We are here to help with your Medicare medical equipment insurance coverage.  As a service to our customers, Atlantic Healthcare Products:

  • Accepts Medicare assignment on most items.
  • Executes Medicare insurance claims.
  • Completes reworking of denied claims.

We will spend the time necessary to secure the proper documentation for your covered medical equipment and supplies so that you can focus on being well. 

Below you will find Medicare qualification criteria for the specified items.

Ready to start your medical insurance claim? Click on the button below and submit your information.

Medicare Criteria Checklist

Catheters

The checklist below is derived from Medicare’s Coverage criteria for Urological Catheters. Without the below criteria being fully and legible documented in the physicians chart notes and Rx, Medical justification has not been met for the items requested.

 

Review of Face-to-Face Examination Chart Notes for Catheters.

 

Criteria for Chart Notes for Internal Catheters:   

▢  Medical records verify that the beneficiary has permanent urinary incontinence or permanent urinary retention 

– AND –

▢  The Impairment of urination is not expected to be medically or surgically corrected within 3 months 

– AND –

▢  Documentation of usage indicating description of the catheter and the usage. 

    • Up to 200/month

▢  Additional Documentation if prescribing for: 

    • Coude catheters: 
      • Medical records document the medical necessity of this type of catheter.
      • Need to rule out why straight catheters cannot be used 
    • Sterile Intermittent Catheter Kits.  
      • There are several pathways for qualification, please call us at  561-290-1434

Detailed Written Order (DWO)-   *** Please sign the attached Detailed Written Order ***

▢  Beneficiary’s name

▢  Physician’s Name 

▢  Description of each item (“intermittent”; “Coude”; w/ French size; Lubricant)

▢  Specific Frequency of Use (3-4 times per day) (“prn” orders are not acceptable) 

▢  Quantity to Dispense per month

▢  Refill frequency or # of Refills

▢  Signature of treating physician  with date (Stamps are not acceptable)

    • Physician’s Signature on written order meets CMS Signature Requirements. 
      • http://www.cgsmedicare.com/jc/pubs/news/2010/0410/cope12069.html

Group 1 Support Surfaces

The checklist below is derived from Medicare’s Coverage criteria for Group 1 Support Surfaces. Without the below criteria being fully and legible documented in the physician’s chart notes and Rx, Medical justification has not been met for the items requested.

Review of Face-to-Face Examination Chart Notes for Group 1 Support Surfaces.

Criteria for Chart Notes for Group 1 Support Surfaces:   

▢  The examination occurred within 6 months prior to the date of the written order.

▢  The examination documents that the beneficiary was evaluated and/or treated for a condition that supports the need for a group 1 pressure reducing support surface.

Medical Justification Indicated in Chart Notes: (Beneficiary must meet 1 of the following)

1) The beneficiary is completely immobile -i.e., beneficiary cannot make changes in body position without assistance, -OR-

2) The beneficiary has limited mobility -i.e., beneficiary cannot independently make changes in body position significant enough to alleviate pressure, & at least one of the conditions A-D below:, -OR-

▢  3) The beneficiary has any stage pressure ulcer on the trunk or pelvis, & at least one of conditions A-D below:

Conditions: (one or more must be indicated for Medical Justification 2 or 3 listed above)

A.  Impaired nutritional status

B.  Fecal or urinary incontinence

C.  Altered sensory perception

D.  Compromised circulatory status

Conditions for criteria 2 and 3 (in each case the medical record must document the severity of the condition sufficiently to demonstrate the medical necessity for a pressure reducing support surface)

Hospital Beds

The checklist below is derived from Medicare’s Coverage criteria for a Hospital Bed. Without the below criteria being fully and legible documented in the physician’s chart notes and Rx, Medical justification has not been met.

Checklist for Face-to Face Examination Chart Notes for a Hospital Bed

 

Criteria for F2F Chart Notes for Hospital Bed:   

▢  Is the Reason for the face-to-face encounter conducted by the physician, to evaluate and/or treat the condition that supports the item(s) of DME ordered. –(“follow-up” is not acceptable)

▢  Is there a description of how the diagnosis limits the patient’s condition

▢  Is there an indication that the beneficiary (one of the below): 

▢  has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed- condition must be clearly stated  -or- 

▢  requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain, and why -or-

▢  requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration -or-

▢  requires traction equipment, which can only be attached to a hospital bed

▢  Indication if alternate methods such as pillows and wedges have been ruled out and why.

▢  Indication that requires frequent changes in body position and/or has an immediate need for a change in body position w/ explanation. 

Detailed Written Order- 

▢  beneficiary’s name, 

▢  item of DME ordered,

▢  the prescribing practitioner’s National Provider Identifier (NPI), 

▢  signature of the ordering practitioner and  

▢  date of the order.

▢  Is the Detailed written order dated after the F2F, but not more than 6 months old

Please Note: Medicare pays for hospital bed rentals only. The hospital beds that we rent are Full Electric Hospital Beds (FEHB). These type of beds are an out of pocket upgrade to the Fixed Hospital Bed that Medicare covers. To obtain a Full Electric Hospital Bed, upon qualification, we will apply Medicare’s Fee Schedule to the rental rate of a Full Electric Hospital Bed. 

