Or. Admin. Code § 410-122-0330

Current through Register Vol. 63, No. 11, November 1, 2024

Section 410-122-0330 - Power-Operated Vehicle

(1) Indications and limitations of coverage and medical appropriateness:

(a) The Division may cover a power-operated vehicle (POV) when conditions of coverage in OAR 410-122-0080(1) and all of the following criteria are met:

(A) The client has a mobility limitation that significantly impairs their ability to participate in one or more mobility-related activities of daily living (MRADLs) in or out of the home. MRADLs include but are not limited to tasks such as toileting, feeding, dressing, grooming, and bathing. A mobility limitation is one that:

(i) Prevents the client from accomplishing an MRADL entirely; or

(ii) Places the client at reasonably determined heightened risk of morbidity or mortality secondary to attempts to perform an MRADL; or

(iii) Prevents the client from completing an MRADL within a reasonable time frame.

(B) An appropriately fitted cane or walker cannot resolve the client's mobility limitation;

(C) The client does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair to perform MRADLs during a typical day:

(i) Assessment of upper extremity function shall consider limitations of strength, endurance, range of motion, or coordination, presence of pain, and deformity or absence of one or both upper extremities;

(ii) An optimally-configured manual wheelchair features an appropriate wheelbase, device weight, seating options, and other appropriate non-powered accessories.

(D) The client has sufficient strength, postural stability, or other physical or mental capabilities needed to safely operate a POV;

(E) If the client shall be using the POV in the home, the client's home provides adequate maneuvering space, maneuvering surfaces, and access between rooms for the operation of the POV being requested. The Division does not reimburse for adapting living quarters;

(F) The client is able to:

(i) Safely transfer to and from the POV;

(ii) Operate the tiller steering system, and

(iii) Maintain postural stability and position while operating the POV.

(G) Use of a POV shall significantly improve the client's ability to participate in their MRADLs;

(H) The client is willing to use the requested POV on a regular basis;

(I) The Division does not cover services or upgrades that primarily allow performance of leisure or recreational activities. Such services include but are not limited to backup POVs, backpacks, accessory bags, awnings, additional positioning equipment if the POV meets the same need, custom colors, and wheelchair gloves.

(b) For a POV to be covered, the treating practitioner or nurse practitioner must conduct a face-to-face examination of the client before writing the order:

(A) The durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) provider must receive a written report of this examination within 45 days after the face-to-face examination and prior to delivery of the device;

(B) When this examination is performed during a hospital or nursing facility stay, the DMEPOS provider must receive the report of the examination within 45 days after date of discharge;

(C) The practitioner may refer the client to a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), to perform part of this face-to-face examination. This person may not be an employee of the DMEPOS provider or have any direct or indirect financial relationship, agreement, or contract with the DMEPOS provider. When the DMEPOS provider is owned by a hospital, a PT/OT working in the inpatient or outpatient hospital setting may perform part of the face-to-face examination:

(i) If the client was referred to the PT/OT before being seen by the practitioner, then once the practitioner has received and reviewed the written report of this examination, the practitioner must see the client and perform any additional examination that is needed. The practitioner's report of the visit shall state concurrence or any disagreement with the PT/OT examination. In this situation, the practitioner must provide the DMEPOS provider with a copy of both examinations within 45 days of the face-to-face examination with the practitioner;

(ii) If the practitioner examined the client before referring the client to a PT/OT, then again in person after receiving the report of the PT/OT examination, the 45-day period begins on the date of that second practitioner visit. However, it is also acceptable for the practitioner to review the written report of the PT/OT examination, to sign and date that report, and to state concurrence or any disagreement with that examination. In this situation, the practitioner must send a copy of the note from his initial visit to evaluate the client plus the annotated, signed, and dated copy of the PT/OT examination to the DMEPOS provider. The 45-day period begins when the practitioner signs and dates the PT/OT examination;

(iii) If the POV is a replacement of a similar item that was previously covered by the Division or when only POV accessories are being ordered and all other coverage criteria in this rule are met, a face-to-face examination is not required.

