Local Coverage Determination (LCD):
Wheelchair Options/Accessories (L11462)
Contractor Information
Contractor Name
Noridian Administrative
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Contract Number
19003
Contract Type
DME MAC
LCD Information
Document Information
LCD ID
L11462
LCD Title
Wheelchair Options/Accessories
AMA CPT/ADA CDT Copyright Statement
CPT only copyright 2002-2013 American Medical
Association. All Rights Reserved. CPT is a registered
trademark of the American Medical Association.
Applicable FARS/DFARS Apply to Government Use. Fee
schedules, relative value units, conversion factors
and/or related components are not assigned by the
AMA, are not part of CPT, and the AMA is not
recommending their use. The AMA does not directly or
indirectly practice medicine or dispense medical
services. The AMA assumes no liability for data
contained or not contained herein. The Code on Dental
Procedures and Nomenclature (Code) is published in
Current Dental Terminology (CDT). Copyright ©
American Dental Association. All rights reserved. CDT
and CDT-2010 are trademarks of the American Dental
Association.
Jurisdiction
Alaska
American Samoa
Arizona
California - Entire State
Guam
Hawaii
Iowa
Idaho
Kansas
Missouri - Entire State
Montana
North Dakota
Nebraska
Nevada
Oregon
South Dakota
Utah
Washington
Wyoming
Northern Mariana Islands
Original Effective Date
For services performed on or after 10/01/1993
Revision Effective Date
For services performed on or after 01/01/2013
Revision Ending Date
10/31/2013
Retirement Date
N/A
Notice Period Start Date
08/15/2006
Notice Period End Date
N/A
CMS National Coverage Policy CMS Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1,
Sections 280.1, 280.3
Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity
Printed on 4/16/2014. Page 1 of 14
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 local coverage determination, the criteria for "reasonable and necessary", based on
Social Security Act § 1862(a)(1)(A) provisions, are defined by the following indications and limitations of
coverage and/or medical necessity.
For an option or accessory for a manual wheelchair to be covered, a detailed written order (DWO) must be
received by the supplier before a claim is submitted. If the supplier bills for an item without first receiving the
completed DWO, the item will be denied as not reasonable and necessary. (See related Policy Article for
information on order for power wheelchair accessories.)
Options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare
coverage criteria and the option/accessory itself is medically necessary. Coverage criteria for specific items are
described below.
If these criteria are not met, the item will be denied as not reasonable and necessary.
ARM OF CHAIR:
Adjustable arm height option (E0973, K0017, K0018, K0020) is covered if the beneficiary requires an arm height
that is different than that available using nonadjustable arms and the beneficiary spends at least 2 hours per day
in the wheelchair.
An arm trough (E2209) is covered if the beneficiary has quadriplegia, hemiplegia, or uncontrolled arm
movements.
FOOTREST/ LEGREST:
Elevating legrests (E0990, K0046, K0047, K0053, K0195) are covered if:
The beneficiary has a musculoskeletal condition or the presence of a cast or brace which prevents 90
degree flexion at the knee; or
The beneficiary has significant edema of the lower extremities that requires an elevating legrest; or
The beneficiary meets the criteria for and has a reclining back on the wheelchair.
NONSTANDARD SEAT FRAME DIMENSIONS:
A nonstandard seat width and/or depth for a manual wheelchair (E2201-E2204) is covered only if the
beneficiary’s physical dimensions justify the need.
WHEELS/TIRES FOR MANUAL WHEELCHAIRS:
A gear reduction drive wheel (E2227) or a lever activated wheel drive (E0988) is covered if all of the following
criteria are met:
The beneficiary has been self-propelling in a manual wheelchair for at least one year; and
The beneficiary has had a specialty evaluation that was performed by a licensed/certified medical
professional, such as a PT or OT, or physician who has specific training and experience in rehabilitation
wheelchair evaluations and that documents the need for the device in the beneficiary’s home. The PT, OT,
or physician may have no financial relationship with the supplier; and
The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional
(ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection
for the beneficiary.
BATTERIES/ CHARGERS:
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Up to two sealed batteries (E2359, E2361, E2363, E2365, E2371, K0733) at any one time are allowed if required
for a power wheelchair.
A non-sealed battery (E2358, E2360, E2362, E2364, E2372) will be denied as not reasonable and necessary.
A single mode battery charger (E2366) is appropriate for charging a sealed lead acid battery. If a dual mode
battery charger (E2367) is provided as a replacement, it will be denied as not reasonable and necessary.
The usual maximum frequency of replacement for a lithium-based battery (E2397) is one every 3 years. Only one
battery is allowed at any one time.
POWER TILT AND/OR RECLINE SEATING SYSTEMS (E1002-E1010):
A power seating system – tilt only, recline only, or combination tilt and recline – with or without power elevating
legrests will be covered if criteria 1, 2, and 3 are met and if criterion 4, 5, or 6 is met:
The beneficiary meets all the coverage criteria for a power wheelchair described in the Power Mobility
Devices LCD; and
A specialty evaluation that was performed by a licensed/certified medical professional, such as a physical
therapist (PT) or occupational therapist (OT) or physician who has specific training and experience in
rehabilitation wheelchair evaluations documents the beneficiary’s seating and positioning needs. The PT,
OT, or physician may have no financial relationship with the supplier; and
The seating system is provided by a supplier that employs a RESNA-certified Assistive Technology
Professional (ATP) who specializes in rehabilitation wheelchairs and who has direct, in-person involvement
in the selection of the seating system for the beneficiary; and
The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional
weight shift; or
The beneficiary utilizes intermittent catheterization for bladder management and is unable to
independently transfer from the wheelchair to bed; or
The power seating system is needed to manage increased tone or spasticity.
