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LCD for Wheelchair Seating (L15887)

Contractor Information

Contractor Name Palmetto GBA Contractor Number 00885 Contractor Type DMERC

LCD Information

LCD Database ID Number L15887 LCD Title Wheelchair Seating Contractor's Determination Number WCS.0405 AMA CPT / ADA CDT Copyright Statement CPT codes, descriptions and other data only are copyright 2004 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. CMS National Coverage Policy Primary Geographic Jurisdiction AL AR CO FL GA KY LA MS NC NM OK PR SC TN TX VI Oversight Region Region VI CMS Consortium Southern DMERC Region LCD Covers Region C Original Determination Effective Date For services performed on or after 07/01/2004 Original Determination Ending Date Revision Effective Date For services performed on or after 04/01/2005 Revision Ending Date Indications and Limitations of Coverage and/or Medical Necessity For any item to be covered by Medicare, it must: 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this medical policy, “reasonable and necessary” is defined by the following indications and limitations of coverage and/or medical necessity. A general use seat cushion (E2601,E2602) and a general use wheelchair back cushion (E2611-E2612) is covered for a patient who has a wheelchair which meets Medicare coverage criteria. If the patient does not have a covered wheelchair, then the cushion will be denied as not medically necessary. A nonadjustable skin protection seat cushion (E2603,E2604) or an adjustable skin protection seat cushion (K0108) is covered for a patient who meets both of the following criteria: 1) The patient has a wheelchair and the patient meets Medicare coverage criteria for it; and 2) The patient has either of the following: a) Current pressure ulcer (707.03, 707.04, 707.05) or past history of a pressure ulcer (707.03, 707.04, 707.05) on the area of contact with the seating surface; or b) Absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift due to one of the following diagnoses: spinal cord injury resulting in quadriplegia or paraplegia (344.00-344.1), other spinal cord disease (336.0-336.3), multiple sclerosis (340), other demyelinating disease (341.0-341.9), cerebral palsy (343.0-343.9), anterior horn cell diseases including amyotrophic lateral sclerosis (335.0-335.21, 335.23-335.9), post polio paralysis (138), traumatic brain injury resulting in quadriplegia (344.09), spina bifida (741.00-741.93), childhood cerebral degeneration (330.0-330.9), Alzheimer’s disease (331.0), Parkinson’s disease (332.0). A positioning seat cushion (E2605,E2606), positioning back cushion (E2613-E2616, E2620, E2621), and positioning accessory (E0955-E0957, E0960) is covered for a patient who meets both of the following criteria: 1) The patient has a wheelchair and the patient meets Medicare coverage criteria for it; and 2) The patient has any significant postural asymmetries that are due to one of the diagnoses listed in criterion 2b above or to one of the following diagnoses: monoplegia of the lower limb (344.30-344.32, 438.40-438.42) or hemiplegia (342.00-342.92, 438.20-438.22) due to stroke, traumatic brain injury, or other etiology, muscular dystrophy (359.0, 359.1), torsion dystonias (333.4, 333.6, 333.7), spinocerebellar disease (334.0-334.9). A nonadjustable combination skin protection and positioning seat cushion (E2607,E2608) or an adjustable combination skin protection and positioning seat cushion (K0108) is covered for a patient who meets the criteria for both a skin protection seat cushion and a positioning seat cushion. If a skin protection seat cushion, positioning seat cushion, or combination skin protection and positioning seat cushion is provided for a patient who does not meet the stated coverage criteria, but the coverage criteria for another type of cushion are met, payment will be based on the allowance for the least costly medically appropriate alternative; if the criteria for a another type of seat cushion are not met, the provided cushion will be denied as not medically necessary. If a positioning back cushion is provided for a patient who does not meet the stated coverage criteria, but the coverage criteria for a general use back cushion are met, payment will be based on the allowance for the least costly medically appropriate alternative, E2611; if the criteria for a general use back cushion are not met, the provided cushion will be denied as not medically necessary. If a positioning accessory is provided and the criteria are not met, the item will be denied as not medically necessary. A custom fabricated seat cushion (E2609) is covered if criteria (1) and (3) are met. A custom fabricated back cushion (E2617) is covered if criteria (2) and (3) are met: 1) Patient meets all of the criteria for a prefabricated skin protection seat cushion or positioning seat cushion; 2) Patient meets all of the criteria for a prefabricated positioning back cushion; 3) There is a comprehensive written evaluation by a licensed clinician (who is not an employee of or otherwise paid by a supplier) which clearly explains why a prefabricated seating system is not sufficient to meet the patient’s seating and positioning needs. If a custom fabricated cushion is provided for a patient who does not meet the stated coverage criteria, but the coverage criteria for another type of cushion are met, payment will be based on the allowance for the least costly medically appropriate alternative; if the criteria for another type of cushion are not met, the custom fabricated cushion will be denied as not medically necessary. A seat or back cushion that is provided for use with a transport chair (E1037, E1038) will be denied as not medically necessary. The effectiveness of a powered seat cushion (E2610) has not been established. Claims for a powered seat cushion will be denied as not medically necessary. A prefabricated seat cushion, a prefabricated positioning back cushion, or a brand name custom fabricated seat or back cushion which has not received a written coding verification from the SADMERC or which does not meet the criteria stated in the Coding Guidelines section (see Policy Article) will be denied as not medically necessary. Coverage Topic Durable Medical Equipment Wheelchairs