(c) The Division may authorize a new POV when a client's existing POV is no longer medically appropriate or repair and modifications to the POV exceed replacement costs;

(d) If a client has a medically appropriate POV regardless of payer, the Division may not reimburse for another POV;

(e) The cost of the POV includes all options and accessories that are provided at the time of initial purchase, including but not limited to batteries, battery chargers, weight appropriate upholstery and seating system, tiller steering, non-expandable controller with proportional response to input, complete set of tires, and all accessories needed for safe operation;

(f) Reimbursement for the POV includes all labor charges involved in the assembly of the POV and all covered additions or modifications. Reimbursement also includes support services such as emergency services, delivery, set-up, pick-up and delivery for repairs/modifications, education, and on-going assistance with use of the POV;

(g) If a client-owned POV meets coverage criteria, medically appropriate replacement items including but not limited to batteries may be covered;

(h) If a POV is covered, a manual or power wheelchair provided at the same time or subsequently shall be denied as not medically appropriate;

(i) The Division shall cover one month's rental of a POV if a client-owned POV is being repaired;

(j) The following services are not covered:

(A) POV for functionally ambulatory clients;

(B) A POV used to replace private or public transportation such as an automobile, bus, or taxi;

(C) A POV for a client residing in a nursing facility.

(2) Coding guidelines:

(a) Group 1 POVs (K0800 - K0802) are typically used only inside the home;

(b) Group 2 POVs (K0806 -K0808) have added capabilities not needed for in home use. Client specific clinical documentation must be submitted that supports the medical need for this level of POV and demonstrates that there is no equally effective, less costly alternative that meets the client's medical needs;

(c) A replacement item including but not limited to replacement batteries shall be requested using the specific wheelchair option or accessory code if one exists (see 410-122-0340, Wheelchairs Options/Accessories). If a specific code does not exist, use code K0108 (wheelchair component or accessory, not otherwise specified);

(d) For guidance on correct coding, DMEPOS providers shall contact the Pricing, Data Analysis and Coding (PDAC) Contractor by the Centers for Medicare and Medicaid Services. See 410-122-0180 Healthcare Common Procedure Coding System (HCPCS) Level II Coding for more information.

(3) Documentation requirements: Submit all of the following documentation with the prior authorization (PA) request:

(a) A copy of the written report of the face-to-face examination of the client by the practitioner:

(A) The report must include information related to the following:

(i) The client's mobility limitation and how it interferes with the performance of activities of daily living;

(ii) Why a cane or walker cannot sufficiently resolve the client's mobility limitations;

(iii) Why a manual wheelchair cannot sufficiently resolve the client's mobility limitations;

(iv) The client's physical and mental abilities to operate a POV (scooter):

(I) Besides a mobility limitation, if other conditions exist that limit a client's ability to participate in MRADLs, how these conditions shall be ameliorated or compensated;

(II) How these other conditions shall be ameliorated or compensated sufficiently such that the additional provision of POV shall be reasonably expected to significantly improve the client's ability to perform or obtain assistance to participate in MRADLs.

(B) The face-to-face examination shall provide pertinent information about the following elements but may include other details. Only relevant elements need to be addressed:

(i) Symptoms;

(ii) Related diagnoses;

(iii) History:

(I) How long the condition has been present;

(II) Clinical progression;

(III) Interventions that have been tried and the results;

(IV) Past use of walker, manual wheelchair, POV, or power wheelchair and the results;

(iv) Physical exam:

(I) Weight;

(II) Impairment of strength, range of motion, sensation, or coordination of arms and legs;

(III) Presence of abnormal tone or deformity of arms, legs, or trunk;

(IV) Neck, trunk, and pelvic posture and flexibility;

(V) Sitting and standing balance.

