Complex Power Wheelchair

Complex Power Wheelchair
Face-To-Face Partnership Documentation Checklist


A)   Specialty licensed/certified (LCMP) Examination (Physician Referral to Therapist)

  1. The patient has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a physical therapist or occupational therapist that documents the medical necessity for the wheelchair and it special features. 
  2. The physician will review the written report of the LCMP examination, to sign and date that report, and state concurrence or any disagreement with the LCMP examination.  
B)    Medical Records (Report of the face-to-face mobility examination written in medical records)
  1. What is the patient’s mobility limitation and how does it interfere with the performance of activities of daily living?
  2. Why can’t a cane, walker, or POV meet this patient’s mobility needs in the home?
  3. Does this patient have the physical and mental abilities to operate a power wheelchair safely in the home?
  4. A physical examination was performed relevant to the patients mobility needs.
  5. The patient’s mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity.
  6. Patient does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair.
  7. Patient’s functional mobility deficit can be sufficiently resolved by the use of a power wheelchair.
  8. Delineate the history of events that led to the request for the PMD.
  9. Copy of any History of the present condition (s) and past medical history that is relevant to mobility needs.
C)    PMD Prescription (Seven Element Order Form)
  1. Beneficiary's name.
  2. Description of the item.
  3. Date of completion face-to-face examination.
  4. Diagnosis and conditions that the PMD is expected to modify.
  5. Length of need.
  6. Physician signature.
  7. Date the prescription was written.  
D)   Detailed Written Order (Provided by Supplier after examination)
  1. Beneficiary name.
  2. Detailed description of the item (s) to be provided.
  3. Treating physician’s signature and date order signed.
  4. Start date of order (if the start date is different than the signature date).
Sample Medical Records (Report of the face-to-face mobility examination)   
The face-to-face mobility examination was performed on (John Smith - March 1, 2011). A physical examination was performed relevant to the patients mobility needs by a therapist, his neurological diagnosis of (CP, MS-MD-Post Polo-Stroke) severely impair the patient’s ability to ambulate and interferes with the ability to perform activities of daily living in his home. 
 
The patient does not have the (strength, balance or tone) to use a cane or walker safely and does not have sufficient upper extremity function to propel a manual wheelchair or operate a POV. The patient’s functional mobility deficit can be sufficiently resolved safely by the use of a power wheelchair.