If these criteria are not met, the power seating component(s) will be denied as not reasonable and necessary.
POWER WHEELCHAIR DRIVE CONTROL SYSTEMS:
An attendant control is covered in place of a beneficiary-operated drive control system if the beneficiary meets
coverage criteria for a wheelchair, is unable to operate a manual or power wheelchair and has a caregiver who is
unable to operate a manual wheelchair but is able to operate a power wheelchair.
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 beneficiary has a covered speech generating device. (Refer to the Speech
Generating Devices LCD for details.)
MISCELLANEOUS ACCESSORIES:
Anti-rollback device (E0974) is covered if the beneficiary self-propels and needs the device because of ramps.
A safety belt/pelvic strap (E0978) is covered if the beneficiary 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 beneficiary can perform a slide transfer to a
chair or bed.
A manual fully reclining back option (E1226) is covered if the beneficiary has one or more of the following
conditions:
Printed on 4/16/2014. Page 3 of 14
The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional
weight shift; or
The beneficiary utilizes intermittent catheterization for bladder management and is unable to
independently transfer from the wheelchair to the bed.
If these criteria are not met, the manual reclining back will be denied as not reasonable and necessary.
For information concerning a push-rim activated power assist device for a manual wheelchair, refer to the Power
Mobility Devices medical policy.
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Coding Information
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service.
Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all
Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally
to all claims.
N/A
Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report
this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services
reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all
Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to
apply equally to all Revenue Codes.
N/A
CPT/HCPCS Codes
Group 1 Paragraph: 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
GA - Waiver of liability statement issued, as required by payer policy, individual case
GY - Item or service statutorily excluded or does not meet the definition of any Medicare benefit
GZ - Item or service expected to be denied as not reasonable and necessary
KC - Replacement of special power wheelchair interface
KX - Requirements specified in the medical policy have been met
RB - Replacement of a part of DME furnished as part of a repair
HCPCS CODES:
ARM OF CHAIR:
Group 1 Codes:
E0973 WHEELCHAIR ACCESSORY, ADJUSTABLE HEIGHT, DETACHABLE ARMREST, COMPLETE ASSEMBLY, EACH
E2209 ACCESSORY, ARM TROUGH, WITH OR WITHOUT HAND SUPPORT, EACH
K0015 DETACHABLE, NON-ADJUSTABLE HEIGHT ARMREST, EACH
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K0017
K0018
K0019
K0020
DETACHABLE, ADJUSTABLE HEIGHT ARMREST, BASE, EACH
DETACHABLE, ADJUSTABLE HEIGHT ARMREST, UPPER PORTION, EACH
ARM PAD, EACH
FIXED, ADJUSTABLE HEIGHT ARMREST, PAIR
Group 2 Paragraph: FOOTREST/LEGREST:
Group
E0951
E0952
E0990
E0995
E1020
K0037
K0038
K0039
K0040
K0041
K0042
K0043
K0044
K0045
K0046
K0047
K0050
K0051
K0052
K0053
K0195
2 Codes:
HEEL LOOP/HOLDER, ANY TYPE, WITH OR WITHOUT ANKLE STRAP, EACH
TOE LOOP/HOLDER, ANY TYPE, EACH
WHEELCHAIR ACCESSORY, ELEVATING LEG REST, COMPLETE ASSEMBLY, EACH
WHEELCHAIR ACCESSORY, CALF REST/PAD, EACH
RESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCHAIR, ANY TYPE
HIGH MOUNT FLIP-UP FOOTREST, EACH
LEG STRAP, EACH
LEG STRAP, H STYLE, EACH
ADJUSTABLE ANGLE FOOTPLATE, EACH
LARGE SIZE FOOTPLATE, EACH
STANDARD SIZE FOOTPLATE, EACH
FOOTREST, LOWER EXTENSION TUBE, EACH
FOOTREST, UPPER HANGER BRACKET, EACH
FOOTREST, COMPLETE ASSEMBLY
ELEVATING LEGREST, LOWER EXTENSION TUBE, EACH
ELEVATING LEGREST, UPPER HANGER BRACKET, EACH
RATCHET ASSEMBLY