Coding Information

Type of Bill Code Revenue Codes CPT/HCPCS Codes The appearance of a code in this section does not necessarily indicate coverage. HCPCS MODIFIERS: EY - No physician or other licensed healthcare provider order for this item or service KX - Specific required documentation on file HCPCS CODES: SEAT CUSHIONS: E2601 GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH E2602 GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH E2603 SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH E2604 SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH E2605 POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH E2606 POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH E2607 SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH E2608 SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH E2609 CUSTOM FABRICATED WHEELCHAIR SEAT CUSHION, ANY SIZE E2610 WHEELCHAIR SEAT CUSHION, POWERED BACK CUSHIONS: E2611 GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE E2612 GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE E2613 POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE E2614 POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE E2615 POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE E2616 POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE E2617 CUSTOM FABRICATED WHEELCHAIR BACK CUSHION, ANY SIZE, INCLUDING ANY TYPE MOUNTING HARDWARE E2620 POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE E2621 POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE POSITIONING ACCESSORIES: E0955 WHEELCHAIR ACCESSORY, HEADREST, CUSHIONED, ANY TYPE, INCLUDING FIXED MOUNTING HARDWARE, EACH E0956 WHEELCHAIR ACCESSORY, LATERAL TRUNK OR HIP SUPPORT, ANY TYPE, INCLUDING FIXED MOUNTING HARDWARE, EACH E0957 WHEELCHAIR ACCESSORY, MEDIAL THIGH SUPPORT, ANY TYPE, INCLUDING FIXED MOUNTING HARDWARE, EACH E0960 WHEELCHAIR ACCESSORY, SHOULDER HARNESS/STRAPS OR CHEST STRAP, INCLUDING ANY TYPE MOUNTING HARDWARE E0966 MANUAL WHEELCHAIR ACCESSORY, HEADREST EXTENSION, EACH E1028 WHEELCHAIR ACCESSORY, MANUAL SWINGAWAY, RETRACTABLE OR REMOVABLE MOUNTING HARDWARE FOR JOYSTICK, OTHER CONTROL INTERFACE OR POSITIONING ACCESSORY MISCELLANEOUS: A9900 MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS CODE E0992 MANUAL WHEELCHAIR ACCESSORY, SOLID SEAT INSERT E2291 BACK, PLANAR, FOR PEDIATRIC SIZE WHEELCHAIR INCLUDING FIXED ATTACHING HARDWARE E2292 SEAT, PLANAR, FOR PEDIATRIC SIZE WHEELCHAIR INCLUDING FIXED ATTACHING HARDWARE E2293 BACK, CONTOURED, FOR PEDIATRIC SIZE WHEELCHAIR INCLUDING FIXED ATTACHING HARDWARE E2294 SEAT, CONTOURED, FOR PEDIATRIC SIZE WHEELCHAIR INCLUDING FIXED ATTACHING HARDWARE E2618 WHEELCHAIR ACCESSORY, SOLID SEAT SUPPORT BASE (REPLACES SLING SEAT), FOR USE WITH MANUAL WHEELCHAIR OR LIGHTWEIGHT POWER WHEELCHAIR, INCLUDES ANY TYPE MOUNTING HARDWARE E2619 REPLACEMENT COVER FOR WHEELCHAIR SEAT CUSHION OR BACK CUSHION, EACH K0108 WHEELCHAIR COMPONENT OR ACCESSORY, NOT OTHERWISE SPECIFIED K0669 WHEELCHAIR ACCESSORY, SEAT OR BACK CUSHION, DOES NOT MEET SPECIFIC CODE CRITERIA OR NO WRITTEN CODING VERIFICATION FROM SADMERC ICD-9 Codes that Support Medical Necessity The presence of an ICD-9 code listed in this section is not sufficient by itself to assure coverage. Refer to the section on "Indications and Limitation of Coverage and/or Medical Necessity" for other coverage criteria and payment information. For HCPCS codes E2603, E2604, and adjustable skin protection seat cushions billed with code K0108: 138 LATE EFFECTS OF ACUTE POLIOMYELITIS 330.0 - 330.9 331.0 ALZHEIMER'S DISEASE 332.0 PARALYSIS AGITANS 335.0 - 335.21 335.23 - 335.9 336.0 - 336.3 340 MULTIPLE SCLEROSIS 341.0 - 341.9 343.0 - 343.9 344.00 - 344.1 707.03 DECUBITUS ULCER, LOWER BACK 707.04 DECUBITUS ULCER, HIP 707.05 DECUBITUS ULCER, BUTTOCK 741.00 - 741.93 For HCPCS codes E0955-E0957, E0960, E2605, E2606, E2613-E2617, E2620, and E2621: 138 LATE EFFECTS OF ACUTE POLIOMYELITIS 330.0 - 330.9 331.0 ALZHEIMER'S DISEASE 332.0 PARALYSIS AGITANS 333.4 HUNTINGTON'S CHOREA 333.6 IDIOPATHIC TORSION DYSTONIA 333.7 SYMPTOMATIC TORSION DYSTONIA 334.0 - 334.9 335.0 - 335.21 335.23 - 335.9 336.0 - 336.3 340 MULTIPLE SCLEROSIS 341.0 - 341.9 342.00 - 342.92 343.0 - 343.9 344.00 - 344.1 344.30 - 344.32 359.0 CONGENITAL HEREDITARY MUSCULAR DYSTROPHY 359.1 HEREDITARY PROGRESSIVE MUSCULAR DYSTROPHY 438.20 - 438.22 438.40 - 438.42 741.00 - 741.93 For HCPCS codes E2607, E2608, and adjustable skin protection and positioning seat cushions billed with code K0108, either 1) One of the following ICD-9 codes: 138 LATE EFFECTS OF ACUTE POLIOMYELITIS 330.0 - 330.9 331.0 ALZHEIMER'S DISEASE 332.0 PARALYSIS AGITANS 335.0 - 335.21 335.23 - 335.9 336.0 - 336.3 340 MULTIPLE SCLEROSIS 341.0 - 341.9 343.0 - 343.9 344.00 - 344.1 741.00 - 741.93 Or 2) A combination of ICD-9 code 707.03, 707.04, or 707.05 AND one of the following ICD-9 codes: 333.4 HUNTINGTON'S CHOREA 333.6 IDIOPATHIC TORSION DYSTONIA 333.7 SYMPTOMATIC TORSION DYSTONIA 334.0 - 334.9 342.00 - 342.92 344.30 - 344.32 359.0 CONGENITAL HEREDITARY MUSCULAR DYSTROPHY 359.1 HEREDITARY PROGRESSIVE MUSCULAR DYSTROPHY 438.20 - 438.22 438.40 - 438.42 For HCPCS code E2609: 138 LATE EFFECTS OF ACUTE POLIOMYELITIS 330.0 - 330.9 331.0 ALZHEIMER'S DISEASE 332.0 PARALYSIS AGITANS 333.4 HUNTINGTON'S CHOREA 333.6 IDIOPATHIC TORSION DYSTONIA 333.7 SYMPTOMATIC TORSION DYSTONIA 334.0 - 334.9 335.0 - 335.21 335.23 - 335.9 336.0 - 336.3 340 MULTIPLE SCLEROSIS 341.0 - 341.9 342.00 - 342.92 343.0 - 343.9 344.00 - 344.1 344.30 - 344.32 359.0 CONGENITAL HEREDITARY MUSCULAR DYSTROPHY 359.1 HEREDITARY PROGRESSIVE MUSCULAR DYSTROPHY 438.20 - 438.22 438.40 - 438.42 707.03 DECUBITUS ULCER, LOWER BACK 707.04 DECUBITUS ULCER, HIP 707.05 DECUBITUS ULCER, BUTTOCK 741.00 - 741.93 For HCPCS codes E2601, E2602, E2611, E2612, E2618, and E2619: Not Specified For codes A9900, E2610, and E2619: None Diagnoses that Support Medical Necessity Refer to previous section. ICD-9 Codes that DO NOT Support Medical Necessity For the specific HCPCS codes indicated above, all ICD-9 codes that are not specified in the preceding section. For HCPCS codes E2610 and E2619, all ICD-9 codes ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation Diagnoses that DO NOT Support Medical Necessity For the specific HCPCS codes indicated above, all diagnoses that are not specified in the previous section. For HCPCS codes E2610 and E2619, all diagnoses.

