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View AnswerTo document the inability to perform Mobility Related Activities of Daily Living (MRADLs), a clinician must conduct a mandatory face-to-face mobility evaluation. This evaluation serves as the primary record for Medicare’s medical necessity determination and must focus on the patient’s functional limitations exclusively within the home environment.
According to the documentation requirements, the medical record must include:
- Objective Findings of Impairment: The clinician must record specific, observable deficits in tasks such as bed mobility, transferring (e.g., from bed to chair or toilet), walking, wheeling, and negotiating stairs.
- The "Within the Home" Rule: Documentation must demonstrate that the deficit exists inside the residence (bedroom, bathroom, kitchen, or hallways). Limitations occurring only in the community, such as navigating parking lots, do not satisfy primary coverage criteria.
- Insufficiency of Other Devices: The record must explain why a cane, walker, or manual wheelchair is inadequate. This includes noting issues like unsteady gait, fatigue, pain, or the need for hands-on assistance when using these devices.
- Precise Clinical Language: The clinician should use specific justifications, such as an inability to propel a manual wheelchair due to upper extremity weakness (e.g., a 3/5 MMT rating) or severe balance deficits that prevent safe transfers.
- Physical Exam Details: The notes must include specific measurements of range of motion, muscle strength, coordination, and safety awareness to justify the chosen device.
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