Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Wheelchair Options and Accessories

Policy #:05.00.67o

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

MEDICALLY NECESSARY

Options and accessories for wheelchairs are considered medically necessary and, therefore, covered if an individual has a wheelchair that meets Company coverage criteria and the option/accessory itself is medically necessary. In addition, medical necessity criteria apply for certain accessories, as follows:

ARM OF CHAIR
A detachable, adjustable arm height option (Healthcare Common Procedure Coding System [HCPCS] codes E0973, K0017, K0018, K0020) is medically necessary when an individual requires an arm height that is different than the available height using a nonadjustable arm, and the individual spends at least two hours per day in the wheelchair.

An arm trough (HCPCS code E2209) is medically necessary when an individual has quadriplegia, hemiplegia, or uncontrolled arm movements.

FOOTREST/LEGREST
Elevating leg rests (HCPCS codes E0990, K0046, K0047, K0053, and K0195) are medically necessary when any of the following criteria are met:
  • The individual has a musculoskeletal condition or a cast or brace that prevents 90-degree flexion at the knee.
  • The individual has significant edema of the lower extremities that requires an elevating leg rest.
  • The individual meets the criteria for and has a reclining back on the wheelchair.

NONSTANDARD SEAT-FRAME DIMENSIONS
A nonstandard seat width and/or depth (HCPCS codes E2201--E2204, E2340--2343) for a manual or power wheelchair is medically necessary only if an individual's dimensions justify the need.

WHEELS/TIRES FOR MANUAL WHEELCHAIRS
Gear-reduction drive wheels for a manual wheelchair (HCPCS code E2227) or a lever-activated wheel drive (E0988) are medically necessary when all of the following criteria are met:
  • The individual has been self-propelling in a manual wheelchair for at least one year.
  • The individual has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), or by a professional provider who has specific training and experience in rehabilitation wheelchair evaluations and who documents the need for the device in the individual's home.
  • The wheelchair is provided by a supplier that employs a Rehabilitation Engineering and Assistive Technology Society of North America (RESNA)--certified Assistive Technology Supplier (ATS) or Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the individual.

BATTERIES/CHARGERS
Up to two sealed batteries (HCPCS codes E2359, E2361, E2363, E2365, E2371, and K0733) at any one time are medically necessary if required for a power wheelchair.

POWER-TILT AND/OR -RECLINE SEATING SYSTEMS (HCPCS codes E1002-E1010)
A power-seating system (tilt only, recline only, or combination tilt and recline) with or without power-elevating leg rests is medically necessary if an individual meets ALL of the medical necessity criteria for a power wheelchair as described in the policy that addresses power-mobility devices and both of the following criteria:
  • A specialty evaluation, including the documentation of the individual’s seating and positioning needs, was performed by a licensed/certified medical professional, such as a PT or OT, or a professional provider who has specific training and experience in rehabilitation wheelchair evaluations. In addition, the seating system must be provided by a supplier that employs a RESNA-certified ATP who specializes in rehabilitation wheelchairs and who has direct, in-person involvement in the selection of the seating system for the individual.
  • The individual meets one of the following criteria:
    • The individual is at high risk for developing a pressure ulcer and is unable to perform a functional weight shift.
    • The individual utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to the bed.
    • The individual needs the power seating system to manage increased tone or spasticity.

POWER WHEELCHAIR DRIVE-CONTROL SYSTEMS
An attendant control (HCPCS code E2331) (instead of a standard drive-control system) is considered medically necessary in place of an individual-operated drive-control system, when ALL of the following criteria are met:
  • The individual meets all of the medically necessity criteria for a wheelchair
  • The individual is unable to operate a manual or power wheelchair
  • The individual has a caregiver who is unable to operate a manual wheelchair but is able to operate a power wheelchair.

If an attendant control is provided in addition to a patient-operated drive-control system, it is considered not medically necessary and, therefore, not covered.