General Information

Documentation Requirements Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider" (42 U.S.C. section 13951 (e)). It is expected that the patient's medical records will reflect the need for the care provided. The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available to the DMERC upon request. An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available to the DMERC upon request. Items delivered before a signed written order has been received by the supplier must be submitted with an EY modifier added to each affected HCPCS code. The ICD-9 code which justifies the need for these items must be included on the claim. For a nonadjustable skin protection seat cushion (E2603,E2604) or an adjustable skin protection seat cushion (K0108), a KX modifier should be added to the code if either criterion (a), (b), or (c) is met: a) If there is a past history of or current pressure ulcer in the area of contact with the seating surface; or b) If there is absent or impaired sensation in the area of contact with the seating surface due to one of the diagnoses listed as a covered diagnosis; or c) If there is an inability to carry out a functional weight shift due to one of the diagnoses listed as a covered diagnosis. For a positioning seat cushion (E2605,E2606), positioning back cushion (E2613-E2616, E2620, E2621), or positioning accessory (E0955-E0957, E0960), a KX modifier should be added to the code if the patient has significant postural asymmetries due to one of the diagnoses listed as a covered diagnosis. For a nonadjustable combination skin protection and positioning seat cushion (E2607,E2608) or an adjustable skin protection and positioning seat cushion (K0108), a KX modifier should be added to the code if criterion (a) or (b) or (c) is met and criterion (d) is met: a) If there is a past history or current pressure ulcer in the area of contact with the seating surface; or b) If there is absent or impaired sensation in the area of contact with the seating surface due one of the diagnoses listed as a covered diagnosis for skin protection cushions (except 707.03, 707.04, 707.05); or c) If there is an inability to carry out a functional weight shift due one of the diagnoses listed as a covered diagnosis for skin protection cushions (except 707.03, 707.04, 707.05); and d) If the patient has significant postural asymmetries due to one of the diagnoses listed as a covered diagnosis for positioning cushions. For a custom fabricated seat or back cushion (E2609, E2617), a KX modifier should be added to the code if criterion (a) is met and criterion (b), (c), or (d) is met: a) For E2609 or E2617, there is a comprehensive written evaluation by a licensed clinician (who is not an employee of or otherwise paid by a supplier) which explains why a prefabricated seating system is not sufficient to meet the patient’s seating and positioning needs; b) For E2609, there is a past history of or current pressure ulcer in the area of contact with the seating surface; or c) For E2609, there is absent or impaired sensation in the area of contact with the seating surface or an inability to carry out a functional weight shift due to one of the diagnoses listed as a covered diagnosis for skin protection cushions; d) For E2609 or E2617, the patient has significant postural asymmetries due to one of the diagnoses listed as a covered diagnosis for positioning cushions. If the requirements for the KX modifier are not met, the supplier may submit additional documentation with the claim to justify coverage, but the KX modifier must not be used. When billing for a custom fabricated cushion (E2609, E2617), the claim must include the manufacturer and model name/ number of the product (if applicable), or if not, a detailed description of the product that was provided. Claims for adjustable cushions billed with code K0108 must clearly state “cushion” and must include the name of the manufacturer, the product name, the model number, and the width of the cushion which was provided. This information should be entered in the narrative field of an electronic claim or attached to a hard copy claim. The product name/number that is listed must exactly match the complete product name/number that is listed in the Product Classification List on the SADMERC web site. Refer to the Supplier Manual for more information on documentation requirements. Appendices Utilization Guidelines Sources of Information and Basis for Decision ANSI/ RESNA Subcommittee on Wheelchair Seating Standards, Wheelchair Seating-Part 2:Test methods for devices that manage tissue integrity - Seat Cushions, ISO16840-2, www.wheelchairstandards.pitt.edu Brienza, et al, Seat Cushion Optimization: A comparison of interface pressure and tissue stiffness characteristics for spinal cord injured and elderly subjects, Arch Phys Med Rehabil, April 1998, 79:388-394 California Dept. of Consumer Affairs, Technical Bulletin 133, Requirements, Test Procedure and Apparatus for Testing the Flame Retardance of Resilient Materials Used in Upholstered Furniture, March 2000, www.dca.ca.gov/bhfti/bulletin.htm Sprigle, et al, Development of uniform terminology and procedures to describe wheelchair cushion characteristics, J Rehabil Res Devel, July/Aug 2001, 38(4):449-461 Sprigle, et al, Reduction of Sitting Pressures with Custom Contoured Cushions, J Rehab Res Devel, 1990, 27(2):127-134 Advisory Committee Meeting Notes Refer to the original LCD. Start Date of Comment Period 12/03/2001 End Date of Comment Period 01/21/2002 Start Date of Notice Period 03/01/2004 Revision History Number WCS.004 Revision History Explanation Revision Effective Date: 04/01/2005 HCPCS CODES AND MODIFIERS: Added: E2291-E2294 Revision Effective Date: 01/01/2005 INDICATIONS AND LIMITATIONS OF COVERAGE: Added references to codes E2620, E2621 Replaced K codes with new E codes Added statements related to adjustable seat cushions HCPCS CODES: Added codes E2620, E2621, E2618, E2619 Replaced K codes with new E codes (E2601-E2617, E2619) ICD-9 CODES SUPPORTING MEDICAL NECESSITY: Added codes E2620, E2621 Replaced K codes with new E codes Corrected the diagnosis set for codes E2607 and E2608 Added statements related to adjustable seat cushions DOCUMENTATION REQUIREMENTS: Added references to codes E2620, E2621 Replaced K codes with new E codes Revised item (d) under the KX modifier requirements for codes E2607 and E2608 Added statements related to adjustable seat cushions Added claim submission requirements for custom fabricated cushions Revised the claim submission requirements for K0108 Revision Effective Date: 10/01/2004 INDICATIONS AND LIMITATIONS OF COVERAGE: Revised acceptable diagnosis codes for decubitus ulcers ICD-9 CODES SUPPORTING MEDICAL NECESSITY: Changed acceptable ICD-9 codes for decubitus ulcers from 707.0 to 707.03, 707.04, 707.05 Corrected the diagnosis set for K0658 to match the narrative description in the Indications and Limitations of Coverage section DOCUMENTATION REQUIREMENTS: Revised general requirements in paragraph 1 Corrected the code range for positioning accessories Revised acceptable diagnosis codes for decubitus ulcers Revision Effective Date: 07/01/2004 HCPCS CODES: Added E0966 Documentation Requirements: Revised the criteria or use of the KX modifier for combination and skin protection and postioning seat cushions. Last Reviewed On Related Documents Article(s) A17985 - Wheelchair Seating – Policy Article – Effective April 2005 LCD Attachments There are no attachments for this LCD

Other Versions

Updated on 11/30/2004 with effective dates 01/01/2005 - N/A Updated on 11/30/2004 with effective dates 01/01/2005 - N/A Updated on 11/07/2004 with effective dates 10/01/2004 - 12/31/2004 Updated on 10/13/2004 with effective dates 10/01/2004 - N/A Updated on 10/13/2004 with effective dates 10/01/2004 - N/A Updated on 09/09/2004 with effective dates 10/01/2004 - N/A Updated on 07/25/2004 with effective dates 07/01/2004 - 09/30/2004 Updated on 05/24/2004 with effective dates 07/01/2004 - N/A Updated on 02/23/2004 with effective dates 07/01/2004 - N/A

This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this policy was developed in cooperation with the contractor's Advisory Committee, which includes representatives from Palmetto GBA.

