Nursing Home Finder | Nursing Home Reviews | Healthcare News | Medicare | Medigap
Mobility Assessment Form - Healthcare Quality Improvement Campaign
Looking For Medicare Insurance call 1-800-MEDIGAP

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?

Looking for Medicare Supplemental Insurance call 1-800-MEDIGAP

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: ____________

  1. 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____________________
  2. Why can’t a cane or walker meet this patient’s mobility needs in the home?
  3. Why can’t a manual wheelchair meet this patient’s mobility needs in the home?
  4. How has your patient’s condition changed so that they now require a Power Wheelchair to complete their ADLs?
  5. 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______________________________

  1. Does your patient have the physical and mental abilities to safely operate a Power Wheelchair in the home?
    Yes No
  2. 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:_____________________
Category

Mobility Assessment Form

Tags

References

Consumers

We are working hard top provide valuable information for individuals and families. We make updates regularly so check back often. Join our Mailing list for UPDATE NOTICES and more information.

Providers

Frontline workers and Care Givers  ..WE APPRECIATE YOU! We are dedicated to helping you provide the highest Quality of Care and working hard to help Advance Quality Care in America.

Facility Owners

If you are a facility owner, we understand your unique position especially during these crazy times that is why we are teaming with the top professionals in research, legal and government to help you rise to the occasion.

Trending news and information in the healthcare community!

Author Recent Posts Jeff Cline Latest posts by […]
Author Recent Posts Jeff Cline Latest posts by […]
Author Recent Posts Jeff Cline Latest posts by […]
Author Recent Posts Jeff Cline Latest posts by […]

More... HEALTHCARE NEWS

This site is a non-government resource , providing information in a simple and straightforward way.

If you’re looking for the government’s Medicare site, please navigate to www.medicare.gov.

Nothing on this website should ever be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition, including decisions about the correct medication for your condition, as well as prior to undertaking any specific exercise or dietary routine.

The purpose of this communication may be a solicitation of insurance or product offered from various advertising networks. Contact will be made by a licensed insurance agent/producer or insurance company or adviser. Medicare Supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program. Many of our advertisers sell insurance offered from a number of different Medicare Supplement insurance companies.

This site is a non-government resource , providing information in a simple and straightforward way. Nothing on this website should ever be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition, including decisions about the correct medication for your condition, as well as prior to undertaking any specific exercise or dietary routine. The purpose of any insurance communication is the solicitation of insurance. Contact will be made by a licensed insurance agent/producer or insurance company. Medicare Supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program. Our advertisers sell insurance offered from a number of different Medicare Supplement insurance companies. The trademarks or service marks sold or described herein, or in blogs or advertisements, are owned by the respective trademark owners and nothing herein should be construed as a representation by this site owner or team members.