CAM RELEASE ASSEMBLY, FOOTREST OR LEGREST, EACH
SWINGAWAY, DETACHABLE FOOTRESTS, EACH
ELEVATING FOOTRESTS, ARTICULATING (TELESCOPING), EACH
ELEVATING LEG RESTS, PAIR (FOR USE WITH CAPPED RENTAL WHEELCHAIR BASE)
Group 3 Paragraph: NONSTANDARD SEAT FRAME DIMENSIONS:
Group 3 Codes:
MODIFICATION TO PEDIATRIC SIZE WHEELCHAIR, WIDTH ADJUSTMENT PACKAGE (NOT TO BE
E1011
DISPENSED WITH INITIAL CHAIR)
MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME, WIDTH GREATER THAN OR EQUAL TO
E2201
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
SEAT HEIGHT LESS THAN 17" OR EQUAL TO OR GREATER THAN 21" FOR A HIGH STRENGTH,
K0056
LIGHTWEIGHT, OR ULTRALIGHTWEIGHT WHEELCHAIR
Group 4 Paragraph: REAR WHEELS FOR MANUAL WHEELCHAIRS:
Group
E0961
E0967
E0988
E2205
E2206
E2211
E2212
E2213
E2214
E2215
E2216
E2217
E2218
4 Codes:
MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK BRAKE EXTENSION (HANDLE), EACH
MANUAL WHEELCHAIR ACCESSORY, HAND RIM WITH PROJECTIONS, ANY TYPE, EACH
MANUAL WHEELCHAIR ACCESSORY, LEVER-ACTIVATED, WHEEL DRIVE, PAIR
MANUAL WHEELCHAIR ACCESSORY, HANDRIM WITHOUT PROJECTIONS (INCLUDES ERGONOMIC OR
CONTOURED), ANY TYPE, REPLACEMENT ONLY, EACH
MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK ASSEMBLY, COMPLETE, EACH
MANUAL WHEELCHAIR ACCESSORY, PNEUMATIC PROPULSION TIRE, ANY SIZE, EACH
MANUAL WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC PROPULSION TIRE, ANY SIZE, EACH
MANUAL WHEELCHAIR ACCESSORY, INSERT FOR PNEUMATIC PROPULSION TIRE (REMOVABLE), ANY
TYPE, ANY SIZE, EACH
MANUAL WHEELCHAIR ACCESSORY, PNEUMATIC CASTER TIRE, ANY SIZE, EACH
MANUAL WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC CASTER TIRE, ANY SIZE, EACH
MANUAL WHEELCHAIR ACCESSORY, FOAM FILLED PROPULSION TIRE, ANY SIZE, EACH
MANUAL WHEELCHAIR ACCESSORY, FOAM FILLED CASTER TIRE, ANY SIZE, EACH
MANUAL WHEELCHAIR ACCESSORY, FOAM PROPULSION TIRE, ANY SIZE, EACH
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E2219 MANUAL WHEELCHAIR ACCESSORY, FOAM CASTER TIRE, ANY SIZE, EACH
E2220 MANUAL WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) PROPULSION TIRE, ANY SIZE, EACH
MANUAL WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE (REMOVABLE), ANY SIZE,
E2221
EACH
MANUAL WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE WITH INTEGRATED WHEEL,
E2222
ANY SIZE, EACH
E2224 MANUAL WHEELCHAIR ACCESSORY, PROPULSION WHEEL EXCLUDES TIRE, ANY SIZE, EACH
MANUAL WHEELCHAIR ACCESSORY, CASTER WHEEL EXCLUDES TIRE, ANY SIZE, REPLACEMENT ONLY,
E2225
EACH
E2226 MANUAL WHEELCHAIR ACCESSORY, CASTER FORK, ANY SIZE, REPLACEMENT ONLY, EACH
E2227 MANUAL WHEELCHAIR ACCESSORY, GEAR REDUCTION DRIVE WHEEL, EACH
E2228 MANUAL WHEELCHAIR ACCESSORY, WHEEL BRAKING SYSTEM AND LOCK, COMPLETE, EACH
K0065 SPOKE PROTECTORS, 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
K0071 FRONT CASTER ASSEMBLY, COMPLETE, WITH PNEUMATIC TIRE, EACH
K0072 FRONT CASTER ASSEMBLY, COMPLETE, WITH SEMI-PNEUMATIC TIRE, EACH
K0073 CASTER PIN LOCK,EACH
K0077 FRONT CASTER ASSEMBLY, COMPLETE, WITH SOLID TIRE, EACH
Group 5 Paragraph: BATTERIES/CHARGERS:
Group 5 Codes:
E2358 POWER WHEELCHAIR ACCESSORY, GROUP 34 NON-SEALED LEAD ACID BATTERY, EACH
POWER WHEELCHAIR ACCESSORY, GROUP 34 SEALED LEAD ACID BATTERY, EACH (E.G. GEL CELL,
E2359
ABSORBED GLASSMAT)
E2360 POWER WHEELCHAIR ACCESSORY, 22 NF NON-SEALED LEAD ACID BATTERY, EACH
POWER WHEELCHAIR ACCESSORY, 22NF SEALED LEAD ACID BATTERY, EACH, (E.G. GEL CELL,
E2361
ABSORBED GLASSMAT)
E2362 POWER WHEELCHAIR ACCESSORY, GROUP 24 NON-SEALED LEAD ACID BATTERY, EACH
POWER WHEELCHAIR ACCESSORY, GROUP 24 SEALED LEAD ACID BATTERY, EACH (E.G. GEL CELL,
E2363
ABSORBED GLASSMAT)
E2364 POWER WHEELCHAIR ACCESSORY, U-1 NON-SEALED LEAD ACID BATTERY, EACH
POWER WHEELCHAIR ACCESSORY, U-1 SEALED LEAD ACID BATTERY, EACH (E.G. GEL CELL, ABSORBED
E2365
GLASSMAT)
POWER WHEELCHAIR ACCESSORY, BATTERY CHARGER, SINGLE MODE, FOR USE WITH ONLY ONE
E2366
BATTERY TYPE, SEALED OR NON-SEALED, EACH
POWER WHEELCHAIR ACCESSORY, BATTERY CHARGER, DUAL MODE, FOR USE WITH EITHER BATTERY