OTHER POWER WHEELCHAIR ACCESSORIES
An electronic interface (HCPCS code E2351) that operates a speech-generating device using a power wheelchair control interface is medically necessary when an individual has a medically necessary speech-generating device.

MISCELLANEOUS ACCESSORIES
An anti-rollback device (HCPCS code E0974) is medically necessary when an individual self-propels and needs the device because of ramps.

A safety belt/pelvic strap (HCPCS code E0978) is medically necessary when an individual has weak upper body muscles, upper body instability, or muscle spasticity that require the use of this item for proper positioning.

One example (not all-inclusive) of a medically necessary use for swingaway, retractable, or removable hardware (HCPCS code E1028) would be to move the component out of the way so that an individual could perform a transfer to a chair or bed.

A manual, fully reclining back (HCPCS code E1226) is medically necessary when one or both of the following conditions is present:
The individual is at high risk for developing a pressure ulcer and is unable to perform a functional weight shift.
The individual utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to the bed.

For information related to push-rim--activated power-assist devices, refer to the Policy Cross References section for power-mobility devices: Power Wheelchairs (PWCs), Power-Operated Vehicles (POVs), and Push-Rim Activated Power-Assist Devices.

NOT MEDICALLY NECESSARY

If the criteria for the specific item(s) described above are not met, the item(s) are considered not medically necessary and, therefore, not covered.

An option/accessory that is beneficial primarily in allowing an individual to perform leisure or recreational activities is considered not medically necessary and, therefore, not covered.

A nonsealed battery (HCPCS codes E2358, E2360, E2362, E2364, and E2372) is considered not medically necessary and, therefore, not covered.

A single-mode battery charger (E2366) is appropriate for charging a sealed lead acid battery. However, if a dual-mode battery charger (HCPCS code E2367) is provided as a replacement, it is considered not medically necessary and, therefore, not covered.

NOT PRIMARILY MEDICAL IN NATURE (BENEFIT CONTRACT EXCLUSION)

A power-seat-elevation system (HCPCS code E2300) and a power-standing system (HCPCS code E2301) are not primarily medical in nature (benefit contract exclusions) and, therefore, not covered. Power wheelchairs with a seat elevator or a standing system that is integral to the wheelchair are distinguished from other power wheelchairs by a feature that is not primarily medical in nature; therefore, they are not covered. If a wheelchair has an electrical connection device, the sole function of which is to operate a power-seat elevator or power-standing feature, it will be considered not primarily medical in nature (benefit contract exclusion) and, therefore, not covered.

A manual standing system for a manual wheelchair (HCPCS code E2230) is not primarily medical in nature (benefit contract exclusion) and, therefore, not covered.

An electronic interface used to control lights or other electrical devices is not primarily medical in nature (benefit contract exclusion) and, therefore, not covered.

The following features that may be found in a power wheelchair are not primarily medical in nature (benefit contract exclusions) and, therefore, not covered:
  • Stair climbing
  • Electronic balance
  • Ability to elevate the seat by balancing on two wheels
  • Remote operation

ADDITIONAL REIMBURSEMENT INFORMATION

Codes for wheelchair reimbursement include all labor charges involved in the assembly of the wheelchair, as well as support services such as emergency services, delivery, set-up, education, and ongoing assistance with the use of the wheelchair.

A loaner wheelchair accessory may be required when a wheelchair accessory needs a repair and must be removed from an individual for more than one day.

When repairs are required during a rental period, the Company-contracted durable medical equipment (DME) provider who supplied the rental wheelchair accessory must supply a loaner wheelchair accessory. The loaner wheelchair accessory is not eligible for reimbursement.

When a purchased wheelchair accessory requires repair, a one-month wheelchair accessory rental is considered medically necessary and, therefore, covered.

A loaner wheelchair accessory should be billed using the specific code for the wheelchair accessory being loaned.

Requests for loaner wheelchair accessories for periods greater than one month are subject to review.