LCD for Manual Wheelchair Bases (L11443)

Contractor Information

Contractor Name Palmetto GBA Contractor Number 00885 Contractor Type DMERC

LCD Information

LCD Database ID Number L11443 LCD Title Manual Wheelchair Bases Contractor's Determination Number WCA.0405 AMA CPT / ADA CDT Copyright Statement CPT codes, descriptions and other data only are copyright 2004 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. CMS National Coverage Policy CMS Manual System, Pub. 100-3, Medicare National Coverage Determinations Manual, Chapter 1, Section 280.1, 280.3 Primary Geographic Jurisdiction AL AR CO FL GA KY LA MS NC NM OK PR SC TN TX VI Oversight Region Region VI CMS Consortium Southern DMERC Region LCD Covers Region C Original Determination Effective Date For services performed on or after 10/01/1993 Original Determination Ending Date Revision Effective Date For services performed on or after 04/01/2005 Revision Ending Date Indications and Limitations of Coverage and/or Medical Necessity For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this medical policy, the criteria for "reasonable and necessary" are defined by the following indications and limitations of coverage and/or medical necessity. For an item to be covered by Medicare, a written signed and dated order must be received by the supplier before a claim is submitted to the DMERC. If the supplier bills for an item addressed in this policy without first receiving the completed order, the item will be denied as not medically necessary. A wheelchair is covered if the patient's condition is such that without the use of a wheelchair, he would otherwise be bed or chair confined. This basic requirement must be met for coverage of any wheelchair. Payment is made for only one wheelchair at a time. Backup chairs are denied as not medically necessary. One month's rental of a wheelchair is covered if a patient-owned wheelchair is being repaired. A standard hemi-wheelchair (K0002) is covered when the patient requires a lower seat height (17" to 18") because of short stature or to enable the patient to place his/her feet on the ground for propulsion. A lightweight wheelchair (K0003) is covered when a patient: a) Cannot self-propel in a standard wheelchair using arms and/or legs and b) The patient can and does self-propel in a lightweight wheelchair. A high strength lightweight wheelchair (K0004) is covered when a patient meets the criteria in (1) and/or (2): 1) The patient self-propels the wheelchair while engaging in frequent activities that cannot be performed in a standard or lightweight wheelchair. 2) The patient requires a seat width, depth, or height that cannot be accommodated in a standard, lightweight or hemi-wheelchair, and spends at least two hours per day in the wheelchair. A high strength lightweight wheelchair is rarely medically necessary if the expected duration of need is less than three months (e.g., post-operative recovery). Coverage of an ultralightweight wheelchair (K0005) is determined on an individual consideration basis. If a K0005 wheelchair base is determined to be not medically necessary but criteria are met for a less costly wheelchair, payment will be based on the least costly alternative (K0001 - K0004). However, since K0005 is in a different payment category it will be denied as not medically necessary if billed as a purchase. A heavy duty wheelchair (K0006) is covered if the patient weighs more than 250 pounds or the patient has severe spasticity. An extra heavy duty wheelchair (K0007) is covered if the patient weighs more than 300 pounds. When the stated coverage criteria relating to medical necessity are not met, a claim will be considered for coverage if there is additional documentation which justifies the medical necessity for the item in the individual case. If the documentation does not support the medical necessity of the wheelchair which is billed, but does support the medical necessity of a lower level wheelchair, payment will be based on the allowance for the least costly medically acceptable alternative. Coverage Topic Durable Medical Equipment Wheelchairs

Coding Information

Type of Bill Code Revenue Codes CPT/HCPCS Codes The appearance of a code in this section does not necessarily indicate coverage. HCPCS MODIFIERS: EY - No physician or other licensed health care provider order for this item or service HCPCS CODES: E1161 MANUAL ADULT SIZE WHEELCHAIR, INCLUDES TILT IN SPACE E1229 WHEELCHAIR, PEDIATRIC SIZE, NOT OTHERWISE SPECIFIED E1231 WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, RIGID, ADJUSTABLE, WITH SEATING SYSTEM E1232 WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, ADJUSTABLE, WITH SEATING SYSTEM E1233 WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, RIGID, ADJUSTABLE, WITHOUT SEATING SYSTEM E1234 WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, ADJUSTABLE, WITHOUT SEATING SYSTEM E1235 WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITH SEATING SYSTEM E1236 WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITH SEATING SYSTEM E1237 WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITHOUT SEATING SYSTEM E1238 WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITHOUT SEATING SYSTEM K0001 STANDARD WHEELCHAIR K0002 STANDARD HEMI (LOW SEAT) WHEELCHAIR K0003 LIGHTWEIGHT WHEELCHAIR K0004 HIGH STRENGTH, LIGHTWEIGHT WHEELCHAIR K0005 ULTRALIGHTWEIGHT WHEELCHAIR K0006 HEAVY DUTY WHEELCHAIR K0007 EXTRA HEAVY DUTY WHEELCHAIR K0009 OTHER MANUAL WHEELCHAIR/BASE ICD-9 Codes that Support Medical Necessity Not specified. Diagnoses that Support Medical Necessity Not specified. ICD-9 Codes that DO NOT Support Medical Necessity Not specified. ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation Diagnoses that DO NOT Support Medical Necessity Not specified.

General Information

Documentation Requirements Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider" (42 U.S.C. section 13951(e)). It is expected that the patient's medical records will reflect the need for the care provided. The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available to the DMERC upon request. An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available to the DMERC upon request. Items billed to the DMERC before a signed and dated order has been received by the supplier must be submitted with an EY modifier added to each affected HCPCS code. A Certificate of Medical Necessity (CMN), which has been completed, signed, and dated by the treating physician, must be kept on file by the supplier, and made available to the DMERC on request. The CMN for manual wheelchairs is CMS Form 844. The initial claim must include a copy of the CMN. Manual wheelchairs described by codes E1161, E1231-E1234, K0005 and K0009 are eligible for Advance Determination of Medicare Coverage (ADMC). Refer to the ADMC chapter in the Supplier Manual for details concerning the ADMC process. If the DMERC requests documentation of the medical necessity for a K0005 wheelchair, the documentation must include a description of the patient's routine activities. This may include what types of activities the patient frequently encounters and whether the patient is fully independent in the use of the wheelchair. Describe the features of the K0005 base which are needed compared to the K0004 base. When code K0009 or E1229 is billed, the claim must include the manufacturer, the product name/number, and information justifying the medical necessity for the item. Documentation for individual consideration might include information on the patient's diagnosis, the patient's abilities and limitations as they relate to the equipment (e.g., degree of independence/dependence, frequency, and nature of the activities the patient performs, etc.), the duration of the condition, the expected prognosis, and past experience using similar equipment. Refer to the Supplier Manual for more information on documentation requirements. Appendices Utilization Guidelines Refer to Indications and Limitations of Coverage and/or Medical Necessity. Sources of Information and Basis for Decision Reserved for future use. Advisory Committee Meeting Notes Start Date of Comment Period 04/16/1993 End Date of Comment Period 05/31/1993 Start Date of Notice Period 08/01/1993 Revision History Number MWC.004 Revision History Explanation Revision effective date: 04/01/2005 LMRP converted to LCD and Policy Article HCPCS CODES AND MODIFIERS: Added: E1229 DOCUMENTATION REQUIREMENTS: Revised documentation requirements for K0005. Added reference to E1229. Revision effective date: 04/01/2004 CODING GUIDELINES: Revises the definition of codes K0001-K0007, especially seat width and depth.Adds a definition for E1161 Adds a definition for pediatric wheelchairs, E1231-E1238 Revision effective date: 04/01/2003 HCPCS CODES AND MODIFIERS: Added: E1161, E1231-E1238, EY INDICATIONS AND LIMITATIONS OF COVERAGE: Adds standard language concerning coverage of items without an order. CODING GUIDELINES: Moves Definitions section to this section. DOCUMENTATION REQUIREMENTS: Adds standard language concerning use of EY modifier for items without an order. Adds codes E1161 and E1231-E1234 to those eligible for Advance Determination of Medicare Coverage. Revises documentation requirements for K0005 and K0009. The revision dates listed below are the dates the revisions were published and not necessarily the effective dates for the revisions. 01/01/2002 - The revisions include changes in codes, coverage and payment rules, coding guidelines, and documentation requirements, including Advance Determination of Medicare Coverage (ADMC), which have occurred since the policies were last published. 06/01/1997 – Incorporated Indications information into Coverage and Payment Rules section. Added information for K0005 in Coverage and Payment Rules and Documentation section. This LCD was converted from an LMRP on 2/8/2005 Last Reviewed On Related Documents Article(s) A25580 - Manual Wheelchair Bases - Policy Article - Effective April 2005 LCD Attachments CMN Manual Wheelchairs (60,242 bytes) CMN Section C Continuation Form (22,901 bytes)

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This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this policy was developed in cooperation with the contractor's Advisory Committee, which includes representatives from Palmetto GBA.