(v) Functional assessment indicating any problems with performing the following activities including the need to use a cane, walker, or the assistance of another person:

(I) Transferring between a bed, chair, and power mobility device;

(II) Walking around their home or community including information on distance walked, speed, and balance.

(b) The practitioner's written order, received by the DMEPOS provider within thirty (30) days after the practitioner's face-to-face examination that includes all of the following elements:

(A) Client's name;

(B) Description of the item that is ordered. This may be general (e.g., "POV" or "power mobility device") or may be more specific:

(i) If this order does not identify the specific type of POV that is being requested, the DMEPOS provider must clarify this by obtaining another written order that lists the specific POV that is being ordered and any options and accessories requested;

(ii) The items on this order may be entered by the DMEPOS provider. This subsequent order must be signed and dated by the treating practitioner, received by the DMEPOS provider, and submitted to the authorizing authority, but does not have to be received within 45 days following the face-to-face examination.

(C) Most significant ICD-10 diagnosis code that relates specifically to the need for the POV;

(D) Length of need;

(E) Practitioner's signature;

(F) Date of practitioner's signature.

(c) For all requested equipment and accessories, include the manufacturer's name, product name, model number, standard features, specifications, dimensions, and options;

(d) Detailed information about client-owned equipment (including serial numbers) as well as any other equipment being used or available to meet the client's medical needs, including the age of the equipment and why it cannot be grown (expanded) or modified, if applicable;

(e) A written evaluation of the client's living quarters performed by the DMEPOS provider. This assessment must support that the client's home can accommodate and allow for the effective use of a POV, including but is not limited to evaluation of door widths, counter/table height, accessibility (e.g., ramps), electrical service, etc.;

(f) All HCPCS to be billed on this claim (both codes that require authorization and those that do not require authorization);

(g) Any additional documentation that supports indications of coverage are met as specified in this rule;

(h) The above documentation must be kept on file by the DMEPOS provider;

(i) Documentation that the coverage criteria have been met must be present in the client's medical record. This documentation and any additional medical information from the DMEPOS provider must be made available to the Division upon request.

(4) Billing:

(a) Procedure Codes:

(A) K0800 Power operated vehicle, Group 1 standard, patient weight capacity up to and including 300 pounds - PA;

(B) K0801 Power operated vehicle, Group 1 heavy duty, patient weight capacity, 301 to 450 pounds - PA;

(C) K0802 Power operated vehicle, Group 1 very heavy duty, patient weight capacity, 451 to 600 pounds - PA.

(D) K0806 Power operated vehicle, Group 2 standard, patient weight capacity up to and including 300 pounds - PA

(E) K0807 Power operated vehicle, Group 2 heavy-duty, patient weight capacity 301 to 450 pounds - PA

(F) K0808 Power operated vehicle, Group 2 very heavy-duty, patient weight capacity 451 to 600 pounds - PA

(b) The Division shall purchase, rent, and repair;

(c) Item considered purchased after thirteen (13) months of rent or the Division fee schedule purchase price is met, whichever is less.

Or. Admin. Code § 410-122-0330

OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP 8-2002, f. & cert. ef. 4-1-02; OMAP 47-2002, f. & cert. ef. 10-1-02; OMAP 44-2004, f. & cert. ef. 7-1-04; OMAP 25-2006, f. 6-14-06, cert. ef. 7-1-06; DMAP 12-2007, f. 6-29-07, cert. ef. 7-1-07; DMAP 15-2007, f. 12-5-07, cert. ef. 1-1-08; DMAP 37-2008, f. 12-11-08, cert. ef. 1-1-09; DMAP 51-2015, f. 9-22-15, cert. ef. 10/1/2015; DMAP 36-2017(Temp), f. 9-14-17, cert. ef. 9-15-17 thru 3-13-18; DMAP 12-2018, amend filed 03/07/2018, effective 3/8/2018; DMAP 101-2023, amend filed 12/29/2023, effective 1/1/2024

Statutory/Other Authority: ORS 413.042 & 414.065

Statutes/Other Implemented: ORS 414.065