Dwo Form PDF Details

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QuestionAnswer
Form NameDwo Form
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesdwo medicare form pdf, detailed written order template, medicare dwo, behavior forms pdf

Form Preview Example

 

 

 

 

Document #:

 

Rev.:

 

DETAILED WRITTEN ORDER

 

09.DWO.HCD.15b

B

 

Homecare Dimensions

 

 

Effective:

 

 

 

 

09/15/2009

 

 

 

 

 

 

 

 

Title:

 

 

 

 

Page #:

 

Wheelchair

 

 

 

 

1 of 5

 

K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0009, K00195

 

 

 

 

 

 

 

 

 

 

 

Initial Date of Medical Necessity: ___________________

 

 

 

 

 

Patient Name: _______________________________________

Medicare #: ____________________________

Address: ____________________________________ City: ____________________ ST: _____

Zip: __________

Phone #: _______________________ Cell #: _______________________

DOB: ___________________________

Email: ______________________________________________

Length of Need: ___________ (99 = LIFETIME

Diagnosis Code: _______________________________________________________________________________

Medical records: The Medical Records will need to document that ALL of the following coverage criteria are met: Patient has 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 in the home; AND

Mobility limitation cannot be sufficiently and safely resolved by use of appropriately fitted cane or walker; AND The patient’s home provides adequate access between rooms, maneuvering space, and surfaces for use of the

manual wheelchair that is provided; AND

Use of a manual wheelchair will significantly improve the patient’s ability to participate in MRADLs and the patient will use it on a regular basis in the home; AND

The patient has not expressed an unwillingness to use the manual wheelchair that is provided in the home; AND The patient has sufficient upper extremity function and other physical and mental capabilities needed to safely

self-propel the manual wheelchair that is provided in the home during a typical day; AND

The patient has a caregiver who is available, willing, and able to provide assistance with the wheelchair.

Equipment Ordered: All wheelchairs are billed using the specific codes listed in the Local Coverage Determination.

ORDERED

CODE

DETAILED DESCRIPTION OF ORDERED ITEMS

 

 

 

 

K0001

Standard wheelchair

 

 

 

 

K0002

Standard hemi-wheelchair: Medical record supports patient requires a lower seat height (17”-18”) because:

 

 

Short stature, or

 

 

Need to place feet on ground for propulsion

 

K0003

Lightweight wheelchair: Medical record supports that patient:

 

 

Cannot self-propel in a standard wheelchair using arms and/or legs; and

 

 

Can and does self-propel in a lightweight wheelchair.

 

K0004

High strength lightweight wheelchair: Medical record supports that patient:

 

 

Self-propels the wheelchair while engaging in frequent activities that cannot be performed in a standard or

 

 

lightweight wheelchair; and/or

 

 

Requires seat width, depth, height that cannot be accommodated in a standard, lightweight, or hemi-

 

 

wheelchair and spends at least two hours per day in the wheelchair.

 

K0005

Ultra lightweight wheelchair: Payment is determined on an individual consideration basis. Documentation must

 

 

include:

 

 

Description of patient’s routine activities; and

 

 

Types of activities patient frequently encounters; and

 

 

Information concerning whether or not patient is fully independent in use of the wheelchair; and

 

 

Description of the K0005 features that are needed compared to the K0004 base.

 

K0006

Heavy-duty wheelchair: Medical record supports that patient:

 

 

Weighs more than 250 pounds; and

 

 

Has severe spasticity.

 

 

 

 

K0007

Extra heavy-duty wheelchair: Medical record supports patient weighs more than 300 pounds.

 

 

 

 

 

 

 

Document #:

Rev.:

 

 

 

DETAILED WRITTEN ORDER

09.DWO.HCD.15b

B

 

 

 

Homecare Dimensions

Effective:

 

 

 

09/15/2009

 

 

 

 

 

 

Title:

 

 

Page #:

 

 

 

Wheelchair

 

2 of 5

 

 

 

K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0009, K00195

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ORDERED

CODE

DETAILED DESCRIPTION OF ORDERED ITEMS

 

 

 

 

 

 

 

 

K0009

Other manual wheelchair/base: Medical records justifying medical necessity of the item that might include:

 

 

 

Diagnosis

 

 

 

 

 

Abilities and limitations as they relate to the equipment

 

 

 

 

 

Duration of the condition

 

 

 

 

 

Expected prognosis

 

 

 

 

 

Past experience using similar equipment

 

 

 

K0195

Elevating leg rests, pair: Medical records support that patient:

 

 

 

 

 

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; or

 

 

 

The patient meets the criteria for and has a reclining back on the wheelchair.