[FEHB Rental $180/month – Medicare ~~$60/month] = Out of pocket $85/month] 13/months)

Manual Wheelchair

The checklist below is derived from Medicare’s Coverage criteria for a Manual Wheelchair. Without the below criteria being fully and legible documented in the physician’s chart notes and Rx, Medical justification has not been met.

 

Checklist for Face-to-Face Examination Chart Notes for a Manual Wheelchair

 

Criteria for F2F Chart Notes for Manual Wheelchair – K0001   

▢  Is the Reason for the face-to-face encounter conducted by the physician, to evaluate and/or

      treat the condition that supports the item(s) of DME ordered.  –(“follow-up” is not acceptable)

▢  Is there a description of how the diagnosis limits the patient’s condition

▢  Is there an indication that the beneficiary meets ALL below criteria: 

▢  The beneficiary has a mobility limitation that impairs their ability to participate in  MRADL’s in the home?  (MRADL’s: toileting, feeding, dressing, grooming, and bathing) 

▢(Mobility Limitation: Prevents, or puts oneself at risk or cannot complete MRADLS Timely fashion)  – AND – 

▢  The mobility limitation cannot be resolved by the use of an appropriately fitted cane or walker.  – AND –

▢  The beneficiary’s home provides adequate access between rooms, maneuvering space, and surfaces for use of the Manual Wheelchair.   – AND –

▢  A manual wheelchair will improve the beneficiary’s ability to participate in MRADLs in the home. Does the beneficiary have a willingness to use the manual wheelchair in the home?    – AND –

There is a caregiver who is available, willing, and able to provide assistance with the wheelchair. If yes, indicate Name and Relation of caregiver – OR –  Does the beneficiary have sufficient upper extremity function and physical and mental capabilities needed to self-propel the manual wheelchair?

▢  Option for high Strength Lightweight Wheelchair –  K0004  

▢  The member self‐propels the wheelchair while engaging in frequent activities in the home that cannot be performed in a standard or lightweight wheelchair. (and/or)

▢  The member requires a seat width, depth, or height that cannot be accommodated in a standard, lightweight, or hemi‐wheelchair, and spends at least two hours per day in the wheelchair.

▢  Note: A high strength lightweight wheelchair is rarely medically necessary if the expected duration of need is less than three months (e.g., postoperative recovery).  

 ▢  Option for Reclining Back Wheelchair– 

▢  In addition to above, the beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or 2) utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to the bed. 

           ▢  Option for Elevating Leg Rests– 

▢  Does the beneficiary have a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee OR

▢  Significant edema of the feet or legs  that requires an elevating leg rest OR

▢  Meets the criteria for and has a reclining back on the wheelchair.

▢  Option for Adjustable Armrest- 

▢  Does the beneficiary require an arm height that is different than those available using non adjustable arms?  Why?

▢  Number of hours the beneficiary spend per day in the wheelchair

▢  Additional Safety Features Indicated

▢  Anti Tippers

▢  Brake Extensions

▢  Heel Loops Seat Belt   

 

Detailed Written Order- 

▢  beneficiary’s name, 

▢  item of DME ordered,

▢  the prescribing practitioner’s National Provider Identifier (NPI), 

▢  signature of the ordering practitioner and  

▢  date of the order.

▢  Is the Detailed written order dated after the F2F, but not more than 6 months old

We offer K0001 Wheelchairs

Seat Widths: 18” or  20”

Overall Width: 26.5”, 28.5”

Weight Capacity: 250 lb

Item Weight: 41, 43 lbs 

Or upgrade to a K0004 Transformer Wheelchair

Seat Widths: 18” or  20”

Overall Width: 26.5”, 28.5”

Weight Capacity: 250 lbs

Item Weight: 31lbs, 33lbs

Without Wheels: 21lbs, 23 lbs

           Upgrade is Fee Schedule difference:  $21.00/ month for 13 months

 

Power Wheelchair

The checklist below is derived from Medicare’s Coverage criteria for a Power Wheelchair. Without the below criteria being fully and legible documented in the physician’s chart notes and Rx, Medical justification has not been met.

Checklist for Face-to-Face Examination Chart Notes for a Power Wheelchair

Do the Medical records relevant to mobility needs 1) indicate and 2) support: 

▢  Reason: ‘Mobility evaluation for a Power Wheelchair’ or Powered Mobility Device –PMD

▢  Any other reason, or “follow-up” is not acceptable

▢  History of present condition and relevant past medical history:

▢  Symptoms that limit ambulation

▢  Diagnoses that are responsible for symptoms

▢  Medications or other treatment for symptoms

▢  Progression of ambulation difficulty over time

▢  Distance beneficiary can walk without stopping

▢  Pace of ambulation

▢  History of falls, including frequency, circumstances leading to falls

▢  Physical examination relevant to mobility needs:

▢  Height and weight

▢  Cardiopulmonary examination

▢  Arm and leg strength tests and range of motion tests. 

