🦽 Group 3 Power Wheelchair (PWC) Checklist
Critical Requirement
All Group 3 PWCs (K0848–K0864) require a Prior Authorization (PA) prior to delivery/billing.
1. Standard Written Order (SWO)
Must be received prior to delivery.
- Valid Order Date: Is the date after the Face-to-Face exam?
- Beneficiary Info: Name and MBI (Medicare ID) present?
- Description: Specific description (Brand/Model or HCPCS narrative)?
- Note: Can list “Group 3 PWC” generally, but must include all separately billable options/accessories.
- Practitioner: Treating Practitioner Name, NPI, and Legible Signature?
2. Face-to-Face (F2F) Exam
Must occur within 6 months prior to the order date.
- Mobility Limitation: Documented inability to perform MRADLs (toileting, feeding, dressing, grooming) in the home?
- Rule-Outs: Clearly states why a cane, walker, or manual wheelchair is insufficient?
- Specific: Patient lacks upper extremity function to self-propel an optimal manual chair.
- Neurological Diagnosis: (Required for Group 3) Does the patient have a neurological condition, myopathy, or congenital skeletal deformity?
- Cognitive Ability: Patient has the mental/physical capability to operate the chair safely?
- Or: Caregiver is available and unable to use a manual chair?
3. Specialty Evaluation (LCMP & ATP)
- LCMP Eval: Performed by a PT or OT with no financial relationship to the supplier?
- ATP Involvement: Proof of “Direct, in-person involvement” by our RESNA-certified ATP?
- Is the ATP’s signature included on the assessment?
- Attestation: Signed statement that there is no financial relationship between the LCMP and the supplier?
4. Home Assessment
Must be completed on or before the delivery date.
- Access Verified: Documented adequate access between rooms, doorway widths, and thresholds?
- Mitigation: If the patient cannot access a necessary room, is there a plan documented (e.g., commode for inaccessible bathroom)?
5. Specific Power Option Criteria
Check the category being billed:
☐ Single Power Option (K0856-K0860)
- Criteria: Patient meets Neuro diagnosis AND requires:
- A non-proportional drive control (SIP n PUFF, Head array); OR
- Meets criteria for Power Tilt or Recline (High risk of pressure ulcer + unable to weight shift).
☐ Multiple Power Option (K0861-K0864)
- Criteria: Patient meets Neuro diagnosis AND:
- Uses a ventilator mounted to the chair; OR
- Requires BOTH Power Tilt and Power Recline (Risk of pressure ulcers + unable to weight shift).
6. Delivery (POD) & Billing
- Delivery Ticket: Includes Brand, Model, Serial Numbers?
- Signature: Signed by patient (or authorized rep) with Relationship noted?
- Date of Service: Matches the date the patient actually received the item?
- KX Modifier: Applied to claim? (Certifying all documentation is on file).
- Prior Auth #: Entered on the claim?