Understanding Medical Necessity for Standard Power Mobility

Stepping into a power mobility device (PMD) evaluation is an exciting opportunity to make a meaningful difference in a patient’s independence and quality of life. While there are regulations to understand, clinical details to capture, and documentation requirements to follow, the process becomes more manageable when you know what to look for.

This article outlines the standards of medical necessity justification for payers, especially Medicare. Meeting documentation standards significantly decreases administrative time spent on gathering additional documentation or requesting corrections.

Ensuring the Face-to-Face Encounter is Well Documented

A face-to-face encounter is an in-person documented visit meant to diagnose, treat, or manage the patient’s clinical condition and is typically completed by the treating or ordering practitioner. During the visit, the treating or ordering practitioner should clearly document why the patient needs PMD equipment and why the payer should supply payment for the equipment. The following are a few things the document should address to justify a need:   

• The face-to-face exam was the primary reason for the visit

• Detailed evaluation and tailored treatment for the patient’s medical conditions

• Why the PMD is medically necessary

• How the PMD plays a role in the patient’s overall treatment plan

Accurately Address the Patient's Needs During the Face-to-Face

When outlining the medical necessity of a PMD for insurance, the treating or ordering practitioner may use a structured checklist to determine which mobility device is appropriate for the patient. This helps determine why lower-level devices (i.e., canes or walkers) may not meet the patient’s needs and why an alternative recommendation can better support the patient’s mobility needs.

During the face-to-face evaluation, it’s important to remember that good documentation isn’t just about checking boxes; it’s about accurately representing the patient’s medical necessity. Be sure the face-to-face evaluation addresses the following questions:

• What’s the patient’s medical diagnosis?

• How does their condition affect their ability to complete mobility-related activities of daily living (MRADLs)?

• Why won’t a cane or walker meet their home mobility needs?

• Why won’t a manual wheelchair or power-operated vehicle meet their home mobility needs?

• Has the patient had a history of falls, fatigue, or energy exertion?

• Does the patient have the physical and mental capabilities to safely operate a PMD at home?

• Why is a powered mobility device medically necessary?

Demonstrating medical necessity is often the deciding factor for an insurance provider to approve or deny a claim for mobility equipment.

Review the Face-to-Face Documents Thoroughly Before Submitting

The face-to-face encounter must be adequately documented in a detailed narrative note. It should contain relevant information about the patient’s medical condition as it relates to their mobility independence in completing MRADLs, such as:

• Symptoms and diagnoses limiting ambulation

• Medications or other symptom treatment

• Progressive ambulation difficulty over time

• Other related ambulatory problem diagnoses

• How far can they walk without stopping

• How walking a few feet may negatively impact them

• What they currently use for ambulatory assistance

• What changed that now requires the need for a PMD

• Standing up without help from a seated position

• Patient’s medical record documenting their ability to perform MRADLs in the home

• Patient’s weight and height

• Cardiopulmonary exam

• Musculoskeletal exam (arm and leg strength and range of motion)

• Neurological exam (gait, balance, and coordination)

• Important lab tests, X-rays, or other diagnostic tests about their mobility needs

Common PMD Documentation Pitfalls (and How to Avoid Them)

The Office of Inspector General (OIG) released a report in the fall of 2021 that found more than 60% of power wheelchair claims lacked sufficient documentation to determine medical necessity or were deemed medically unnecessary. These mistakes led to patients being improperly fitted for equipment, an increase in the amount of care needed downstream, and an estimated $4 billion in equipment recovery costs.

A few common mistakes identified by the OIG that led to high rates of fraud, waste, and abuse are:

• Submitting documentation that doesn’t support the need for equipment

• Submitting documentation that lacks sufficient information to determine medical necessity

• Missing dates and signatures from the referring doctor or physician

• Incorrectly listing diagnosis codes

• Crossing out errors without dating and initialing who and when the error was crossed out

• No notes indicating when the face-to-face evaluation occurred, and what the outcome was

• Not sharing if the visit was a telehealth visit, and what the outcome was

• Making too many addenda to the original paperwork

• Getting the face-to-face evaluation signed by anyone other than the physician who performed the evaluation

Accurately documenting medical necessity ensures patients can maintain their level of independence, perform activities of daily living, reduce fall rates, prevent the development of pressure sores, stay in their homes, and reduce costs for the healthcare system downstream.

Submitting Medical Necessity Documentation

Rehab Medical staffs more than 50 of the nation's top insurance specialists, making it the company's second largest department. This highly qualified team is divided into five distinct stages: Verification, Follow-Up, Review, Submissions, and Approvals. Each stage of the process has a specific area of focus, but they all work directly and efficiently with the patient and practitioner to ensure the requested mobility solution meets the patient's needs and is covered by their insurance.

When it comes to submitting documents of medical necessity, Rehab Medical's submissions team will play a major role in ensuring all documents are accurate and in compliance with applicable state and federal regulations. Given this is a very important step of the process, employees on this team are well-trained and educated on all insurance requirements and guidelines required for a patient to be approved by traditional insurance companies such as Medicare and Medicaid.

The team starts by reviewing patient information to confirm it meets requirements and guidelines outlined by insurance companies such as Medicare and Medicaid. Once documents are confirmed, the team then submits all documents to the patient's insurance company.

In the event the claim is denied by insurance, Rehab Medical's submissions team will consult with the insurance company to get a better understanding of the denial reason and identify next steps for getting the patient the equipment they need.

Key Takeaways

In the end, documenting for a power mobility device really comes down to painting a clear picture of why the equipment is necessary. When describing the patient’s physical abilities, explain the challenges they face in moving around their home, show why simpler devices won’t work, and confirm they can safely use a powered option, to ensure the right decision is made for their specific health condition.