Elevating leg rests that are used with a wheelchair that is purchased or owned by the individual are coded E0990.

Use HCPCS code E1028 to report swingaway hardware that is used with any of the following:
  • Swingaway hardware used with remote joysticks or touchpads
  • Swingaway or flip-down hardware for head-control interfaces (E2327-E2330)
  • Swingaway hardware for an indicator display box that is related to the multi-motor electronic connection codes E2310 or E2311

Code E1028 is not to be used for swingaway hardware that is used with a sip-and-puff interface (E2325) because swingaway hardware is included in the allowance for code E2325. Code E1028 is not to be used for hardware on a wheelchair tray (E0950). Refer to the Cross References section for additional policies that address the use of code E1028 for positioning accessories.

When reinforced back upholstery or reinforced seat upholstery is used in conjunction with heavy-duty or extra-heavy-duty wheelchair bases, the reimbursement for reinforced upholstery is included in the reimbursement for the wheelchair base. Reinforced back and seat upholstery are not covered when used in conjunction with other manual wheelchair bases.

Fixed, swingaway, or detachable footrests and fixed-height, fixed, swingaway, or detachable armrests are included in the reimbursement for the wheelchair base.

Fixed, swingaway, or detachable nonadjustable height armrests with arm pads (K0015) are not eligible for separate reimbursement.

Detachable, adjustable height armrests (K0017, K0018, K0020) are eligible for separate reimbursement.

A sealed battery (HCPCS codes E2359, E2361, E2363, E2365, E2371, E2397, K0733) is eligible for separate reimbursement when billed with a wheelchair base.

The maximum frequency of replacement for a lithium-based battery (HCPCS code E2397) is one every three years. Only one battery is allowed at any one time.

Accessories to the wheelchair base must be billed on the same claim as the wheelchair base itself.

The use of a wheelchair component or accessory for additional heavy duty or bariatric features for power-seating systems is not eligible for separate reimbursement.

POWER WHEELCHAIR BASIC EQUIPMENT PACKAGE

Each power wheelchair is required to include all of the following items on initial issue. These items are not separately reimbursable at the time of initial issue, unless otherwise noted:
  • Lap belt or safety belt
    • Shoulder harnesses and straps and chest straps and vest may be billed separately.
  • Battery charger
    • Single-mode battery charger
  • Tires and casters
    • Complete set of tires and casters (any type)
  • Legrest/footrest
    • Legrest
      • There is no separate reimbursement if fixed, swingaway, or detachable nonelevating leg rests with or without a calf pad are provided.
      • Elevating leg rests may be reimbursed separately.
    • Footrests/foot platform
      • There is no separate reimbursement for fixed, swingaway, or detachable footrests or a foot platform without angle adjustment.
      • There is no separate reimbursement for angle-adjustable footplates with Group 1 or Group 2 power wheelchairs (PWCs).
      • Angle-adjustable footplates may be reimbursed separately with Group 3 and Group 5 PWCs.
  • Armrest
    • There is no separate reimbursement if fixed, swingaway, or detachable nonadjustable armrests with an arm pad are provided.
    • Adjustable-height armrests may be reimbursed separately.
  • Weight-specific components (eg, braces, bars, upholstery, brackets, motors, gears) per individual's weight capacity
  • Seat and back frame dimensions
    • Any seat width and depth, with the following exceptions that may be reimbursed separately for Group 3 PWCs with a sling or solid seat or back:
      • For Standard Duty, seat width and/or depth greater than 20 inches
      • For Heavy Duty, seat width and/or depth greater than 22 inches
      • For Very Heavy Duty, seat width and/or depth greater than 24 inches
    • Any back width, with the following exceptions that may be reimbursed separately for Group 3 PWCs with a sling or solid seat or back:
      • For Standard Duty, back width greater than 20 inches
      • For Heavy Duty, back width greater than 22 inches
      • For Very Heavy Duty, back width greater than 24 inches
  • Controller and input device
    • There is no separate reimbursement if a nonexpandable controller and a standard proportional joystick (integrated or remote) are provided.
    • An expandable controller, a nonstandard joystick (ie, nonproportional or mini, compact, or short throw proportional), or other alternative control device may be reimbursed separately.
      • For power wheelchairs, which are capable of being upgraded to an expandable controller (K0835--K0891), E2377 is used if an expandable controller is provided at the time of initial issue. Code E2376 is used with complete replacement of an expandable controller.
      • A harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc, that are required for the operation of an expandable controller. It also includes all the necessary fasteners, connectors, and mounting hardware. Code E2313 may be reimbursed separately, in addition to an expandable controller both at initial issue and with complete replacement of the expandable controller.
      • Code K0108 is not eligible for separate reimbursement when billed for any component or feature of an expandable controller at the time of initial issue.
      • The reimbursement for any type of complete expandable controller is included in the allowance for codes E2377 or E2376 and E2313.
      • If individual components of the harness are replaced, code K0108 should be used.