▢  Neurological examination:

▢  Gait

▢  Balance and coordination

▢  PWC Assessment: 

▢  Description of the mobility limitations and how it 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 in the home.

– AND –  

prevents the beneficiary from accomplishing an MRADL entirely;  – or – places beneficiary at a reasonably determined risk secondary to the attempts to perform an MRADL;  – or – prevents beneficiary from completing an MRADL within a reasonable amount of time

▢  Beneficiary’s mobility limitation cannot be sufficiently and safely resolved by use of appropriately fitted cane or walker; 

– AND –

▢  Beneficiary does not have sufficient upper extremity function to self-propel an optimally configured manual wheelchair in the home 

– AND –

▢  Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities; 

– AND –

▢  Beneficiary does not meet coverage criteria for a Scooter or POV 

-AND-

▢  Beneficiary’s mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) are sufficient for safe mobility; — Beneficiary’s weight is less than or equal to weight capacity of wheelchair provided; 

– AND –

▢  Beneficiary’s home provides adequate access;

– AND –

▢  Use of a power wheelchair will significantly improve the beneficiary’s ability to participate in MRADLs and beneficiary will use it in the home.; 

– AND –

▢  Beneficiary has not expressed an unwillingness to use a PWC in the home.

▢  7 Element Order – 

▢  beneficiary’s name, 

▢  item of DME ordered “Power Wheelchair”, “PWC”, or Power Mobility Device 

▢  Length of Need. 

▢  Date of the Face to Face Examination

▢  Date of the order 

▢  Diagnosis or Dx Code

▢  Legible Signature of the ordering practitioner, or signed over printed name. 

▢  Statutory Timing Requirements

▢  Did the Supplier Receive within 45 days the 7 Element Order. 

▢  Did the Supplier Receive within 45 days the F2F Examination Report. 

▢  Will Delivery of the Power Wheelchair be before 120 days after the F2F

Scooter (POV)

The checklist below is derived from Medicare’s Coverage criteria for a Scooter (POV). Without the below criteria being fully and legible documented in the physician’s chart notes and Rx, Medical justification has not been met.

Checklist for Face-to-Face Examination Chart Notes for a Scooter (POV)

Do the Medical records relevant to mobility needs 1) indicate and 2) support: 

Reason: ‘Mobility evaluation for a: Powered Mobility Device, PMD, Scooter or POV

▢ Any other reason, or “follow-up” is not acceptable

History of present condition and relevant past medical history:

▢ Symptoms that limit ambulation

▢ Diagnoses that are responsible for symptoms

▢ Medications or other treatment for symptoms

▢ Progression of ambulation difficulty over time

▢ Distance beneficiary can walk without stopping

▢ Pace of ambulation

▢ History of falls, including frequency, circumstances leading to falls

Physical examination relevant to mobility needs:

▢ Height and weight

▢ Cardiopulmonary examination

▢ Arm and leg strength tests and range of motion tests. 

Neurological examination:

▢ Gait

▢ Balance and coordination

Mobility Assessment: 

▢ Description of the mobility limitations and how it 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 in the home.

– AND –  

▢ prevents the beneficiary from accomplishing an MRADL entirely;  – or – 

▢ places beneficiary at a reasonably determined risk secondary to the attempts to perform an MRADL;  – or –

▢ prevents beneficiary from completing an MRADL within a reasonable amount of time

▢ Beneficiary’s mobility limitation cannot be sufficiently and safely resolved by use of appropriately fitted cane or walker;

– AND –  

▢ Beneficiary does not have sufficient upper extremity function to self-propel an optimally configured manual wheelchair in the home

– AND –  

▢ Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities;

AND –  

▢ Beneficiary’s mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) are sufficient for safe mobility; — Beneficiary’s weight is less than or equal to weight capacity of scooter provided;

– AND –  

▢ Beneficiary’s home provides adequate access; or differ to Provider’s Home Assessment 

– AND –  

▢ Use of a Scooter POV will significantly improve the beneficiary’s ability to participate in MRADLs and beneficiary will use it in the home.;

– AND –  

▢ Beneficiary has not expressed an unwillingness to use a PWC in the home.

7 Element Order – 

▢ beneficiary’s name, 

▢ item of DME ordered “SCooter”, “POV”, or Power Mobility Device 

▢ Length of Need. 

▢ Date of the Face to Face Examination

▢ Date of the order 

▢ Diagnosis or Dx Code

▢ Legible Signature of the ordering practitioner, or signed over printed name. 

Statutory Timing Requirements

▢ Did the Supplier Receive within 45 days the 7 Element Order. 

▢ Did the Supplier Receive within 45 days the F2F Examination Report. 

▢ Will Delivery of the Power Wheelchair be before 120 days after the F2F

 

DMEevaluate.com

Physicians: We invite you to create the Face to Face Chart note through DMEevalumate.com  

Medicare Compliant paperwork the first time!

Please fax your referrals and documentation to 561-290-1434