E2367
TYPE, SEALED OR NON-SEALED, EACH
POWER WHEELCHAIR ACCESSORY, GROUP 27 SEALED LEAD ACID BATTERY, (E.G. GEL CELL, ABSORBED
E2371
GLASSMAT), EACH
E2372 POWER WHEELCHAIR ACCESSORY, GROUP 27 NON-SEALED LEAD ACID BATTERY, EACH
E2397 POWER WHEELCHAIR ACCESSORY, LITHIUM-BASED BATTERY, EACH
POWER WHEELCHAIR ACCESSORY, 12 TO 24 AMP HOUR SEALED LEAD ACID BATTERY, EACH (E.G., GEL
K0733
CELL, ABSORBED GLASSMAT)
Group 6 Paragraph: POWER SEATING SYSTEMS:
Group 6 Codes:
E1002 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, TILT ONLY
E1003 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITHOUT SHEAR REDUCTION
WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITH MECHANICAL SHEAR
E1004
REDUCTION
E1005 WHEELCHAIR ACCESSORY, POWER SEATNG SYSTEM, RECLINE ONLY, WITH POWER SHEAR REDUCTION
WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITHOUT
E1006
SHEAR REDUCTION
WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITH
E1007
MECHANICAL SHEAR REDUCTION
WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITH POWER
E1008
SHEAR REDUCTION
WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, MECHANICALLY LINKED LEG
E1009
ELEVATION SYSTEM, INCLUDING PUSHROD AND LEG REST, EACH
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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
POWER WHEELCHAIR ACCESSORY, ELECTRONIC CONNECTION BETWEEN WHEELCHAIR CONTROLLER AND
E2310 ONE POWER SEATING SYSTEM MOTOR, INCLUDING ALL RELATED ELECTRONICS, INDICATOR FEATURE,
MECHANICAL FUNCTION SELECTION SWITCH, AND FIXED MOUNTING HARDWARE
POWER WHEELCHAIR ACCESSORY, ELECTRONIC CONNECTION BETWEEN WHEELCHAIR CONTROLLER AND
E2311 TWO OR MORE POWER SEATING SYSTEM MOTORS, INCLUDING ALL RELATED ELECTRONICS, INDICATOR
FEATURE, MECHANICAL FUNCTION SELECTION SWITCH, AND FIXED MOUNTING HARDWARE
Group 7 Paragraph: POWER WHEELCHAIR DRIVE CONTROL SYSTEMS:
Group 7 Codes:
POWER WHEELCHAIR ACCESSORY, HAND OR CHIN CONTROL INTERFACE, MINI-PROPORTIONAL REMOTE
E2312
JOYSTICK, PROPORTIONAL, INCLUDING FIXED MOUNTING HARDWARE
POWER WHEELCHAIR ACCESSORY, HARNESS FOR UPGRADE TO EXPANDABLE CONTROLLER, INCLUDING
E2313
ALL FASTENERS, CONNECTORS AND MOUNTING HARDWARE, EACH
POWER WHEELCHAIR ACCESSORY, HAND CONTROL INTERFACE, REMOTE JOYSTICK, NONPROPORTIONAL,
E2321 INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, AND FIXED MOUNTING
HARDWARE
POWER WHEELCHAIR ACCESSORY, HAND CONTROL INTERFACE, MULTIPLE MECHANICAL SWITCHES,
E2322 NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, AND FIXED
MOUNTING HARDWARE
POWER WHEELCHAIR ACCESSORY, SPECIALTY JOYSTICK HANDLE FOR HAND CONTROL INTERFACE,
E2323
PREFABRICATED
E2324 POWER WHEELCHAIR ACCESSORY, CHIN CUP FOR CHIN CONTROL INTERFACE
POWER WHEELCHAIR ACCESSORY, SIP AND PUFF INTERFACE, NONPROPORTIONAL, INCLUDING ALL
E2325
RELATED ELECTRONICS, MECHANICAL STOP SWITCH, AND MANUAL SWINGAWAY MOUNTING HARDWARE
E2326 POWER WHEELCHAIR ACCESSORY, BREATH TUBE KIT FOR SIP AND PUFF INTERFACE
POWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, MECHANICAL, PROPORTIONAL,
E2327 INCLUDING ALL RELATED ELECTRONICS, MECHANICAL DIRECTION CHANGE SWITCH, AND FIXED
MOUNTING HARDWARE
POWER WHEELCHAIR ACCESSORY, HEAD CONTROL OR EXTREMITY CONTROL INTERFACE, ELECTRONIC,
E2328
PROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS AND FIXED MOUNTING HARDWARE
POWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, CONTACT SWITCH MECHANISM,
E2329 NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, MECHANICAL
DIRECTION CHANGE SWITCH, HEAD ARRAY, AND FIXED MOUNTING HARDWARE
POWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, PROXIMITY SWITCH MECHANISM,
E2330 NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, MECHANICAL
DIRECTION CHANGE SWITCH, HEAD ARRAY, AND FIXED MOUNTING HARDWARE
POWER WHEELCHAIR ACCESSORY, ATTENDANT CONTROL, PROPORTIONAL, INCLUDING ALL RELATED
E2331
ELECTRONICS AND FIXED MOUNTING HARDWARE
POWER WHEELCHAIR ACCESSORY, HAND OR CHIN CONTROL INTERFACE, COMPACT REMOTE JOYSTICK,
E2373