POWER-OPERATED VEHICLE (POV) BASIC EQUIPMENT PACKAGE

Each POV is required to include all of the following items on initial issue. These items are not separately reimbursable at the time of initial issue, unless otherwise noted:
  • Battery or batteries required for operation
  • Single-mode battery charger
  • Weight-appropriate upholstery and seating system
  • Tiller steering
  • Nonexpandable controller with proportional response to input
  • Complete set of tires
  • Lap belt or safety belt
  • All accessories needed for safe operation

The allowance for a POV includes all options and accessories that are provided at the time of initial issue, including, but not limited to, batteries, battery chargers, and seating systems. If a patient-owned POV meets coverage criteria, medically necessary replacement items are covered in accordance with the Company's policy. For additional information, refer to the Company policy that addresses the repair and replacement of DME.

A replacement option/accessory for a POV is billed using a wheelchair option/accessory code. All options and accessories provided at the time of initial issue of a POV cannot be billed separately.

The allowance for a rollabout chair includes all options and accessories that are provided at the time of initial issue, which cannot be billed separately. The allowance for a transport chair includes all options and accessories that are provided at the time of initial issue except for elevating leg rests (HCPCS codes E0990, K0195). If a rollabout chair or transport chair are covered, medically necessary replacement items are covered. A replacement accessory for a rollabout or transport chair is billed using HCPCS code E1399. For additional information, refer to the Company policy that addresses the repair and replacement of DME.

FACE-TO-FACE REQUIREMENTS

As a condition for payment, a professional provider must have a face-to-face examination with the individual for whom the item is ordered that meets all of the following requirements:
  • The treating professional provider must have an in-person examination with the individual within the six (6) months prior to the date of the written order prior to delivery.
  • This examination must document that the individual was evaluated and/or treated for a condition that supports the need for the item(s) of DME ordered.

A new face-to-face examination is required each time a new prescription for one of the specified items is ordered. A new prescription is required:
  • For all claims for purchases or initial rentals
  • When there is a change in the prescription for the accessory, supply, drug, etc.
  • If periodic prescription renewal required per medical policy
  • When an item is replaced
  • When there is a change in the supplier
  • When required by state law

In this policy the specified items are:

Code
Narrative
E0958
Manual wheelchair accessory, one-arm drive attachment, each
E0959
Manual wheelchair accessory, adapter for amputee, each
E0961
Manual wheelchair accessory, wheel lock brake extension (handle), each
E0967
Manual wheelchair accessory, hand rim with projections, any type, each
E0968
Commode seat, wheelchair
E0969
Narrowing device, wheelchair
E0971
Manual wheelchair accessory, anti-tipping device, each
E0973
Wheelchair accessory, adjustable height, detachable armrest, complete assembly, each
E0974
Manual wheelchair accessory, anti-rollback device, each
E0978
Wheelchair accessory, positioning belt/safety belt/pelvic strap, each
E0980
Safety vest, wheelchair
E0981
Wheelchair accessory, seat upholstery, replacement only, each
E0982
Wheelchair accessory, back upholstery, replacement only, each
E0985
Wheelchair accessory, seat lift mechanism
E0990
Wheelchair accessory, elevating leg rest, complete assembly, each
E0944
Armrest, each
E1014
Reclining back, addition to pediatric size wheelchair
E1015
Shock absorber for manual wheelchair, each
E1020
Residual limb support system for wheelchair, any type
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
E1227
Special height arms for wheelchair
E1228
Special back height for wheelchair
E1296
Special wheelchair seat height from floor
E1297
Special wheelchair seat depth, by upholstery
E1298
Special wheelchair seat depth and/or width, by construction
E2227
Manual wheelchair accessory, wheel braking system and lock, complete, each

REQUIRED DOCUMENTATION

A specialty evaluation must be performed by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), or by a professional provider who has specific training and experience in rehabilitation wheelchair evaluations and who documents the need for the device and or accessories.

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation:

PRESCRIPTION (ORDER) REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the durable medical equipment (DME) supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES
The durable medical equipment (DME) supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately seven days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately five days before the individual would exhaust their on-hand supply.

If required documentation is not available on file to support a claim at the time of an audit or record request, the durable medical equipment (DME) supplier may be required to reimburse the Company for overpayments.

COLUMN I/COLUMN II REIMBURSEMENT EDITS

The reimbursement for the item(s) represented by the code(s) in column II are included in the reimbursement for the item represented by the code in column I.

