lrLIE Wheelchairs

Posilioning & Mobililg for Senior

'The Wheelchair ExperE'

5?00 West 7Bh Sheel

Bloominglon, Mlrl 55q3SPhqnq t95el9q | -6800

Fax tg5?f9qt-6008

Durable Medical Equipment Prescription

Date Of Birth:Patient Name:

Address:

Phvsician Name:

Diagnosis/ICD-9 codes :

Length ofNeed: Lifetime # of Months Height:_ Weight:A standard wheelchair HcPcs : K00011K0002 wheelchair is covered if:a) Criteria A,B,C,D and E are met; and

b) Criteria F or G is met

c) Criteria H must be met for K0002

d) Criteria I must be met for K0003

e) Criteria J must be mer for K0004

f) Criteria K must be met for K0006

g) Criteria L must be met for K0007

Additional coverage criteria for specific devices are listed below.

Initial all that

Apply

Section B

The patient's mobility limitation cannot be sufficiently resolved by the use of anappropriately fitred cane or walker (Describe ambulation status)

Section A The patient has a mobility limitation that significantly impairs his/her abilityto participate in one or more mobility-related activities of daily living (MRADL'S)such as toileting, feeding, dressing, grooming and bathing in customary locations in thehome. A mobility limitation is one that:

l) Prevent the patient from accomplishing an MRADL entirely, or2) Places the patient at reasonably determined heightened risk of morbidiw ormortality secondary to the attempts to perform an MRADL; or3) Prevents the patient from completing an MRADL within a reasonable time frame

(Describe ADL status)

Section C

The patient's home provides adequate access between rooms, maneuvering space andsurfaces for use of the manual wheelchair that is provided

LTC Wheelchairs 5200 W 78'h St Bloominglon, MN 55435 ph:(952) 941-6800 f: (952 941-6006)

Patient Name Date of Birth

Section D

Use of the manual wheelchair will significantly improve the patient's ability to

participate in MRADLs and the patient will use it on a regular basis in the home

Section E

The patient has not expressed an unwillingness to use the manual wheelchair that is

provided in the home

Section F

The patient has sufficient upper extremity function and other physical and mental

capabilities needed to safely self-propei the uranual wheelcliaii-tliat is provided in the

home during a typical day

Section G

The patient has a caregiver who is available, willing and able to provide assistance with

the wheelchair

Section H ( For K0002 )

The patient requires lower wheelchair seat height because of short stature or to enable

the beneficiary to place his/her feet on the ground for propulsion

Section I (For K0003)

The patient requires a lightweight wheelchair because:

a) The patient cannot self propel in a standard wheelchair in the home

b) The patient can and does propel in a lighrweight wheelchair

c) The patient has UiE limitations of strength, endurance, range of motion, presence ofpain, or deformity or absence of one or both upper extremities are relevant to the

assessment of upper extremity function due to diagnosis of:

(Circle all that apply)

Weakness, Rotator Cuff Injury, CVA, COPD, Arthritis, Other

Section J fi'or K0004)

A high strength lightweight wheelchair is covered when a patient meets the Criteria in

(l) and/or (2): AND

a) The patient engages in frequent activities that cannot be performed in a std or lt. rwt

wheelchair OR

b) The patient requires a special seat width, depth, heights or tilted and spends at least

2 hours per day in the wheelchair OR

c) The patient requires a low seat to floor height to be able to independently foot propel

due to short stature

LTC Wheelchairs 5200 W 78e St Bloomington, MN 55435 ph:(952) 941-6800 f: (952941-6006)

Patient Name Dqre nf Ftirrh

Assessment of Need:( Include home situation, physical limitation and mental capabilities):

Recommendation: tr Std. Wheelchair trHemi-height wheelchair s Lightweight wheelchairK0001 K0002 K0003cltrlElevating Legrest trtrFootrest nHigh Shength Lightweight trHeavy Duty trExtra Heavy DutyRL RL K0004 K0006 K0007trBrake extensions DGeneral purpose Cushion DSkin protection Cushion trGeneral purpose BackE0961 8260t E2622 E2611420"-22" Seat Width tr24" Seat Width trSuper hemi Height UOther

82201

TherapistAlurse Initials and printed Name:TherapistA{urse S i gnature : Date:Prescribing Physician(Print Name)

Prescribing Physician's Signature: Date:

Date of Birth

Patients weight is befween 250-300# or has severe spasticity

Section L (For K0007)

Patients weight is > 300#

Section J (-For E1126-Reclining Back)Must be added to a K0003 or K0004 and have eitlier/or:

a) High risk of developing pressure ulcer and is unable to perform a functional weightshift

b) The patient utilizes intermittent catheterization for bladder management and isunable to independently transfer from the wheelchair to the bed

Please fax this form back to LTC wheelchairs at (952)94l-6006