PROPORTIONAL, INCLUDING FIXED MOUNTING HARDWARE
POWER WHEELCHAIR ACCESSORY, HAND OR CHIN CONTROL INTERFACE, STANDARD REMOTE JOYSTICK
E2374 (NOT INCLUDING CONTROLLER), PROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS AND FIXED
MOUNTING HARDWARE, REPLACEMENT ONLY
POWER WHEELCHAIR ACCESSORY, NON-EXPANDABLE CONTROLLER, INCLUDING ALL RELATED
E2375
ELECTRONICS AND MOUNTING HARDWARE, REPLACEMENT ONLY
POWER WHEELCHAIR ACCESSORY, EXPANDABLE CONTROLLER, INCLUDING ALL RELATED ELECTRONICS
E2376
AND MOUNTING HARDWARE, REPLACEMENT ONLY
POWER WHEELCHAIR ACCESSORY, EXPANDABLE CONTROLLER, INCLUDING ALL RELATED ELECTRONICS
E2377
AND MOUNTING HARDWARE, UPGRADE PROVIDED AT INITIAL ISSUE
Group 8 Paragraph: OTHER POWER WHEELCHAIR ACCESSORIES:
Group 8 Codes:
E1016 SHOCK ABSORBER FOR POWER WHEELCHAIR, EACH
E1018 HEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY DUTY POWER WHEELCHAIR, EACH
POWER WHEELCHAIR ACCESSORY, ELECTRONIC INTERFACE TO OPERATE SPEECH GENERATING DEVICE
E2351
USING POWER WHEELCHAIR CONTROL INTERFACE
E2368 POWER WHEELCHAIR COMPONENT, DRIVE WHEEL MOTOR, REPLACEMENT ONLY
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E2369 POWER WHEELCHAIR COMPONENT, DRIVE WHEEL GEAR BOX, REPLACEMENT ONLY
POWER WHEELCHAIR COMPONENT, INTEGRATED DRIVE WHEEL MOTOR AND GEAR BOX COMBINATION,
E2370
REPLACEMENT ONLY
E2378 POWER WHEELCHAIR COMPONENT, ACTUATOR, REPLACEMENT ONLY
POWER WHEELCHAIR ACCESSORY, PNEUMATIC DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT ONLY,
E2381
EACH
POWER WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT
E2382
ONLY, EACH
POWER WHEELCHAIR ACCESSORY, INSERT FOR PNEUMATIC DRIVE WHEEL TIRE (REMOVABLE), ANY
E2383
TYPE, ANY SIZE, REPLACEMENT ONLY, EACH
E2384 POWER WHEELCHAIR ACCESSORY, PNEUMATIC CASTER TIRE, ANY SIZE, REPLACEMENT ONLY, EACH
POWER WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC CASTER TIRE, ANY SIZE, REPLACEMENT ONLY,
E2385
EACH
POWER WHEELCHAIR ACCESSORY, FOAM FILLED DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT ONLY,
E2386
EACH
E2387 POWER WHEELCHAIR ACCESSORY, FOAM FILLED CASTER TIRE, ANY SIZE, REPLACEMENT ONLY, EACH
E2388 POWER WHEELCHAIR ACCESSORY, FOAM DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT ONLY, EACH
E2389 POWER WHEELCHAIR ACCESSORY, FOAM CASTER TIRE, ANY SIZE, REPLACEMENT ONLY, EACH
POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) DRIVE WHEEL TIRE, ANY SIZE,
E2390
REPLACEMENT ONLY, EACH
POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE (REMOVABLE), ANY SIZE,
E2391
REPLACEMENT ONLY, EACH
POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE WITH INTEGRATED WHEEL,
E2392
ANY SIZE, REPLACEMENT ONLY, EACH
POWER WHEELCHAIR ACCESSORY, DRIVE WHEEL EXCLUDES TIRE, ANY SIZE, REPLACEMENT ONLY,
E2394
EACH
POWER WHEELCHAIR ACCESSORY, CASTER WHEEL EXCLUDES TIRE, ANY SIZE, REPLACEMENT ONLY,
E2395
EACH
E2396 POWER WHEELCHAIR ACCESSORY, CASTER FORK, ANY SIZE, REPLACEMENT ONLY, EACH
K0098 DRIVE BELT FOR POWER WHEELCHAIR
Group 9 Paragraph: MISCELLANEOUS ACCESSORIES:
Group
A9270
A9900
E0705
E0950
E0958
E0959
E0971
E0974
E0978
E0981
E0982
E0985
E1014
E1015
E1017
E1028
E1029
E1030
E1225
E1226
E2207
E2208
E2210
E2230
9 Codes:
NON-COVERED ITEM OR SERVICE
MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS CODE
TRANSFER DEVICE, ANY TYPE, EACH
WHEELCHAIR ACCESSORY, TRAY, EACH
MANUAL WHEELCHAIR ACCESSORY, ONE-ARM DRIVE ATTACHMENT, EACH
MANUAL WHEELCHAIR ACCESSORY, ADAPTER FOR AMPUTEE, EACH
MANUAL WHEELCHAIR ACCESSORY, ANTI-TIPPING DEVICE, EACH
MANUAL WHEELCHAIR ACCESSORY, ANTI-ROLLBACK DEVICE, EACH
WHEELCHAIR ACCESSORY, POSITIONING BELT/SAFETY BELT/PELVIC STRAP, EACH
WHEELCHAIR ACCESSORY, SEAT UPHOLSTERY, REPLACEMENT ONLY, EACH
WHEELCHAIR ACCESSORY, BACK UPHOLSTERY, REPLACEMENT ONLY, EACH
WHEELCHAIR ACCESSORY, SEAT LIFT MECHANISM
RECLINING BACK, ADDITION TO PEDIATRIC SIZE WHEELCHAIR
SHOCK ABSORBER FOR MANUAL WHEELCHAIR, EACH
HEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY DUTY MANUAL WHEELCHAIR, EACH
WHEELCHAIR ACCESSORY, MANUAL SWINGAWAY, RETRACTABLE OR REMOVABLE MOUNTING HARDWARE
