SMS Funding and Documentation 1 — Questions and Answers
Question 1: Under Medicare, which category covers manual and power wheelchairs as Durable Medical Equipment?
- Part A
- Part B (Correct answer)
- Part C (Medicare Advantage only)
- Part D
Correct answer: Part B
Medicare Part B covers Durable Medical Equipment, including manual and power wheelchairs, when medically necessary.
Question 2: What is a Letter of Medical Necessity (LMN) in the context of seating and mobility funding?
- A note from the insurance case manager approving the device
- A clinician-authored document that explains why a specific device is medically required for the patient (Correct answer)
- A form completed by the equipment supplier listing device costs
- A Medicare-required form for all DME orders
Correct answer: A clinician-authored document that explains why a specific device is medically required for the patient
An LMN is written by the prescribing clinician or therapist detailing the patient's diagnosis, functional limitations, and clinical justification for the specific device requested.
Question 3: Which of the following is required documentation for Medicare to cover a power wheelchair?
- A face-to-face examination by the treating physician or NPP within 6 months prior to the written order (Correct answer)
- A home assessment completed by the supplier
- A trial period of at least 30 days in a standard wheelchair
- Physical therapy discharge summary
Correct answer: A face-to-face examination by the treating physician or NPP within 6 months prior to the written order
Medicare requires a face-to-face examination by the treating physician or non-physician practitioner (NPP) within 6 months before the written order for a power wheelchair.
Question 4: The term 'prior authorization' in wheelchair funding refers to:
- Approval from the physician before the therapist evaluates the patient
- Payer approval obtained before the device is provided, to confirm coverage (Correct answer)
- Manufacturer approval for custom modifications
- State Medicaid pre-certification of the supplier
Correct answer: Payer approval obtained before the device is provided, to confirm coverage
Prior authorization is a process where the payer reviews clinical documentation and approves coverage before the device is ordered and delivered.
Question 5: A 'K-level' classification in lower extremity prosthetics is analogous to which concept in wheelchair funding?
- HCPCS code
- Functional level matching device capability to patient ability (Correct answer)
- Coverage determination letter
- CMS competitive bidding area
Correct answer: Functional level matching device capability to patient ability
K-levels classify functional ability to match prosthetic components to patient capability, similar to how wheelchair complexity codes are matched to functional mobility levels.
Question 6: When a Medicare claim for a power wheelchair is denied, the first level of appeal is called:
- Administrative Law Judge (ALJ) hearing
- Qualified Independent Contractor (QIC) redetermination
- Redetermination by the Medicare Administrative Contractor (MAC) (Correct answer)
- Office of Medicare Hearings and Appeals (OMHA)
Correct answer: Redetermination by the Medicare Administrative Contractor (MAC)
The first level of Medicare appeal is a redetermination request submitted to the Medicare Administrative Contractor (MAC) that processed the original claim.
SMS Funding and Documentation 1
Under Medicare, which category covers manual and power wheelchairs as Durable Medical Equipment?