Face to Face mobility

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Physician's Face to Face Evaluation – CMS’ Documentation Requirements***

Your evaluation should provide pertinent information about the following elements, but may include other details. Each element would not have to be addressed in every evaluation:

Medicare requires Face to Face mobility exam to state “Patient is here for a mobility exam

  • History of the present condition(s) and PMH that is relevant to mobility needs
  • Symptoms that limit ambulation
  • Diagnoses that are responsible for these symptomsMedications or other treatment for these symptoms
  • Progression of ambulation difficulty over time
  • Other diagnoses that may relate to ambulatory problems
  • How far the Pt. can walk without stopping
  • Pace of ambulation
  • What ambulatory assistance (cane, walker, wheelchair, caregiver) is currently used
  • What has changed to now requires use of a power mobility device
  • Ability to stand up from a seated position without assistance
  • Description of the home setting and the ability to perform activities of daily living in the home
  • Pt has a mobility limitation that significantly impairs their ability to participate in 1 or more MRADLs in the home (i.e. bathing, toileting, dressing, eating)
  • Use of a mobility device will significantly improve the Pt.’s ability to participate in MRADLs in the home
  • The mobility deficit cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker
  • Pt. does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to perform MRADLs during a typical day
  • Pt. has a physical and/or mental limitation that prevents safe use of a POV in the home and/or the Pt.’s home provides inadequate access for operation of a POV
  • Pt. has the mental and physical capabilities to safely operate the power wheelchair that is provided or the Pt. has a caregiver who is unable to adequately propel an optimally configured manual wheelchair, but is available, willing, and able to safely operate the power wheelchair that is provided
  • Pt.’s weight is less than or equal to the weight capacity of the PWC that is provided
  • Pt. has not expressed an unwillingness to use a PWC in the home

***Unity Medical offers a comprehensive, no charge, EMR & EHR system called DMDRX.


  • Is CMS approved and produces your Face to Face Exam in a narrative format that is compliant with CMS’ mobility requirements.
  • Guides you in the mobility evaluation, SOAP notes creation, PT/OT Rx, and Mobility Rx.
  • Prints your documents when completed.
  • Increases accuracy, saves time, money, and frustration.

***Unity will register you AND train your staff at NO CHARGE.
Please contact Sharon at 941.623.2810 for DMDRX information.

For question or information, please contact:

Bob Shimko APT at 239-980-2238 or Sharon Furr LPN/CCT at 941-623-2810

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