LCD for Wheelchair Options/Accessories (L11451)

Contractor Information

Contractor Name Palmetto GBA Contractor Number 00885 Contractor Type DMERC

LCD Information

LCD Database ID Number L11451 LCD Title Wheelchair Options/Accessories Contractor's Determination Number WCC.0405 AMA CPT / ADA CDT Copyright Statement CPT codes, descriptions and other data only are copyright 2004 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. CMS National Coverage Policy Pub. 100-3 (Medicare National Coverage Determinations Manual), Chapter 1, Sections 280.1, 280.3 Primary Geographic Jurisdiction AL AR CO FL GA KY LA MS NC NM OK PR SC TN TX VI Oversight Region Region VI CMS Consortium Southern DMERC Region LCD Covers Region C Original Determination Effective Date For services performed on or after 10/01/1993 Original Determination Ending Date Revision Effective Date For services performed on or after 04/01/2005 Revision Ending Date Indications and Limitations of Coverage and/or Medical Necessity For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this medical policy, the criteria for "reasonable and necessary" are defined by the following indications and limitations of coverage and/or medical necessity. For an item to be covered by Medicare, a written signed and dated order must be received by the supplier before a claim is submitted to the DMERC. If the supplier bills for an item addressed in this policy without first receiving the completed order, the item will be denied as not medically necessary. Options and accessories for wheelchairs are covered if the following criteria are met: 1) The patient has a wheelchair that meets Medicare coverage criteria, and 2) The patient's condition is such that without the use of a wheelchair, he would otherwise be bed or chair confined (an individual may qualify for a wheelchair and still be considered bed confined), and; 3) The options/accessories are necessary for the patient to perform one or more of the following activities: a) Function in the home; b) Perform instrumental activities of daily living. The medical necessity for all options and accessories must be documented in the patient's medical record and be available to the DMERC on request. If there is insufficient documentation of medical need, the item will be denied as not medically necessary. ARM OF CHAIR: Adjustable arm height option (E0973,K0017, K0018, K0020) is covered if the patient requires an arm height that is different than that available using nonadjustable arms and the patient spends at least 2 hours per day in the wheelchair. An arm trough (K0106) is covered if patient has quadriplegia, hemiplegia, or uncontrolled arm movements. FOOTREST/ LEGREST: Elevating legrests (E0990, K0046, K0047, K0053, K0195) are covered if: 1) The patient has a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee; or 2) The patient has significant edema of the lower extremities that requires having an elevating legrest; or 3) The patient meets the criteria for and has a reclining back on the wheelchair. NONSTANDARD SEAT FRAME DIMENSIONS: A nonstandard seat width and/or depth (E2201-E2204, E2340-E2343) is covered only if the patient's dimensions justify the need. BATTERIES/ CHARGERS: Up to two batteries (E2360-E2365) at any one time are allowed if required for a power wheelchair. A dual mode battery charger (E2367) is not medically necessary; when it is provided as a replacement, payment is based on the allowance for the least costly medically appropriate alternative, E2366. OTHER POWER WHEELCHAIR ACCESSORIES: An electronic interface (E2351) to allow a speech generating device to be operated by the power wheelchair control interface is covered if the patient has a covered speech generating device. (Refer to the medical policy on Speech Generating Devices for details.) MISCELLANEOUS ACCESSORIES: Anti-rollback device (E0974) is covered if the patient propels himself/herself and needs the device because of ramps. A safety belt/pelvic strap (E0978) is covered if the patient has weak upper body muscles, upper body instability or muscle spasticity which requires use of this item for proper positioning. One example (not all-inclusive) of a covered indication for swingaway, retractable, or removable hardware (E1028) would be to move the component out of the way so that a patient could perform a slide transfer to a chair or bed. A fully reclining back option (E1226) is covered if the patient spends at least 2 hours per day in the wheelchair and has one or more of the following conditions/needs: 1) Quadriplegia; 2) Fixed hip angle; 3) Trunk or lower extremity casts/braces that require the reclining back feature for positioning; 4) Excess extensor tone of the trunk muscles; and/or 5) The need to rest in a recumbent position two or more times during the day and transfer between wheelchair and bed is very difficult. A crutch and cane holder (K0102) is not medically necessary. Coverage Topic Durable Medical Equipment Wheelchairs

