Golden Technologies GP620SS User Manual

includes fixed in-line joystick

includes fixed in-line joystick

Red

Phone: [phone]

STANDARD COLORS -

Please Choose One!

Totals

K0824 - Group II, Heavy Duty, Power Wheelchair

X

GP620SS

SEATING OPTIONS -

Additional Charges May Apply

OPTIONS and ACCESSORIES -

Additional Charges May Apply

Blue

$

Fax: [phone]

GP620SS

Compass HD

Power Wheelchair

Evaluated By:

Mark For:

Date:

Account # :

450 lb weight capacity

Model

GP620SS - Center Wheel

* Battery range will vary due to rider weight, drive surface and drive slope

Company:

Address:

Phone:

GOLDEN COMPASS HD ™ - Center-Wheel Drive

with 20" X 20" Van / Pan Seat

SPECIFICATIONS

Length

39.8"

Width

Turning

Radius

20" 1225"

Top

Speed
4 mph

Range*

(miles)

MSRP

$6,697.00

$

Two-Tone Vinyl, Highback Van/Pan Seat

Coffee/Sand

Gray/Charcoal

Proflex Seating
Frame

(2) 22NF Batteries E2361

Detachable, Height
Adjustable Armrests

Swing Away Desk Arm E1028
Oxygen Tank Holder
Elevating Leg Rests (pair) K0195
Stump Support E1020

Standard configuration
mount, flip up armrests and

a lap belt.
Standard configuration
mount, flip up armrests and

a lap belt.

MSRP MSRP

$500.00

E0973

E2208

$250.00

$269.00
$159.00
$250.00

$258.00

MSRP

$500.00

$500.00

Cane Holder Tube
Crutch Holder E2207
Walker Holder
Quad Cane Holder E2207
Powerchair Cover
Rear Basket N/A

Choose 1 Size

Select

One!

16"
18"

Depth

20"

Width

E2207

K0108

N/A

20" 22" 24"16" 18"

$

$55.00

$84.00

$105.60

$86.40

$117.60

$72.00

Swing Away Footrests K0052*

* Replacement Only Flag

Disclaimer:

Golden Technologies reserves the right to alter any specification or MSRP without prior notice!

The HCPCS codes provided are recommendations only and do not guarantee coverage or
payment for the item listed. Suppliers are responsible for determining the applicable billing
codes as well as any and all bundling or coverage guidelines.

$225.00

Pack N' Go

N/A
N/A

$62.40
$19.20

$

Total Cost

GP620SS M 2014-01

If all the LCD coverage criteria are met, add modifier KX to the PWC base code; otherwise DO NOT use modifier KX.

If the PWC is only to be used for mobility outside the home, modifier GY must be added to the base code.

Modifier Reminders

Items billed before a signed and dated order has been received must be submitted with modifier EY added to each affected HCPCS code.

NOTE:

The mobility deficit cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker

The patient does not have sufficient upper extremity function to self propel an optimally-configured manual wheelchair in the home to perform MRADLs

The note clearly indicates that a major reason for the visit was a mobility examination.

The patient is unable to safely transfer to and from a POV and/or unable to operate the tiller steering system and/or unable to maintain postural stability

using a POV in the home and/or the patient’s home provides inadequate access between rooms, maneuvering space, and surfaces for the operation of

Face-to-face medical evaluation meeting all of the following criteria:

BEFORE

The findings are documented in a detailed narrative note in the format used for other entries.

The patient has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living

Proof of Delivery

On-site Home Assessment establishing that:

The beneficiary is able to use the PWC ordered to assist with ADLs in the home

The patient’s home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the PWC that is provided

Description of the item (may be general – e.g., “power mobility device”

The treating physician’s signature

Beneficiary Authorization

Has a date stamp or equivalent documenting supplier’s receipt date

The date the treating physician signed the order

Date stamp or equivalent documents date the supplier received the

Lists the specific base (HCPCS code and narrative description and mfg. name/model), and

Lists all options and accessories that can be billed separately (HCPCS code and narrative description and mfg. name/model), and

Date of completion of the face-to-face examination

Pertinent diagnoses/conditions that relate to the need for the power

Lists the supplier’s charge and Medicare fee schedule allowance for each separately billed item, and

Was signed and dated by physician; and

Written order was received within 45 days after completion of the face-to-face exam and prior to delivering POV to patient.

Detailed Product Description that:

Power Wheel Chair (PWC) Documentation Checklist

Beneficiary’s name

Length of need

All PWC Codes

Detailed Written Order must contain ALL of the following elements:

or may be more specific

Group I PWCs HCPCS Codes K0813 - K0816 and Group II PWCs HCPCS Codes K0820 - K0829

mobility device

The evaluation occurred

(MRADL) in the home

during a typical day

and position while operating the POV in the home and/or the patient’s mental capabilities and physical capabilities are not sufficient for safe mobility

the physician completed 7-element written order.

written order

the PWC that is provided.
The patient has the mental and physical capabilities to safely operate the PWC that is provided or the patient has a caregiver who is unable to

adequately propel an optimally configured manual wheelchair, but is available, willing, and able to safely operate the PWC that is provided.
The patient’s weight is less than or equal to the weight capacity of the PWC that is provided
Use of a PWC will significantly improve the patient’s ability to participate in MRADLs and the patient will use it in the home
The patient has not expressed an unwillingness to use a PWC in the home

Date stamp or equivalent documents date supplier received a copy of the face-to-face exam

Supplier attestation stating that there is no financial relationship between the person completing the face-to-face examination and the supplier

Physicians must document the findings of the face-to-face examination in a detailed narrative note in their charts in the format that they use for
other entries. The note must clearly indicate that a major reason for the visit was a mobility examination.

Many suppliers have created forms which have not been approved by CMS which they send to physicians and ask them to complete. Even if the
physician completes this type of form and puts it in his/her chart, this supplier-generated form is not a substitute for the comprehensive medical
record as noted above. Suppliers are encouraged to help educate physicians on the type of information that is needed to document a patient’s
mobility needs.

See the “Documentation Requirements” section of LCD for Power Mobility Devices for a description of the pertinent information that should be documented
in a face-to-face exam.

The information that the supplier must obtain before submitting a claim to the DME contractor is described in detail in the LCD and Policy Article. However, if
the DME MAC or other Medicare Contractor asks for documentation on individual claims, additional documents (e.g., notes from prior visits, test reports,
etc.) shall also be obtained from the treating physician to provide a historical perspective that reflects the patient’s condition in the continuum of care,
corroborating the information in the face-to-face examination, painting a picture of the patient’s condition and progression of disease over time.

This document is for educational purposes only and should not be considered legal advice.