individual’s assistive technology needs. This definition includes fitting and training in the use of particular devices that augment or restore function or ADLs. ATPs may include licensed medical professions, occupational, physical and speech therapists.
An ATP, who is employed by a durable medical equipment company, is one that helps individuals acquire and use appropriate assistive technology devices that augment or restore function. These ATPs sell and service rehab equipment, assistive technology, and commercially available products and devices. Both types of ATPs work together as a team.
Is the DME provider required to be a RESNA – certified ATP by Medicare?
Effective April 2008, Medicare requires a durable medical equipment provider (DME) to employ a RESNA – certified ATP who specializes in wheelchairs, and provides direct, in – person recommendations for and evaluation of the patient’s wheelchair selection. This rule holds for power wheelchairs in the category of Group 2 (single power option) and above and Group 3 (complex rehab). It is not required for power scooters (POV).
Is a therapist required to be a RESNA – certified ATP by Medicare?
No. However, Medicare does require any written comprehensive evaluations for complex rehab power mobility devices and specialty seating systems document the medical necessity for the wheelchair and its special features, and be completed by a licensed/certified medical professional (LCMP), such as a PT, OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations. These qualifications are met by any therapist holding the ATP credential. The PT or OT must have no financial ties with the DME provider.
What is RESNA
RESNA (Rehabilitation Engineering and Assistive Technology Society of North America) is the premier professional organization dedicated to promoting the health and well-being of people with disabilities through increasing access to technology solutions. The ATP certification through RESNA ensures that professionals attain a certain common level of competence in their ability to perform direct consumer related services in Assistive Technology. These standards aim to enhance service provision to people with disabilities who are seeking technology applications to maximize their ability to function in their environment.
Why is a therapist’s Letter of Medical Necessity (LMN) important documentation for rehab power wheelchairs and specialty seating devices? Why can’t a therapist’s evaluation stand alone when it documents pertinent information about a patient’s physical and functional impairments?
The LMN document is not required by Medicare, but most rehab equipment suppliers will ask for some type of additional documentation for complex rehab wheelchairs and seating systems. Clinicians should document their evaluation results in layman’s terms to “paint the picture” for Medicare. In addition, written documentation should be legible and clear. Do not assume Medicare reviewers will put all the pieces together. As stated in the Medicare guidelines, the written comprehensive evaluation, “must document the medical necessity for the wheelchair and its special features.” A therapist’s evaluation can stand alone IF it reflects a clear picture of why the wheelchair and all its components are medically necessary.
An LMN gives the therapist a chance to specifically state why the recommended power wheelchair, seating system and accessories are medically necessary. In addition, it should review more specific information about how the individual’s functional impairments can be augmented or restored by the recommended equipment.
Finally, an LMN should be signed by the ordering physician to ensure he or she concurs with the therapist’s recommendations.
Does Medicare pre – approve power mobility devices?
Medicare does require prior authorization for some power wheelchair bases. Once the therapist determines which power base best fits your needs and what you qualify for through Medicare, the therapist and DME supplier will determine if prior authorization is required. Other equipment may be eligible for what is called an Advanced Determination of Medicare Coverage (ADMC). Only certain types of equipment are eligible for ADMC and it is not a guarantee of payment.
How can I be sure my patient or family member is getting the proper manual or power mobility device?
First, take into consideration that the 1 – 800 power wheelchair and scooter commercials on TV are advertisements. These ads make operating these devices look all too easy, and the long – term medical outcomes of an improper mobility device may be detrimental to individuals. The ads don’t consider specific individual mobility and seating needs. Most of the time, a salesman will show up at the door or call and want only one thing…..a sale. Service after the sale can be questionable and repairs may take weeks because the equipment providers are not local. Find out more details about the 1 – 800 companies and compare them to local equipment providers before buying.
Second, only use the internet as a resource for education about what is available on the market. Then, call a local equipment provider to ask questions. Buying from the internet can be detrimental if the patient, family member or clinician is unfamiliar with the equipment. Some internet sale items are not specifically made for individual needs. Rather, they are “one size fits all” items. And some internet items offer more features and adjustments on a piece of equipment that only an equipment specialist should mess with. It’s not worth risking harm just to save a buck.
Your best approach is to contact a local DME provider who maintains either a specialist on staff or contracts with a specialist who can properly assess your needs.
Is there a rule that states Medicare will only pay for new equipment every 5 years? Does Medicare automatically replace equipment after 5 years of ownership?
According to the Medicare Benefit Policy Manual, carriers may determine the reasonable useful lifetime of equipment, but in no case can be less than 5 years. Replacement due to wear is not covered during the reasonable useful lifetime of the equipment. During the reasonable useful lifetime, Medicare does cover repairs up to the cost of replacement (but not actual replacement) for medically necessary equipment.
Depending on the Medicare jurisdiction (Illinois falls under Medicare jurisdiction B, Iowa and Missouri fall under Medicare jurisdiction D) and its local coverage determination, replacement of equipment may be accomplished in one of the following situations:
The equipment has irreparable wear and deterioration from day-to-day usage over time and a specific event cannot be identified. Replacement due to irreparable wear takes into consideration the reasonable useful lifetime of the equipment. A new physician’s order and documentation is necessary to reaffirm the medical necessity of the item to be replaced.
The equipment has irreparable damage due to a specific accident or to a natural disaster (e.g., fire, flood). A new physician’s order and documentation is necessary to reaffirm the medical necessity of the item to be replaced.
The equipment no longer meets the beneficiary’s medical and functional needs because he or she suffered a significant change in their medical condition. A new physician’s order and documentation is necessary to affirm the medical necessity of the item to be replaced.
Durable medical equipment suppliers must gather all supporting documentation to justify replacement of equipment before and after the 5 year life expectancy.
The useful lifetime of equipment is based on when the equipment is delivered to the beneficiary, not the age of the equipment.
The Medicare Benefit Policy Manual does not state that equipment is routinely replaced every 5 years.
Will Medicare pay for an outpatient OT or PT Evaluation under Medicare Part B while a patient is receiving Home Health Services under Medicare Part A?
No. Home health agencies can have a contract arrangement with the outpatient provider to pay for the specialty outpatient OT or PT service. Home health agencies receive payment from Medicare Part A under consolidated billing (one lump sum payment). Outpatient therapy services receive payment from Medicare Part B on a fee for service basis. Therefore, Medicare will not pay for services under both types of payment systems during the same treatment period or dates of service.