Navigating the U.S. Medicare guidelines for documenting the medical need for custom seating can seem daunting. We’ll break it down for you here.
To start, Medicare requires that a beneficiary needing custom seating is seen by a Physical or Occupational Therapist to evaluate the seating needs, in addition to a physician. The documentation generated by the physician and therapist will need to contain three primary pieces of information:
- The beneficiary meets Medicare’s coverage criteria for the wheelchair on which the seating will be installed.
- The beneficiary’s condition and diagnosis meet Medicare’s criteria for custom seating. Specifically:
- For custom backs – there are documented, significant postural asymmetries that are the result of a qualifying diagnosis.
- For custom cushions – there is a documented, current pressure ulcer or history of pressure ulcer on the lower back, sacrum, hip or buttock, OR documented absent/impaired sensation in these same areas, OR documented inability to perform a functional weight shift, as the result of a qualifying diagnosis.
- A statement clearly explaining why a prefabricated seating system will not sufficiently meet the medical need of the beneficiary. (This piece of information cannot come from the physician alone, it must be in the written therapy evaluation).
Continue reading, go to Part Two!
If you need assistance with documentation review for your Ride Custom Back and/or Cushion order, we can help, and at no cost to you. Simply contact our Reimbursement Department at (866) 781-1633 x 312.