Manual wheelchair for use inside the home (E1037-E1039, E1161, K0001-K0009)
Certificate of Medical Necessity Must Address (Yes/No/Does Not Apply):
- Does the patient require and use a wheelchair to move around in their residence?
Patient should have a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living such as toileting, feeding, dressing, grooming, and bathing in the home.
Hours per day spent in wheelchair? (1–24) (Round up to next hour)
Able to self-propel (without being pushed) in a standard weight manual wheelchair?
- If NOT, would they be able to do so in the wheelchair which has been ordered?
- If NOT, does the patient have a caregiver who is available, willing, and able to provide assistance with the wheelchair?
For lightweight, high-strength wheelchairs, the pt must have weak upper body strength and cannot propel a standard weight chair. It must be clearly stated that the lightweight wheelchair will help the person perform ADLs safely at home otherwise not achievable with a standard wheelchair.