Coding Information

Type of Bill Code Revenue Codes CPT/HCPCS Codes The appearance of a code in this section does not necessarily indicate coverage. HCPCS MODIFIERS: EY - No physician or other licensed health care provider order for this item or service GY - Item or service statutorily excluded or does not meet the definition of any Medicare benefit KC - Replacement of special power wheelchair interface RP - Replacement HCPCS CODES: ARM OF CHAIR: E0973 WHEELCHAIR ACCESSORY, ADJUSTABLE HEIGHT, DETACHABLE ARMREST, COMPLETE ASSEMBLY, EACH K0015 DETACHABLE, NON-ADJUSTABLE HEIGHT ARMREST, EACH K0017 DETACHABLE, ADJUSTABLE HEIGHT ARMREST, BASE, EACH K0018 DETACHABLE, ADJUSTABLE HEIGHT ARMREST, UPPER PORTION, EACH K0019 ARM PAD, EACH K0020 FIXED, ADJUSTABLE HEIGHT ARMREST, PAIR K0106 ARM TROUGH, EACH L3964 SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED, ADJUSTABLE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L3965 SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED, ADJUSTABLE RANCHO TYPE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L3966 SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED, RECLINING, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L3968 SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED, FRICTION ARM SUPPORT (FRICTION DAMPENING TO PROXIMAL AND DISTAL JOINTS), PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L3969 SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPPORT, MONOSUSPENSION ARM AND HAND SUPPORT, OVERHEAD ELBOW FOREARM HAND SLING SUPPORT, YOKE TYPE SUSPENSION SUPPORT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L3970 SEO, ADDITION TO MOBILE ARM SUPPORT, ELEVATING PROXIMAL ARM L3972 SEO, ADDITION TO MOBILE ARM SUPPORT, OFFSET OR LATERAL ROCKER ARM WITH ELASTIC BALANCE CONTROL L3974 SEO, ADDITION TO MOBILE ARM SUPPORT, SUPINATOR FOOTREST/LEGREST: E0951 HEEL LOOP/HOLDER, ANY TYPE, WITH OR WITHOUT ANKLE STRAP, EACH E0952 TOE LOOP/HOLDER, ANY TYPE, EACH E0990 WHEELCHAIR ACCESSORY, ELEVATING LEG REST, COMPLETE ASSEMBLY, EACH E0995 WHEELCHAIR ACCESSORY, CALF REST/PAD, EACH E1020 RESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCHAIR K0037 HIGH MOUNT FLIP-UP FOOTREST, EACH K0038 LEG STRAP, EACH K0039 LEG STRAP, H STYLE, EACH K0040 ADJUSTABLE ANGLE FOOTPLATE, EACH K0041 LARGE SIZE FOOTPLATE, EACH K0042 STANDARD SIZE FOOTPLATE, EACH K0043 FOOTREST, LOWER EXTENSION TUBE, EACH K0044 FOOTREST, UPPER HANGER BRACKET, EACH K0045 FOOTREST, COMPLETE ASSEMBLY K0046 ELEVATING LEGREST, LOWER EXTENSION TUBE, EACH K0047 ELEVATING LEGREST, UPPER HANGER BRACKET, EACH K0050 RATCHET ASSEMBLY K0051 CAM RELEASE ASSEMBLY, FOOTREST OR LEGREST, EACH K0052 SWINGAWAY, DETACHABLE FOOTRESTS, EACH K0053 ELEVATING FOOTRESTS, ARTICULATING (TELESCOPING), EACH K0195 ELEVATING LEG RESTS, PAIR (FOR USE WITH CAPPED RENTAL WHEELCHAIR BASE) NONSTANDARD SEAT FRAME DIMENSIONS: E1011 MODIFICATION TO PEDIATRIC SIZE WHEELCHAIR, WIDTH ADJUSTMENT PACKAGE (NOT TO BE DISPENSED WITH INITIAL CHAIR) E2201 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME, WIDTH GREATER THAN OR EQUAL TO 20 INCHES AND LESS THAN 24 INCHES E2202 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME WIDTH, 24-27 INCHES E2203 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 20 TO LESS THAN 22 INCHES E2204 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 22 TO 25 INCHES E2340 POWER WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME WIDTH, 20-23 INCHES E2341 POWER WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME WIDTH, 24-27 INCHES E2342 POWER WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 20 OR 21 INCHES E2343 POWER WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 22-25 INCHES K0056 SEAT HEIGHT LESS THAN 17" OR EQUAL TO OR GREATER THAN 21" FOR A HIGH STRENGTH, LIGHTWEIGHT, OR ULTRALIGHTWEIGHT WHEELCHAIR REAR WHEELS FOR MANUAL WHEELCHAIRS: E0961 MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK BRAKE EXTENSION (HANDLE), EACH E0967 MANUAL WHEELCHAIR ACCESSORY, HAND RIM WITH PROJECTIONS, ANY TYPE, REPLACEMENT ONLY, EACH E0986 MANUAL WHEELCHAIR ACCESSORY, PUSH ACTIVATED POWER ASSIST, EACH E2205 MANUAL WHEELCHAIR ACCESSORY, HANDRIM WITHOUT PROJECTIONS, ANY TYPE, REPLACEMENT ONLY, EACH E2206 MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK ASSEMBLY, COMPLETE, EACH K0064 ZERO PRESSURE TUBE (FLAT FREE INSERTS), ANY SIZE, EACH K0065 SPOKE PROTECTORS, EACH K0066 SOLID TIRE, ANY SIZE, EACH K0067 PNEUMATIC TIRE, ANY SIZE, EACH K0068 PNEUMATIC TIRE TUBE, EACH K0069 REAR WHEEL ASSEMBLY, COMPLETE, WITH SOLID TIRE, SPOKES OR MOLDED, EACH K0070 REAR WHEEL ASSEMBLY, COMPLETE, WITH PNEUMATIC TIRE, SPOKES OR MOLDED, EACH FRONT CASTERS FOR MANUAL WHEELCHAIRS: K0071 FRONT CASTER ASSEMBLY, COMPLETE, WITH PNEUMATIC TIRE, EACH K0072 FRONT CASTER ASSEMBLY, COMPLETE, WITH SEMI-PNEUMATIC TIRE, EACH K0073 CASTER PIN LOCK,EACH K0074 PNEUMATIC CASTER TIRE, ANY SIZE, EACH K0075 SEMI-PNEUMATIC CASTER TIRE, ANY SIZE, EACH K0076 SOLID CASTER TIRE, ANY SIZE, EACH K0077 FRONT CASTER ASSEMBLY, COMPLETE, WITH SOLID TIRE, EACH K0078 PNEUMATIC CASTER TIRE TUBE, EACH BATTERIES/CHARGERS: E2360 POWER WHEELCHAIR ACCESSORY, 22 NF NON-SEALED LEAD ACID BATTERY, EACH E2361 POWER WHEELCHAIR ACCESSORY, 22NF SEALED LEAD ACID BATTERY, EACH, (E.G. GEL CELL, ABSORBED GLASSMAT) E2362 POWER WHEELCHAIR ACCESSORY, GROUP 24 NON-SEALED LEAD ACID BATTERY, EACH E2363 POWER WHEELCHAIR ACCESSORY, GROUP 24 SEALED LEAD ACID BATTERY, EACH (E.G. GEL CELL, ABSORBED GLASSMAT) E2364 POWER WHEELCHAIR ACCESSORY, U-1 NON-SEALED LEAD ACID BATTERY, EACH E2365 POWER WHEELCHAIR ACCESSORY, U-1 SEALED LEAD ACID BATTERY, EACH (E.G. GEL CELL, ABSORBED GLASSMAT) E2366 POWER WHEELCHAIR ACCESSORY, BATTERY CHARGER, SINGLE MODE, FOR USE WITH ONLY ONE BATTERY TYPE, SEALED OR NON-SEALED, EACH E2367 POWER WHEELCHAIR ACCESSORY, BATTERY CHARGER, DUAL MODE, FOR USE WITH EITHER BATTERY TYPE, SEALED OR NON-SEALED, EACH POWER SEATING SYSTEMS: E1002 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, TILT ONLY E1003 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITHOUT SHEAR REDUCTION E1004 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITH MECHANICAL SHEAR REDUCTION E1005 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITH