CMS-1590-FC Regulation Effective July 1, 2013
This document is proprietary to Preferred Homecare and for educational purposes only. This information does not guarantee payment from Medicare. January 2014
Written Order Prior to
Delivery (WOPD)
Beneficiary’s name
Detailed description of DME item(s)
(e.g. Standard, Lightweight, Heavy Duty)
Prescribing practitioner’s NPI
Signature & signature date of the
prescribing practitioner (Hand written or
electronic, no stamps)
Date of the order & start date (If start
date is different from the date of the order)
Prescribing practitioner’s printed name
(Must be PECOS enrolled)
Wheelchair accessories (e.g. leg rests, anti-
tipper, brake extension, safety belt)
The WOPD must be completed on or after the date of the
Face to Face visit & completed by the same practitioner
Qualifying Guidelines
Documented diagnosis that is related to
mobility impairment
Documentation that a cane or walker
will not meet the patient’s mobility
Documentation of the patient’s need for
the wheelchair to complete MRADL
(Mobility Related Activities to Daily
Living) in the HOME environment
Coverage will be denied w/out
reference to MRADL activities
Patient is capable of self-propelling the
wheelchair or has a caregiver who is
willing to assist in the home
Patient has a home that has sufficient
space to maneuver the wheelchair
Patient has shown a willingness to use
the wheelchair in the home on a regular
Documentation should include
limitations of strength, endurance,
range of motion, or coordination,
presence of pain, or deformity or
absence of one or both upper
extremities are relevant to the
assessment of upper extremity function
Face to Face/Chart Notes
Documented in-person visit within 6
months prior to the written order
Must reference the medical necessity
of the wheelchair and accessories by
addressing the qualifying guidelines (A
diagnosis alone is not sufficient to meet Medicare
coverage criteria)
Conducted by MD, DO, PA, NP or CNS
Must be signed by MD or DO
(Hand written or electronic, no stamps)
Chart Note Examples
Pt had a stroke and is having difficulty
getting around in her home. She is
confined to the bed and needs a
wheelchair to perform activities of daily
living, like bathing and toileting. She is
unable to use a cane or walker because
she is so unsteady that she will fall and
injure herself. She is participating in
physical therapy to improve her cognitive
abilities. Her husband will assist her with
using the wheelchair in the home until
she is able to propel herself.
Patient diagnosed with Multiple Sclerosis,
unable to now maneuver throughout her
home unassisted and has fallen several
times trying to access the toilet using a
cane. She tried using a walker and feels
unsteady and has to grab onto the
furniture to not fall. She needs the
wheelchair to perform activities of daily
living. She states she feels comfortable
using a wheelchair and is able to self-
See CMS National Coverage Determination (NCD) & Local
Coverage Determination (LCD) for complete coverage policy
Chart Note Examples are for illustrative purposes only and not
specific to any patient’s condition or treatment plan.
Medicare Requirements