 

 

 

 

 

 

 

Treating Physician Signature: __________________________________________

Date: ____________________

Treating Physician Name: _____________________________________________

NPI: _____________________

Continue on Following Page

 

 

 

Document #:

Rev.:

 

DETAILED WRITTEN ORDER

09.DWO.HCD.15b

B

 

Homecare Dimensions

Effective:

 

09/15/2009

 

 

 

 

Title:

 

Page #:

 

Wheelchair

 

3 of 5

 

K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0009, K00195

 

 

 

 

 

 

 

Mobility Related Activities of Daily Living

 

Patient:

_________________________________________________________________________

Medicare #: __________________________ HCD Account #: ____________________________

Mobility related activities of daily living are defined as feeding, toileting, dressing, grooming, and bathing in customary locations of the patient’s home.

A mobility limitation is defined as:

1)Inability to complete the MRADL entirely

2)Patient is at heightened risk of morbidity or mortality when performing the MRADL or

3)Is prevented from completing the MRADL in a reasonable amount of time

Please circle yes or no.

YES

NO

1.

The patient has a mobility limitation that significantly impairs her ability to

 

 

 

participate in one or more mobility- related activities of daily living.

YES

NO

2.

The patient’s mobility limitation cannot be sufficiently resolved with the use of an

 

 

 

appropriately fitted cane or walker.

YES

NO

3.

The patient’s home provides adequate access between rooms, maneuvering

 

 

 

space, and surfaces for use of manual wheelchair is provided.

YES

NO

4.

Use of manual wheelchair will significantly improve the patient’s ability to

 

 

 

participate in MRADL and the patient will use it on a regular basis in the home.

YES

NO

5.

The patient had not expressed an unwillingness to use the manual wheelchair that

 

 

 

is provided in the home.

YES

NO

6.

Patient cannot self propel in a standard wheelchair in the home.

YES

NO

7.

The patient 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.

Treating Physician Signature: __________________________________ Date: ______________

Treating Physician Name: ______________________________________ NPI: ______________

 

 

Document #:

Rev.:

 

DETAILED WRITTEN ORDER

09.DWO.HCD.15b

B

 

Homecare Dimensions

Effective:

 

09/15/2009

 

 

 

 

Title:

 

Page #:

 

Wheelchair

 

4 of 5

 

K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0009, K00195

 

 

 

 

 

 

 

Continue on Following Page

 

 

 

 

Document #:

Rev.:

 

DETAILED WRITTEN ORDER

09.DWO.HCD.15b

B

 

Homecare Dimensions

Effective:

 

09/15/2009

 

 

 

 

Title:

 

Page #:

 

Wheelchair

 

5 of 5

 

K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0009, K00195

 

 

 

 

 

 

 

Medicare Mobility Assistive Equipment Policy

 

Patient:

 

 

_______________________________________________________________________________

 

Medicare #: ____________________________ HCD Account #: _______________________________

The MAE uses an algorithmic approach to determine which piece of equipment, if any, is “reasonable and necessary” to assist a Beneficiary in performing the Mobility-Related Activities of Daily Living (MRADL) within the home.

Please answer the following questions in order to determine which piece of equipment is “reasonable and necessary. Circle Yes or NO for questions:

1 thru 5: If you are ordering a Walker, Cane or Crutches

1 thru 7: If you are ordering a Manual Wheelchair

1 thru 8: If you are ordering a Power Operated Vehicle (POV)

1 thru 9: If you are ordering a Power Wheelchair (PWC)

YES

NO

1.

Does the patient have mobility limitation(s) that significantly impairs their ability to perform

 

 

 

one or more MRADLs within their home?

 

YES

NO

2.

Are there other conditions that limit the patient’s ability to participate in MRADLs at home?

YES

NO

3.

If limitations exist, can they be compensated sufficiently such that the provisions of MAE

 

 

 

will be reasonably expected to significantly improve the

patient’s ability to perform or

 

 

 

obtain assistance to participate in MRADLs in the home?

 

YES

NO

4.

Does the patient or caregiver demonstrate the capability and willingness to consistently

 

 

 

operate the MAE safely?

 

YES

NO

5.

Can the functional mobility deficit be sufficiently resolved by the prescription of a cane or

 

 

 

walker?

 

YES

NO

6.

Does the patient’s home environment support the use of wheelchairs including scooter/

 

 

 

power-operated vehicles (POV)?

 

YES

NO

7.

Does the beneficiary have sufficient upper extremity function to propel a manual

 

 

 

wheelchair in the home to participate in MRADLs during a typical day?

YES

NO

8.

Does the beneficiary have sufficient strength and postural stability to operate a POV/

 

 

 

scooter?

 

YES

NO

9.

Are the additional features, provided by a power wheelchair, needed to allow the

 

 

 

beneficiary to participate in one or more MRADLs?

 

Treating Physician Signature: __________________________________________

Date: ____________________

Treating Physician Name: _____________________________________________

NPI: _____________________

Document Complete

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