POWER SHEAR REDUCTION E1006 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITHOUT SHEAR REDUCTION E1007 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITH MECHANICAL SHEAR REDUCTION E1008 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITH POWER SHEAR REDUCTION E1009 WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, MECHANICALLY LINKED LEG ELEVATION SYSTEM, INCLUDING PUSHROD AND LEG REST, EACH E1010 WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, POWER LEG ELEVATION SYSTEM, INCLUDING LEG REST, PAIR E2300 POWER WHEELCHAIR ACCESSORY, POWER SEAT ELEVATION SYSTEM E2301 POWER WHEELCHAIR ACCESSORY, POWER STANDING SYSTEM E2310 POWER WHEELCHAIR ACCESSORY, ELECTRONIC CONNECTION BETWEEN WHEELCHAIR CONTROLLER AND ONE POWER SEATING SYSTEM MOTOR, INCLUDING ALL RELATED ELECTRONICS, INDICATOR FEATURE, MECHANICAL FUNCTION SELECTION SWITCH, AND FIXED MOUNTING HARDWARE E2311 POWER WHEELCHAIR ACCESSORY, ELECTRONIC CONNECTION BETWEEN WHEELCHAIR CONTROLLER AND TWO OR MORE POWER SEATING SYSTEM MOTORS, INCLUDING ALL RELATED ELECTRONICS, INDICATOR FEATURE, MECHANICAL FUNCTION SELECTION SWITCH, AND FIXED MOUNTING HARDWARE POWER WHEELCHAIR DRIVE CONTROL SYSTEMS: E2320 POWER WHEELCHAIR ACCESSORY, HAND OR CHIN CONTROL INTERFACE, REMOTE JOYSTICK OR TOUCHPAD, PROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, AND FIXED MOUNTING HARDWARE E2321 POWER WHEELCHAIR ACCESSORY, HAND CONTROL INTERFACE, REMOTE JOYSTICK, NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, AND FIXED MOUNTING HARDWARE E2322 POWER WHEELCHAIR ACCESSORY, HAND CONTROL INTERFACE, MULTIPLE MECHANICAL SWITCHES, NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, AND FIXED MOUNTING HARDWARE E2323 POWER WHEELCHAIR ACCESSORY, SPECIALTY JOYSTICK HANDLE FOR HAND CONTROL INTERFACE, PREFABRICATED E2324 POWER WHEELCHAIR ACCESSORY, CHIN CUP FOR CHIN CONTROL INTERFACE E2325 POWER WHEELCHAIR ACCESSORY, SIP AND PUFF INTERFACE, NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, AND MANUAL SWINGAWAY MOUNTING HARDWARE E2326 POWER WHEELCHAIR ACCESSORY, BREATH TUBE KIT FOR SIP AND PUFF INTERFACE E2327 POWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, MECHANICAL, PROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL DIRECTION CHANGE SWITCH, AND FIXED MOUNTING HARDWARE E2328 POWER WHEELCHAIR ACCESSORY, HEAD CONTROL OR EXTREMITY CONTROL INTERFACE, ELECTRONIC, PROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS AND FIXED MOUNTING HARDWARE E2329 POWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, CONTACT SWITCH MECHANISM, NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, MECHANICAL DIRECTION CHANGE SWITCH, HEAD ARRAY, AND FIXED MOUNTING HARDWARE E2330 POWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, PROXIMITY SWITCH MECHANISM, NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, MECHANICAL DIRECTION CHANGE SWITCH, HEAD ARRAY, AND FIXED MOUNTING HARDWARE E2331 POWER WHEELCHAIR ACCESSORY, ATTENDANT CONTROL, PROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS AND FIXED MOUNTING HARDWARE E2399 POWER WHEELCHAIR ACCESSORY, NOT OTHERWISE CLASSIFIED INTERFACE, INCLUDING ALL RELATED ELECTRONICS AND ANY TYPE MOUNTING HARDWARE OTHER POWER WHEELCHAIR ACCESSORIES: E1016 SHOCK ABSORBER FOR POWER WHEELCHAIR, EACH E1018 HEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY DUTY POWER WHEELCHAIR, EACH E2351 POWER WHEELCHAIR ACCESSORY, ELECTRONIC INTERFACE TO OPERATE SPEECH GENERATING DEVICE USING POWER WHEELCHAIR CONTROL INTERFACE E2368 POWER WHEELCHAIR COMPONENT, MOTOR, REPLACEMENT ONLY E2369 POWER WHEELCHAIR COMPONENT, GEAR BOX, REPLACEMENT ONLY E2370 POWER WHEELCHAIR COMPONENT, MOTOR AND GEAR BOX COMBINATION, REPLACEMENT ONLY K0090 REAR WHEEL TIRE FOR POWER WHEELCHAIR, ANY SIZE, EACH K0091 REAR WHEEL TIRE TUBE OTHER THAN ZERO PRESSURE FOR POWER WHEELCHAIR, ANY SIZE, EACH K0092 REAR WHEEL ASSEMBLY FOR POWER WHEELCHAIR, COMPLETE, EACH K0093 REAR WHEEL, ZERO PRESSURE TIRE TUBE (FLAT FREE INSERT) FOR POWER WHEELCHAIR, ANY SIZE, EACH K0094 WHEEL TIRE FOR POWER BASE, ANY SIZE, EACH K0095 WHEEL TIRE TUBE OTHER THAN ZERO PRESSURE FOR EACH BASE, ANY SIZE, EACH K0096 WHEEL ASSEMBLY FOR POWER BASE, COMPLETE, EACH K0097 WHEEL ZERO PRESSURE TIRE TUBE (FLAT FREE INSERT) FOR POWER BASE, ANY SIZE, EACH K0098 DRIVE BELT FOR POWER WHEELCHAIR K0099 FRONT CASTER FOR POWER WHEELCHAIR, EACH MISCELLANEOUS ACCESSORIES: A9270 NON-COVERED ITEM OR SERVICE A9900 MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS CODE E0950 WHEELCHAIR ACCESSORY, TRAY, EACH E0958 MANUAL WHEELCHAIR ACCESSORY, ONE-ARM DRIVE ATTACHMENT, EACH E0959 MANUAL WHEELCHAIR ACCESSORY, ADAPTER FOR AMPUTEE, EACH E0971 ANTI-TIPPING DEVICE WHEELCHAIRS E0972 WHEELCHAIR ACCESSORY, TRANSFER BOARD OR DEVICE, EACH E0974 MANUAL WHEELCHAIR ACCESSORY, ANTI-ROLLBACK DEVICE, EACH E0978 WHEELCHAIR ACCESSORY, POSITIONING BELT/SAFETY BELT/PELVIC STRAP, EACH E0981 WHEELCHAIR ACCESSORY, SEAT UPHOLSTERY, REPLACEMENT ONLY, EACH E0982 WHEELCHAIR ACCESSORY, BACK UPHOLSTERY, REPLACEMENT ONLY, EACH E0985 WHEELCHAIR ACCESSORY, SEAT LIFT MECHANISM E1014 RECLINING BACK, ADDITION TO PEDIATRIC SIZE WHEELCHAIR E1015 SHOCK ABSORBER FOR MANUAL WHEELCHAIR, EACH E1017 HEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY DUTY MANUAL WHEELCHAIR, EACH E1028 WHEELCHAIR ACCESSORY, MANUAL SWINGAWAY, RETRACTABLE OR REMOVABLE MOUNTING HARDWARE FOR JOYSTICK, OTHER CONTROL INTERFACE OR POSITIONING ACCESSORY E1029 WHEELCHAIR ACCESSORY, VENTILATOR TRAY, FIXED E1030 WHEELCHAIR ACCESSORY, VENTILATOR TRAY, GIMBALED E1225 WHEELCHAIR ACCESSORY, MANUAL SEMI-RECLINING BACK, (RECLINE GREATER THAN 15 DEGREES, BUT LESS THAN 80 DEGREES), EACH E1226 WHEELCHAIR ACCESSORY, MANUAL FULLY RECLINING BACK, (RECLINE GREATER THAN 80 DEGREES), EACH K0102 CRUTCH AND CANE HOLDER, EACH K0104 CYLINDER TANK CARRIER, EACH K0105 IV HANGER, EACH K0108 WHEELCHAIR COMPONENT OR ACCESSORY, NOT OTHERWISE SPECIFIED K0452 WHEELCHAIR BEARINGS, ANY TYPE ICD-9 Codes that Support Medical Necessity Not specified. Diagnoses that Support Medical Necessity Not specified. ICD-9 Codes that DO NOT Support Medical Necessity Not specified. ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation Diagnoses that DO NOT Support Medical Necessity Not specified.

