Opinion ID: 3198906
Heading Depth: 3
Heading Rank: 3

Heading: Date of the face-to-face examination

Text: 4. Pertinent diagnoses/conditions that relate to the need for the POV or power wheelchair 5. Length of need 6. Physician’s signature 7. Date of physician signature Although the DME supplier “may provide a template order listing the seven required elements,” the supplier is expressly “prohibited from completing any part of it.” Only the physician who conducted the examination may prepare the order, which the supplier must receive within forty-five days of the face-to-face examination. Relying on the physician’s order, the supplier prepares a “detailed product description.” Although the supplier selects the “specific power mobility device that is appropriate” based on the order, the options are narrowly confined by specific medical requirements. For example, a separate “Wheelchair Seating” LCD provides that a “skin protection seat cushion” is covered only if the beneficiary has one of several specific medical conditions (e.g., a “current pressure ulcer”) that the UNITED STATES V. ADEBIMPE 29 physician diagnosed.2 Moreover, final approval of the specific device selected rests with the physician, who “must sign and date the detailed product description and the supplier must receive it prior to delivery.” As a final step, “[p]rior to or at the time of delivery” of the power mobility device, “the supplier or practitioner must perform an onsite evaluation of the beneficiary’s home to verify that the beneficiary can adequately maneuver the device that is provided considering physical layout, doorway width, doorway thresholds, and surfaces.” In other words, Medicare requires confirmation that the device is compatible with the beneficiary’s home. Once this process is complete, the DME supplier submits the claim to Medicare for payment. The supplier must add one of four “modifier” codes to the claim submission: KX, GA, GY, and GZ. The GA and GZ modifiers are used where there is “an expectation of a medical necessity denial,” while the GY modifier is required when the power mobility device is “only needed for mobility outside the home.” This leaves the KX modifier as the only option when the DME supplier seeks reimbursement for a power wheelchair used within the home and “all of the coverage criteria specified in [the] LCD have been met.”