FOR JOYSTICK, OTHER CONTROL INTERFACE OR POSITIONING ACCESSORY
WHEELCHAIR ACCESSORY, VENTILATOR TRAY, FIXED
WHEELCHAIR ACCESSORY, VENTILATOR TRAY, GIMBALED
WHEELCHAIR ACCESSORY, MANUAL SEMI-RECLINING BACK, (RECLINE GREATER THAN 15 DEGREES, BUT
LESS THAN 80 DEGREES), EACH
WHEELCHAIR ACCESSORY, MANUAL FULLY RECLINING BACK, (RECLINE GREATER THAN 80 DEGREES),
EACH
WHEELCHAIR ACCESSORY, CRUTCH AND CANE HOLDER, EACH
WHEELCHAIR ACCESSORY, CYLINDER TANK CARRIER, EACH
WHEELCHAIR ACCESSORY, BEARINGS, ANY TYPE, REPLACEMENT ONLY, EACH
MANUAL WHEELCHAIR ACCESSORY, MANUAL STANDING SYSTEM
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E2295 MANUAL WHEELCHAIR ACCESSORY, FOR PEDIATRIC SIZE WHEELCHAIR, DYNAMIC SEATING FRAME,
ALLOWS COORDINATED MOVEMENT OF MULTIPLE POSITIONING FEATURES
K0105 IV HANGER, EACH
K0108 WHEELCHAIR COMPONENT OR ACCESSORY, NOT OTHERWISE SPECIFIED
ICD-9 Codes that Support Medical Necessity
Group 1 Paragraph: Not specified.
Group 1 Codes: N/A
ICD-9 Codes that DO NOT Support Medical Necessity
Paragraph: Not specified.
N/A
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General Information
Associated 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.” It is
expected that the beneficiary's medical records will reflect the need for the care provided. The beneficiary'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 upon request.
PRESCRIPTION (ORDER) REQUIREMENTS
Wheelchair options and accessories provided for a manual wheelchair base must meet the following requirements
for dispensing and detailed written orders. See the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS SECTION
below for prescription requirements for options and accessories provided for a power wheelchair base.
GENERAL (PIM 5.2.1)
All items billed to Medicare require a prescription. An order for each item billed must be signed and dated by the
treating physician, kept on file by the supplier, and made available upon request. Items dispensed and/or billed
that do not meet these prescription requirements and those below must be submitted with an EY modifier added
to each affected HCPCS code.
DISPENSING ORDERS (PIM 5.2.2)
Equipment and supplies may be delivered upon receipt of a dispensing order except for those items that require a
written order prior to delivery. A dispensing order may be verbal or written. The supplier must keep a record of
the dispensing order on file. It must contain:
•
Description of the item
•
Beneficiary's name
•
Prescribing Physician's name
•
Date of the order and the start date, if the start date is different from the date of the order
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•
Physician signature (if a written order) or supplier signature (if verbal order)
For the “Date of the order” described above, use the date the supplier is contacted by the physician (for verbal
orders) or the date entered by the physician (for written dispensing orders).
Signature and date stamps are not allowed. Signatures must comply with the CMS signature requirements
outlined in PIM 3.3.2.4.
The dispensing order must be available upon request.
For items that are provided based on a dispensing order, the supplier must obtain a detailed written order before
submitting a claim.
DETAILED WRITTEN ORDERS (PIM 5.2.3)
A detailed written order (DWO) is required before billing. Someone other than the ordering physician may
produce the DWO. However, the ordering physician must review the content and sign and date the document. It
must contain:
•
•
•
•
•
Beneficiary's name
Physician's name
Date of the order and the start date, if start date is different from the date of the order
Detailed description of the item(s) (see below for specific requirements for selected items)
Physician signature and signature date
For the “Date of the order” described above, use the date the supplier is contacted by the physician (for verbal
orders) or the date entered by the physician (for written dispensing orders).
