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.....Enteral Feeding
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Phone: ...919.876.4336
.....Fax: .......919.876.4485
.....Address: 3430 Tarheel Drive,
...................Suite 104
...................Raleigh, NC 27609


 
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WHEELCHAIRS
MANUAL WHEELCHAIR BASE
Indications and Limitations of Coverage and/or Medical Necessity
Documentation Requirements
MOTORIZED/POWER WHEELCHAIR BASE
Indications and Limitations of Coverage and/or Medical Necessity
Documentation Requirements

 

MANUAL WHEELCHAIR BASE

Indications and Limitations of Coverage and/or Medical Necessity

A wheelchair is covered if the patient's condition is such that without the use of a wheelchair, he would otherwise be bed or chair confined. An individual may qualify for a wheelchair and still be considered bed confined. This basic requirement must be met for coverage of any wheelchair.

A standard hemi-wheelchair (K0002) is covered when the patient requires a lower seat height (17" to 18") because of short stature or to enable the patient to place his/her feet on the ground for propulsion.

A lightweight wheelchair (K0003) is covered when a patient:

a) Cannot self-propel in a standard wheelchair using arms and/or legs and

b) The patient can and does self-propel in a lightweight wheelchair.

A high-strength lightweight wheelchair (K0004) is covered when a patient meets the criteria in (1) and/or (2):

1) The patient self-propels the wheelchair while engaging in frequent activities that cannot be performed in a standard or lightweight wheelchair.

2) The patient requires a seat width, depth, or height that cannot be accommodated in a standard, lightweight or hemi-wheelchair, and spends at least two hours per day in the wheelchair.

Coverage of an ultralightweight wheelchair (K0005) is determined on an individual consideration basis.

A heavy duty wheelchair (K0006) is covered if the patient weighs more than 250 pounds or the patient has severe spasticity.

An extra heavy duty wheelchair (K0007) is covered if the patient weighs more than 300 pounds.

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Documentation Requirements

An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available to the DMERC upon request.

A Certificate of Medical Necessity (CMN), which has been completed, signed, and dated by the treating physician, must be kept on file by the supplier and made available to the DMERC on request. The CMN for manual wheelchairs is HCFA Form 844. The initial claim must include a copy of the CMN.

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MOTORIZED/POWER WHEELCHAIR BASE

Indications and Limitations of Coverage and/or Medical Necessity

A power wheelchair is covered when all of the following criteria are met:

1) The patient's condition is such that without the use of a wheelchair the patient would otherwise be bed or chair confined, and;

2) The patient's condition is such that a wheelchair is medically necessary and the patient is unable to operate a wheelchair manually and;

3) The patient is capable of safely operating the controls for the power wheelchair.

A patient who requires a power wheelchair usually is totally nonambulatory and has severe weakness of the upper extremities due to a neurologic or muscular disease/condition.

If the documentation does not support the medical necessity of a power wheelchair but does support the medical necessity of a manual wheelchair, payment is based on the allowance for the least costly medically appropriate alternative.

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Documentation Requirements

It is expected that the patient's medical records will reflect the need for the care provided. The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available to the DMERC upon request.

An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available to the DMERC upon request.

A Certificate of Medical Necessity (CMN), which has been completed, signed, and dated by the treating physician, must be kept on file by the supplier and made available to the DMERC on request.

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