Column IColumn II
Power-Operated Vehicle
K0800,K0801,K0802,K0806,K0807,
K0808,K0812
E0973, E2209, K0015, K0017, K0018, K0019, K0020, L3964, L3965, L3966, L3969, L3970, L3972, L3974, E0951, E0952, E0990, E0995,E1020, K0037, K0038, K0039, K0040, K0041, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052, K0053, K0195, E1011,E1012, E2201, E2202, E2203, E2204, K0056, E0961, E0967,E2205, E2206,E2211,E2212, E2213, E2214, E2215, E2216, E2217, E2218, E2219, E2220, E2221, E2222, E2223, E2224, E2225, E2226, K0065, K0069, K0070, K0071, K0072, K0073, K0077, E2361, E2363, E2365, E2366, E2371, K0733, E1002, E1003, E1004, E1005, E1006, E1007,E1008, E1009, E1010, E2310, E2311, E2321, E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329, E2330, E2331, E2373, E2374, E2375, E2376, E2377, E2399, E1016, E1018, E2351, E2368, E2369, E2370, E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2393, E2394, E2395, E2396, K0098, E0705, E0950, E0958, E0959, E0971, E0974, E0978, E0981, E0982, E0985, E1014, E1015, E1017, E1028, E1029, E1030, E1225, E1226, E2207, E2208, E2210, K0105, K0108,E2227,E2228, E2312, E2313, E2397
Rollabout Chair
E1031
E0973, E2209, K0015, K0017, K0018, K0019, K0020, L3964, L3965, L3966, L3969, L3970, L3972, L3974, E0951, E0952, E0990, E0995, E1020, K0037, K0038, K0039, K0040, K0041, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052, K0053, K0195, E1011, E1012, E2201, E2202, E2203, E2204, K0056, E0961, E0967, E2205, E2206, E2211, E2212, E2213, E2214, E2215, E2216, E2217, E2218, E2219, E2220, E2221, E2222,E2223,E2224,E2225,E2226,K0065,K0069,K0070,K0071,K0072,K0073, K0077, E2361, E2363, E2365, E2366, E2371, K0733, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E2310, E2311, E2321, E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329, E2330, E2331, E2373, E2374, E2375, E2376, E2377, E2399, E1016, E1018, E2351, E2368, E2369, E2370, E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2393, E2394,E2395, E2396, K0098, E0705, E0950, E0958, E0959, E0971, E0974, E0978, E0981, E0982, E0985, E1014, E1015, E1017, E1028, E1029, E1030, E1225, E1226, E2207, E2208, E2210, K0105, K0108, E2227, E2228, E2312, E2313, E2397
Transport Chair
E1037, E1038, E1039
E0973, E2209, K0015, K0017, K0018, K0019, K0020, L3964, L3965, L3966, L3969, L3970, L3972, L3974, E0951, E0952, E0995,E1020, K0037, K0038, K0039, K0040, K0041, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052, K0053, E1011, E1012, E2201, E2202, E2203, E2204, K0056, E0961, E0967, E2205, E2206, E2211, E2212, E2213, E2214, E2215, E2216, E2217, E2218, E2219, E2220, E2221, E2222, E2223, E2224, E2225, E2226, K0065, K0069, K0070, K0071, K0072, K0073, K0077, E2361, E2363, E2365, E2366, E2371, K0733, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E2310, E2311, E2321, E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329, E2330, E2331, E2373, E2374, E2375,E2376,E2377,E2399,E1016,E1018,E2351,E2368,E2369,E2370,E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2393, E2394, E2395, E2396, K0098, E0705, E0950, E0958, E0959, E0971, E0974, E0978, E0981, E0982, E0985, E1014, E1015, E1017, E1028, E1029, E1030, E1225, E1226, E2207, E2208, E2210, K0105, K0108, E2227, E2228, E2312, E231, .E2397
Manual Wheelchair Base
E1161, E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0009
E0967, E0981, E0982, E0995, E2205, E2206, E2210, E2220, E2221, E2222, E2224, E2225, E2226, K0015, K0017, K0018, K0019, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0052, K0069, K0070, K0071, K0072
Power Wheelchair Base Groups 1 and 2
K0813,K0814,K0815,K0816,K0820
K0821,K0822,K0823,K0824,K0825
K0826,K0827,K0828,K0829,K0830
K0831,K0835,K0836,K0837,K0838
K0839,K0840,K0841,K0842,K0843
E0971, E0978, E0981, E0982, E0995, E1225, E2366, E2368, E2369, E2370, E2374, E2375, E2376, E2378, E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2394, E2395, E2396, K0015, K0017, K0018, K0019, K0037, K0040, K0041, K0042, K0043, K0044, K0045, K0046, K0047, K0051, K0052, K0098
Power Wheelchair Base Group 3
K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864

Power Wheelchair Base Group 4
K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884

Power Wheelchair Base Group 5
K0890, K0891
E0971, E0978, E0981, E0982, E0995, E1225, E2366, E2368, E2369, E2370, E2374, E2375, E2376, E2378, E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2394, E2395, E2396, K0015, K0017, K0018, K0019, K0037, K0041, K0042, K0043, K0044, K0045, K0046, K0047, K0051, K0052, K0098
E0973K0017, K0018, K0019
E0950E1028
E0990E0995, K0042, K0043, K0044, K0045, K0046, K0047
Power-tilt and/or -recline seating systems
E1002, E1003, E1004, E1005, E1006, E1007, E1008
E0973, K0015, K0017, K0018, K0019, K0020, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052
E1009, E1010E0990, E0995, K0042, K0043, K0044, K0045, K0046, K0047, K0052, K0053, K0195
E2325E1028
E1020E1028
K0039K0038
K0045K0043, K0044
K0046K0043
K0047K0044
K0053E0990, E0995, K0042, K0043, K0044, K0045, K0046, K0047
K0069E2220, E2224
K0070E2211, E2212, E2224
K0071E2214, E2215, E2225, E2226
K0072E2219, E2225, E2226
K0077E2221, E2222, E2225, E2226
K0195E0995, K0042, K0043, K0044, K0045, K0046, K0047