Frequency of use information on orders must contain detailed instructions for use and specific amounts to be
dispensed. Reimbursement shall be based on the specific utilization amount only. Orders that only state “PRN” or
“as needed” utilization estimates for replacement frequency, use, or consumption are not acceptable. (PIM 5.9)
The detailed description in the written order may be either a narrative description or a brand name/model
number.
Signature and date stamps are not allowed. Signatures must comply with the CMS signature requirements
outlined in PIM 3.3.2.4.
The DWO must be available upon request.
A prescription is not considered as part of the medical record. Medical information intended to demonstrate
compliance with coverage criteria may be included on the prescription but must be corroborated by information
contained in the medical record.
MEDICAL RECORD INFORMATION
GENERAL (PIM 5.7 -5.9)
The Indications and Limitations of Coverage and/or Medical Necessity section of this LCD contains
numerous reasonable and necessary (R&N) requirements. The Nonmedical Necessity Coverage and Payment
Rules section of the related Policy Article contains numerous non-reasonable and necessary, benefit category and
statutory requirements that must be met in order for payment to be justified. Suppliers are reminded that:
•
•
Supplier-produced records, even if signed by the ordering physician, and attestation letters (e.g. letters of
medical necessity) are deemed not to be part of a medical record for Medicare payment purposes.
Templates and forms, including CMS Certificates of Medical Necessity, are subject to corroboration with
information in the medical record.
Information contained directly in the contemporaneous medical record is the source required to justify payment
except as noted elsewhere for prescriptions and CMNs. The medical record is not limited to physician’s office
records but may include records from hospitals, nursing facilities, home health agencies, other healthcare
professionals, etc. (not all-inclusive). Records from suppliers or healthcare professionals with a financial interest
in the claim outcome are not considered sufficient by themselves for the purpose of determining that an item is
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reasonable and necessary.
CONTINUED USE
Continued use describes the ongoing utilization of supplies or a rental item by a beneficiary.
Suppliers are responsible for monitoring utilization of DMEPOS rental items and supplies. No monitoring of
purchased items or capped rental items that have converted to a purchase is required. Suppliers must
discontinue billing Medicare when rental items or ongoing supply items are no longer being used by the
beneficiary.
Beneficiary medical records or supplier records may be used to confirm that a DMEPOS item continues to be used
by the beneficiary. Any of the following may serve as documentation that an item submitted for reimbursement
continues to be used by the beneficiary:
•
•
•
Timely documentation in the beneficiary’s medical record showing usage of the item, related
option/accessories and supplies.
Supplier records documenting the request for refill/replacement of supplies in compliance with the Refill
Documentation Requirements This is deemed to be sufficient to document continued use for the base
item, as well.
Supplier records documenting beneficiary confirmation of continued use of a rental item
Timely documentation is defined as a record in the preceding 12 months unless otherwise specified elsewhere in
this policy.
CONTINUED MEDICAL NEED
For all DMEPOS items, the initial justification for medical need is established at the time the item(s) is first
ordered; therefore, beneficiary medical records demonstrating that the item is reasonable and necessary are
created just prior to, or at the time of, the creation of the initial prescription. For purchased items, initial months
of a rental item or for initial months of ongoing supplies or drugs, information justifying reimbursement will come
from this initial time period. Entries in the beneficiary’s medical record must have been created prior to, or at the
time of, the initial DOS to establish whether the initial reimbursement was justified based upon the applicable
coverage policy.
For ongoing supplies and rental DME items, in addition to information described above that justifies the initial
provision of the item(s) and/or supplies, there must be information in the beneficiary’s medical record to support
that the item continues to be used by the beneficiary and remains reasonable and necessary. Information used to
justify continued medical need must be timely for the DOS under review. Any of the following may serve as
documentation justifying continued medical need:
•
•
•
•
A recent order by the treating physician for refills
A recent change in prescription
A properly completed CMN or DIF with an appropriate length of need specified
Timely documentation in the beneficiary’s medical record showing usage of the item.
Timely documentation is defined as a record in the preceding 12 months unless otherwise specified elsewhere in
the policy.
PROOF OF DELIVERY (PIM 4.26, 5.8)
Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD
documentation in their files. For medical review purposes, POD serves to assist in determining correct coding and
billing information for claims submitted for Medicare reimbursement. Regardless of the method of delivery, the
contractor must be able to determine from delivery documentation that the supplier properly coded the item(s),
that the item(s) delivered are the same item(s) submitted for Medicare reimbursement and that the item(s) are
intended for, and received by, a specific Medicare beneficiary.
Suppliers, their employees, or anyone else having a financial interest in the delivery of the item are prohibited
from signing and accepting an item on behalf of a beneficiary (i.e., acting as a designee on behalf of the
beneficiary). The signature and date the beneficiary or designee accepted delivery must be legible.
For the purpose of the delivery methods noted below, designee is defined as “Any person who can sign and
accept the delivery of durable medical equipment on behalf of the beneficiary.”
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Proof of delivery documentation must be available to the Medicare contractor on request. All services that do not
have appropriate proof of delivery from the supplier will be denied and overpayments will be requested. Suppliers
who consistently fail to provide documentation to support their services may be referred to the OIG for imposition
of Civil Monetary Penalties or other administrative sanctions.
Suppliers are required to maintain POD documentation in their files. For options and accessories for wheelchairs,
there are two methods of delivery:
1.
2.