General Information

Documentation Requirements Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider" (42 U.S.C. section 13951(e)). It is expected that the patient's medical records will reflect the need for the care provided. The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available to the DMERC upon request. An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available to the DMERC upon request. Items billed to the DMERC before a signed and dated order has been received by the supplier must be submitted with an EY modifier added to each affected HCPCS code. Wheelchair options/accessories which require a Certificate of Medical Necessity (CMN) are: E0973, E0990, K0017, K0018, K0020, E1226, K0046, K0047, K0053, and K0195. For these items, a CMN which has been completed, signed and dated by the treating physician must be kept on file by the supplier and made available to the DMERC on request. For these items, the CMN may act as a substitute for a written order if it contains all of the required elements of an order. Depending on the type of wheelchair, the CMN for these options/accessories is either CMS Form 843 (power wheelchairs) or CMS Form 844 (manual wheelchairs). For these items, the initial claim must include a copy of the CMN. Accessories to the wheelchair base must be billed on the same claim as the wheelchair base itself. If multiple pages are needed when a hard copy claim is filed, subtotals must not be entered on each page; the total must be entered only on the last page. When billing option/accessory codes as a replacement (modifier RP), documentation of the medical necessity for the item, make and model name of the wheelchair base it is being added to, and the date of purchase of the wheelchair must be submitted with the claim. When code K0108 is billed, the claim must include a narrative description of the item, the manufacturer, the model name or number (if applicable), and information justifying the medical necessity for the item. If a formal wheelchair evaluation has been performed, it would be appropriate to include this information as documentation. When K0108 is used for nonstandard seat dimensions of a power wheelchair (see Policy Article, Coding Guidelines section), the claim must include a description or the product name of the seat component, the width and depth of the seat, and the manufacturer and product name/ number of the wheelchair base. When code E2399 is billed, the claim must include: - A clear narrative description of the item that is being provided - If billing for replacement, the claim must describe the item that is being replaced and the reason for replacement. Documentation for individual consideration might include information on the patient's diagnosis, the patient's abilities and limitations as they relate to the equipment (e.g., degree of independence/dependence, frequency and nature of the activities the patient performs, etc.), the duration of the condition, the expected prognosis, past experience using similar equipment. Refer to the Supplier Manual for more information on documentation requirements. Appendices Utilization Guidelines Refer to Indications and Limitations of Coverage and/or Medical Necessity. Sources of Information and Basis for Decision Reserved for future use Advisory Committee Meeting Notes Start Date of Comment Period 04/16/1993 End Date of Comment Period 05/31/1993 Start Date of Notice Period 08/01/1993 Revision History Number WCOA005 Revision History Explanation Revision effective date: 04/01/2005 HCPCS CODES AND MODIFIERS: Added: KC, E2205, E2206, E2368, E2369, E2370 Revised: E0951, E0952, E0967, E0978, E0986, E1010, E1011, E1014, E1225, E1226 Discontinued: K0059, K0060, K0061, K0081 DOCUMENTATION REQUIREMENTS: Specified documentation when billing K0108 for nonstandard power wheelchair seat dimensions or when billing E2399. Revision Effective Date: 07/01/2004 LMRP converted to LCD and Policy Article format. HCPCS CODES AND MODIFIERS: Discontinued: E0192, E0962-E0965, E1012, E1013, E1025-E1027, K0023, K0024, K0114-K0116. See Wheelchair Seating policy. Moved: E0966, E0992 See Wheelchair Seating policy. Removed E1028 from the Power Drive Control section. It remains in the Miscellaneous section. INDICATIONS AND LIMITATIONS OF COVERAGE: Removed coverage criteria for wheelchair seat and back cushions and related items. These are now addressed in the Wheelchair Seating policy. Corrected the code range for nonstandard dimensions for power wheelchairs. Deleted coverage criteria for one arm drive attachment (E0958). Moved non-medical necessity coverage and payment rules to the related Policy Article. DOCUMENTATION REQUIREMENTS: Moved GY modifier instructions to Policy Article. Deleted references to discontinued codes. Revision effective date: 01/01/2004 HCPCS CODES AND MODIFIERS: Added: A9270, A9900, E0950-E0952, E0955-E0957, E0959-E0961, E0966, E0967, E0972-E0974, E0978, E0981, E0982, E0985, E0986, E0990, E0992, E0995, E1002-E1010, E1028-E1030, E1225, E1226, E2201-E2204, E2300, E2301, E2310, E2311, E2320-E2331, E2340-E2343, E2351, E2360-E2367, E2399, RP Discontinued: K0016, K0022, K0025-K0033, K0035, K0036, K0048, K0049, K0054, K0055, K0057, K0058, K0062, K0063, K0079, K0080, K0082-K0089, K0100, K0103, K0107 Revised: E0958 CMS NATIONAL COVERAGE POLICY:Revises manual references. INDICATIONS AND LIMITATIONS OF COVERAGE: Adds coverage guidelines for electrical connection devices for power seating systems (E2310, E2311) and electronic connection device for speech generating device (E2351). States that the following items are noncovered: power seat elevation feature (E2300), power standing feature, electronic interface for lights/ other electrical devices. States that a solid seat insert (E0992) is not separately payable. Revises coverage criteria for nonstandard seat width and depth (E2201-E2204, E2340-E2343). CODING GUIDELINES:Revises guidelines for use of RP modifier.Revises list of codes that are invalid for claim submission to the DMERC. Adds definitions for many new codes. APPENDICES:Adds correct coding guidelines for: power tilt and/or recline systems, E1009, E1010, E2325.Revises correct coding guidelines for: manual wheelchair bases, power wheelchair bases, E0990, K0053, K0195. Revision effective date: 04/01/2003 HCPCS CODES AND MODIFIERS: Added: E0951, E0958, E0971, E1011-E1018, E1020, E1025-E1027, EY Discontinued: K0021, K0034, K0101 Revised: K0082-K0089 INDICATIONS AND LIMITATIONS OF COVERAGE: Adds standard language concerning coverage of items without an order. Revises/adds statements concerning coverage of batteries and POV accessories that were previously published in a DMERC bulletin. CODING GUIDELNES: Moves Definitions section to this section. Revises the definition of code K0116. Adds previously published statement concerning coding of POV accessories. Clarifies the billing of bilateral items. DOCUMENTATION REQUIREMENTS: Adds standard language concerning use of EY modifier for items without an order. Revises standard language concerning use of CMNs. APPENDICES: Adds POVs and new adult tilt-in-space and pediatric wheelchair codes to the table. Adds anti-tipping device (E0971) and wheel locks (K0081) to the accessories that are included in the allowance for power wheelchairs. The revision dates listed below are the dates the revisions were published and not necessarily the effective dates for the revisions. 03/01/1998 – Added "for wheelchair" to description for HCPCS code E0192. 06/01/1997 – Added HCPCS codes. Revised all sections of the policy. 10/01/1995 – Added codes K0053 and K0195 to statement in the Indications section as follows: “Elevating legrests (K0046-K0048, K0053, K0195) are covered if…” 04/01/1995 – Removed codes K0067, K0074, and K0094 from columns in Attachment 2 – Correct coding guidelines. Last Reviewed On Related Documents Article(s) A20284 - Wheelchair Options/Accessories - Policy Article – Effective April 2005 LCD Attachments Manual Wheelchair CMN (60,242 bytes) Motorized Wheelchair (69,144 bytes) Contiuation Form (22,901 bytes)

Other Versions

Updated on 01/21/2005 with effective dates 07/01/2004 - N/A Updated on 11/07/2004 with effective dates 07/01/2004 - N/A Updated on 05/24/2004 with effective dates 07/01/2004 - N/A

This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this policy was developed in cooperation with the contractor's Advisory Committee, which includes representatives from Palmetto GBA.

 

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