Guidelines

SEATING SYSTEM FEATURES FOR POWER TILT, POWER RECLINE, POWER TILT AND RECLINE

A power-tilt seating system (E1002) must have the following features:
  • Ability to tilt greater than or equal to 20 degrees from horizontal
  • Back height of at least 20 inches
  • Ability to adjust the seat back to back angle
  • Ability to support an individual's weight of at least 250 pounds

A power-recline seating system (E1003-E1005) must have the following features:
  • Ability to recline greater than or equal to 150 degrees from horizontal
  • Back height of at least 20 inches
  • Ability to support an individual's weight of at least 250 pounds

A power-tilt and -recline seating system (E1006-E1008) must have the following features:
  • Ability to tilt greater than or equal to 20 degrees from horizontal
  • Ability to recline to greater than or equal to 150 degrees from horizontal
  • Back height of at least 20 inches
  • Ability to support an individual's weight of at least 250 pounds

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, wheelchairs are covered under the medical benefits of the Company’s products when medical necessity criteria in the medical policy are met.

A wheelchair or power-operated vehicle (POV) is considered customized if it has been upgraded, constructed, or modified in any way that is not based on medical necessity. A customized wheelchair may be a benefit contract exclusion. Individual benefits must be verified.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

The FDA has approved several wheelchairs and considers them Class II devices.

Description

Wheelchair options and accessories are types of durable medical equipment (DME) that are used with mobility-assistive equipment (MAE) such as manual wheelchairs, power wheelchairs, and power-operated vehicles (POVs). Wheelchair options and accessories may be essential for the functionality of the MAE; they may also be medically necessary for the user's safety and/or ability to perform mobility-related activities of daily living (MRADLs) in the home. MRADLs such as toileting, feeding, dressing, grooming, and bathing usually take place in specific locations in the home. Mobility limitations may impact an individual's ability to participate in MRADLs in their customary locations within the home and/or to perform them in a timely and safe manner. The use of MAE, including options and accessories, may be appropriate to facilitate the performance of MRADLs in the home.

Wheelchair options and accessories may include, but are not limited to, armrests, footrests, wheels, tires, and drive-control systems. Some wheelchair options and accessories are included (ie, standard features) with MAE, while others are prescribed on an individual basis according to medical necessity criteria. In either case, a single option/accessory may apply, or a range of options/accessories may be necessary.
References


Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 280.3: Mobility assistive equipment (MAE). [CMS Web site]. 05/05/05. Available at:
http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=219&ncdver=2&bc=AgAAgAAAAAAAAA%3d%3d& Accessed July 13, 2016

Noridian Healthcare Solutions. Local Coverage Determination (LCD). L33792: Wheelchair options/accessories. 10/01/2015. Available at:https://med.noridianmedicare.com/documents/6547796/6558289/Wheelchair+Options+Accessories.pdf/e43667cc-121f-42dd-99fb-b4b0372e522e July 13, 2016.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

See Attachment A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: Wheelchair Options and Accessories
Description: HCPCS Level II Codes For Wheelchair Options And Accessories




Policy History

05.00.67o
10/01/2018This policy has been identified for the HCPCS code update, effective 10/01/2018.

The following HCPCS code narrative has been revised this policy:

Changed from: K0037 High mount flip-up footrest, replacement only, each
Changed to: K0037 High mount flip-up footrest, each

Revisions from 05.00.67n
08/15/2018This policy has been reissued in accordance with the Company's annual review process.
01/01/2018This policy has been identified for the HCPCS code update, effective 01/01/2018.

The following HCPCS codes have been added to this policy:
  • E0953 Wheelchair accessory, lateral thigh or knee support, any type including fixed mounting hardware, each
  • E0954 Wheelchair accessory, foot box, any type, includes attachment and mounting hardware, each foot

Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 10/01/2018
Version Issued Date: 10/01/2018
Version Reissued Date: n/a

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