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Face-to-Face Mobility Examination Report
For a Power Wheelchair
Patient Information Date of Face to Face Examination: _
Name: HICN:
Mailing Address: Telephone: ( )
City: State: Zip: DOB: Age: Male Female
Physician or Treating Practitioner Information
Name: UPIN:
Mailing Address: Telephone: ( )
City: State: Zip:
Current Symptoms, Related Diagnosis, and History (Must Be Completed by Treating Practitioner)
What medical conditions/diseases limit your patient’s mobility in their home?
How do the above conditions interfere with their ability to perform Activities of Daily Living (ADLs) in their home?
Abnormality of Gait
De-conditioning
Edema
Other, Please describe:
Fatigue
Numbness
Pain
Shortness of Breath
Tremor
Weakness
Cerebral Vascular Disease / CVA
COPD
CHF
Degenerative Joint Disease
Diabetes/Neuropathy
Other, Please describe:
Hemiplegia/Hemiparesis
Multiple Sclerosis
Muscular Dystrophy
Osteoarthritis
Paraplegia/paresis
Parkinson’s Disease
Renal Failure
Rheumatoid Arthritis
Physical Exam (Must Be Completed by Treating Practitioner)
Ht: Wt: B/P: Pulse
(resting):
Pulse
(exertion):
Shortness of Breath
at Rest?
Y N
Shortness of Breath
w/exertion?
Y N
Is O2 required?
Y N
Number of Liters? O2 Sats?
Any current pressure
sores?
Y N
History of pressure
sores?
Y N
Location? Stage? Able to shift weight?
Y N
Poor Balance
Y N
Poor Endurance
Y N
History of Falls
Y N
Risk of Falls
Y N
Significant Edema
Y N
Upper Body Weakness: _ Mild Moderate Severe Gait Pattern: ___Non-Ambulatory Upper Body Pain: Mild _ Moderate Severe __Max Assist Lower Body Weakness: Mild _ Moderate Severe Mod Assist
Lower Body Pain: Mild Moderate Severe _ Ataxic Contracture: RUE / LUE RLE / LLE Shuffling
Page 2 of 3
Face-to-Face Examination Report
For a Power Wheelchair
Patient Name: ___________________ Treating Practitioner: ____________
- Please select all of the Activities of Daily Living (ADLs) that your patient is unable to perform inside their home
without the aid of powered mobility equipment.
Feeding
Bathing
Grooming
Moving from Room to Room
Dressing
Toileting
Other, Please describe____________________ - Why can’t a cane or walker meet this patient’s mobility needs in the home?
- Why can’t a manual wheelchair meet this patient’s mobility needs in the home?
- How has your patient’s condition changed so that they now require a Power Wheelchair to complete their ADLs?
- Please indicate why a Power Operated Vehicle (POV)/Scooter will not meet this patient’s mobility needs in the
home
Patient Requires Joy Stick Controller
Patient Presents Poor Trunk Stability
Patient Requires Adjustable Height Armrests
Patient Unable to Safely Operate a POV
Patient Requires Elevating Leg Rests
Patient Requires Fully Reclining Back
Patient’s Home Presents Insufficient Space for Maneuverability
Other, Please describe______________________________
- Does your patient have the physical and mental abilities to safely operate a Power Wheelchair in the home?
Yes No - Is your patient willing and motivated to use a power wheelchair in the home?
Yes No
Page 3 of 3
Patient Name: _________________ Treating Practitioner: ____________
If you intend to prescribe a power mobility device (PMD) for your patient, you should:
I. Complete this form for your patient’s medical record;
II. Enter a specific chart note in the patient’s medical record indicating that you have:
a) Conducted a Face-to-Face Examination;
b) Completed a Face-to-Face Mobility Evaluation Report;
c) Completed a Prescription for a specific PMD.
III. Provide copies of the prescription, the report, and the chart note detailed above to the power mobility
device provider.
If you do not believe that the documentation listed above provides adequate support for the PMD prescription,
you may provide additional supporting documentation. Additional documentation may include physician office
records, hospital records, nursing home records, home health agency records, records from other healthcare
professionals, and test reports.
NOTE:
The Centers for Medicare and Medicaid Services (CMS) recognizes the increased documentation burden for
PMDs. Therefore, code (G0372) has been established to recognize the additional physician service and
resources required to establish and document the need for PMDs. The payment amount for this documentation
preparation is $21.60 in addition to the office visit. Additional information can be obtained through CMS’
MedLearn Matters Number 4121 (http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4121.pdf).
I certify that the information provided is a true and accurate representation of my patient’s current condition and
that a major reason for the visit was a mobility examination. I hereby incorporate this document into my patient’s
medical record.
Physician or Treating Practitioner
Signature:__________________________________________Date:_____________________
