Wheelchair Documentation Needs (ACA, Face to Face visit is required)
The following qualification criteria need to be documented in the patients’ medical record notes to qualify for the prescribed equipment. Note: Face to face and justification notes are valid for six months.

Standard wheelchair – All of the following need to be sufficiently documented to support the need for the prescribed equipment.

  • Explain the patient’s mobility limitation that significantly impairs (His or Her) ability to participate in one or more mobility-related activities of daily living (MRADL) in the home.
    Note: explain the MRADL in detail.
  • Explain how the patient’s mobility limitation will be sufficiently resolved by the use of a wheelchair and not a fitted cane or walker.
  • Explain the patient’s home environment.
    Note: Must discuss the following- Adequate access between rooms, maneuvering space, and floor surfaces for the use of the wheelchair.
  • Explain how the use of a wheelchair significantly improve the patient’s participation in MRADLs and will (HE or SHE) use it on a regular basis.
  • Explain that the patient willing to use the wheelchair.
  • Explain the patient’s physical and mental ability and/or caregiver situation.
    Note: Must discuss the following- patient has sufficient upper extremity function and the physical and mental capabilities needed to safely self-propel the wheelchair or patient has a caregiver who is able to provide assistance.

Lightweight Wheelchair, document the above information and the following.

  • Explain why the patient is unable to self-propel in a standard wheelchair in the home and why they can self-propel in a lightweight chair.

Hemi (low seat) Wheelchair, document the above information and the following.

  • Explain why the patient requires a seat height lower than 17"-18".

Heavy Duty Wheelchair, document the above information and the following.

  • Document the patient’s weight. Note patient must weigh over 250 lbs.

Extra Heavy Duty Wheelchair, document the above information and the following.

  • Document the patient’s weight. Note patient must weigh over 300 lbs.

Reclining Wheelchair, document the above information and the following.

  • Explain why the patient is at a high risk for development of a pressure ulcer and is unable to perform a functional weight shift.
    OR
  • Explain that the patient utilizes intermittent catheterization for bladder management and why the patient is unable to independently transfer from the wheelchair to the bed.

Diagnosis: See LCD (Local coverage determination) at NGSMedicare.com for any additional qualifying information questions, diagnosis codes and descriptions

Medicare approved detailed equipment descriptions for wheelchairs
Standard Wheelchair, (HCPC-K0001)
light weight Wheelchair , (HCPC-K0003)
Hemi (low seat) Wheelchair , (HCPC-K0002)
Heavy duty Wheelchair, (HCPC-K0006) Note: patient must weigh 250lbs. or more
Extra heavy duty Wheelchair, (HCPC-K0007) Note: patient must weigh 300lbs. or more
Reclining Wheelchair, (HCPC- E1060)

Patient notes/justification – Must be documented using your normal dictation process. Letter of medical necessity, notes wrote on letter head or prescriptions are not valid.

Prescription/order requirements – Must contain Patient’s name, date of the order and Start date, detailed equipment description (See above), Physician’s NPI (national provider number), signature of the ordering physician and a signature date.