Medicare for Manual Wheelchairs

Medicare patients in need of a manual wheelchair can qualify for one by meeting certain requirements including the inability to move at a normal capabilitynew medicare wheelchair. A doctor must provide a certificate of necessity noting the type of wheelchair needed when using medicare for manual wheelchairs. A manual wheelchair is powered by the patient or pushed by a caregiver. If the patient meets the requirements for being able to sit and power the chair or has a caregiver to do so, they may be prescribed a manual wheelchair. Once the necessity is documented a Medicare supplier, like Towson Medical Equipment, must be used to purchase or rent the manual wheelchair. The approved supplier will send a representative to the patient’s house to measure and make sure the right fit is accomplished.  One example of a Medicare approved manual wheelchair is the Drive Medical Cruiser III which is an easy to fold model with flip back arms and swing away footrests. The purpose of a manual wheelchair is to provide easy transportation, comfortable seating and functional independence for the patient it is prescribed for.  If you have Medicare Insurance then you should consider using Medicare for Manual Wheelchairs when prescribed by your doctor.

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Medicare for Manual Wheelchairs (k1-Standard)                         Get PDF Here:     Manual Wheelchair Order Form

Using Medicare for manual wheelchairs is complicated but with these forms and our awesome staff we can help get the job done quickly.

Included in this package:

  • Standard frame (16X16, 18X16, 20X16)
  • Standard arm rests (desk or full)
  • General use seat cushion (3”)
  • General use back cushion
  • Seat belt
  • Anti- tippers
  • Brake extensions
  • Standard footrests

(elevating footrests available with DX of fracture or edema)

 

* If your patient has MEDICARE only (part B):

Please note this is a rental for 13 months

Please expect a first month’s co-pay of $72.61

Each additional month is $10 or less.

 

Included in the Required Paperwork Packet:

  • A detailed written order
  • A face-to-face form
  • Medicare’s requirements of what MUST be included in the patient’s chart notes.

 

* All documents must be signed by the same provider.

* Provider must be PECOS certified.

 

PATIENT:                                DOB:

ADDRESS:

PHONE: (   )    –                          SOCIAL SECURITY #: XX

 

 

EFFECTIVE DATE:       

ICD-10 DIAGNOSIS CODES:____________________________________

ICD-9 DIAGNOSIS CODES:      ________________________________

DESCRIPTION OF ITEM: MANUAL WHEELCHAIR- STANDARD

Patient requires Elevating Leg Rests

LENGTH OF NEED:        (99 = lifetime)

 

I, the undersigned, certify that the above prescribed items are medically necessary as part of my treatment plan for this patient and have not been prescribed as a convenience.

 

PHYSICIAN:      

ADDRESS:

PHONE: (   )    –                      FAX: (   )    –

NPI #:

 

 

 

SIGNATURE:                                                                   ___    DATE:                             

 

FACE TO FACE FORM

PATIENT:                                                                                           DOB:      

ADDRESS:      

CITY, STATE, ZIP:      ,

PHONE: (   )    –                    SOCIAL SECURITY #: xx

 

 

EFFECTIVE DATE:                                                 

ICD-10 DIAGNOSIS CODES:________________________________________

ICD-9 DIAGNOSIS CODES:                                                                                             

DATE OF FACE-TO-FACE EXAMINATION: ___                                                        

DESCRIPTION OF ITEM:                                                                                                                                                                                                                                     

LENGTH OF NEED:                         (99 = lifetime)

 

I, the undersigned, certify that the above prescribed items are medically necessary as part of my treatment plan for this patient and have not been prescribed as a convenience.

PHYSICIAN:      

ADDRESS:      

CITY, STATE, ZIP:      ,

PHONE: (   )    –                                FAX: (   )    –

NPI #:

 

SIGNATURE:                                                                   ___    DATE:                            

 

 

PLEASE PROVIDE CHART NOTES (NOT THIS SHEET) THAT ADDRESS ALL OF THE FOLLOWING:

 

  1. The patient has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming and bathing in customary locations within the home.
  2. The patient’s mobility limitation cannot be sufficiently resolved by the use of an appropriately-fitted cane or walker, and the use of a manual wheelchair will significantly improve the patient’s ability to participate in the MRADLs.
  3. The patient’s home provides adequate access between rooms, maneuvering space, and surfaces for the use of the manual wheelchair that is provided.
  4. The patient will need to use the manual wheelchair on a day to day basis within the home, and is willing to do so.
  5. The patient has sufficient upper extremity function and the other physical and mental capabilities needed to safely provide a manual wheelchair (limitations of strength, endurance, range of motion or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function) OR has a caregiver who is available, willing and able to provide assistance with the wheelchair.

 

IF THE PATIENT REQUIRES ELEVATING LEG RESTS:

  1. The patient has a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee OR the patient has significant edema of the lower extremities that requires an elevating leg rest.