Delivery directly to the beneficiary or authorized representative
Delivery via shipping or delivery service
Method 1—Direct Delivery to the Beneficiary by the Supplier
Suppliers may deliver directly to the beneficiary or the designee. In this case, POD to a beneficiary must be a
signed and dated delivery slip. The POD record must include:
•
•
•
•
•
•
Beneficiary’s name
Delivery address
Sufficiently detailed description to identify the item(s) being delivered (e.g., brand name, serial number,
narrative description)
Quantity delivered
Date delivered
Beneficiary (or designee) signature and date of signature
The date of signature on the delivery slip must be the date that the DMEPOS item was received by the beneficiary
or designee. In instances where the supplies are delivered directly by the supplier, the date the beneficiary
received the DMEPOS supply must be the date of service on the claim.
Method 2—Delivery via Shipping or Delivery Service Directly to a Beneficiary
If the supplier utilizes a shipping service or mail order, the POD documentation must be a complete record
tracking the item(s) from the DMEPOS supplier to the beneficiary. An example of acceptable proof of delivery
would include both the supplier’s own detailed shipping invoice and the delivery service’s tracking information.
The supplier’s record must be linked to the delivery service record by some clear method like the delivery
service’s package identification number or supplier’s invoice number for the package sent to the beneficiary. The
POD record must include:
•
•
•
•
•
•
•
Beneficiary’s name
Delivery address
Delivery service’s package identification number, supplier invoice number or alternative method that links
the supplier’s delivery documents with the delivery service’s records.
Sufficiently detailed description to identify the item(s) being delivered (e.g., brand name, serial number,
narrative description)
Quantity delivered
Date delivered
Evidence of delivery
If a supplier utilizes a shipping service or mail order, suppliers must use the shipping date as the date of service
on the claim.
Suppliers may also utilize a return postage-paid delivery invoice from the beneficiary or designee as a POD. This
type of POD record must contain the information specified above.
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS
For options and accessories provided at the time of initial issue of a power wheelchair, once the supplier has
determined the specific power mobility device that is appropriate for the beneficiary based on the physician's 7element order, the supplier must prepare a written document (termed a detailed product description). This
detailed product description (DPD) must comply with the requirements for a detailed written order as outlined in
the Supplier Manual and CMS’ Program Integrity Manual (Internet-Only Manual, Pub. 100-8), Chapter 5.
Regardless of the form of the description, there must be sufficient detail to identify the item(s) in order to
determine that the item(s) dispensed is properly coded.
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The physician must sign and date the detailed product description and the supplier must receive it prior to
delivery of the PWC or POV. A date stamp or equivalent must be used to document the supplier receipt date. The
detailed product description must be available on request.
For items provided for a power mobility device other than at the time of initial issue, there must be a detailed
written order which is signed and dated by the physician. This order must be received by the supplier prior to
delivery.
If a power wheelchair accessory is delivered before a signed and dated order has been received by the supplier, it
must be submitted with an EY modifier added to each affected HCPCS code.
KX, GA, GY, AND GZ MODIFIERS:
For accessories for a power mobility device, if the requirements related to a 7-element order and face-to-face
examination in the Power Mobility Devices Policy Article have not been met, the GY modifier must be added to the
codes for all accessories.
For accessories provided with a manual wheelchair or power mobility device, if it is only needed for mobility
outside the home, the GY modifier must be added to the codes for all accessories.
If the conditions for use of the GY modifier are not met, the KX modifier must be added to the code for the
accessory only if (a) the coverage criteria that are specified in the Manual Wheelchair Bases or Power Mobility
Devices LCD have been met and (b) any specific coverage criteria for the accessory in this LCD have been met. If
the coverage criteria are not met, the KX modifier must not be used.
If the conditions for use of the GY modifier are not met and if the requirements for use of the KX modifier are not
met, the GA or GZ modifier must be added to a claim line for the accessory. When there is an expectation of a
medical necessity denial, suppliers must enter the GA modifier on the claim line if they have obtained a properly
executed Advance Beneficiary Notice (ABN) or the GZ modifier if they have not obtained a valid ABN.
If the GY modifier is used, the KX, GA, and GZ modifiers should not be used.
Claim lines billed without a GA, GY, GZ, or KX modifier will be rejected as missing information.
MISCELLANEOUS:
The medical necessity for all options and accessories must be documented in the beneficiary’s medical record and
be available on request. This documentation might include information on why the beneficiary needs the item, the
beneficiary’s diagnosis, the beneficiary’s abilities and limitations as they relate to the equipment (e.g., degree of
independence/dependence, frequency and nature of the activities the beneficiary performs, etc.), the duration of
the condition, the expected prognosis, and past experience using similar equipment.
Accessories to the wheelchair base must be billed on the same claim as the wheelchair base when provided on
the same date of service.
When billing option/accessory codes as a replacement, 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 initial issue of the wheelchair
must be available upon request.
Refer to the Supplier Manual for more information on documentation requirements.
Appendices
PIM citations above denote references to CMS Program Integrity Manual, Internet Only Manual 100-8.
Utilization Guidelines
Refer to Indications and Limitations of Coverage and/or Medical Necessity.
Sources of Information and Basis for Decision
Reserved for future use.
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Revision History Information
Printed on 4/16/2014. Page 13 of 14
Please note: The Revision History information included in this LCD prior to 1/24/2013 will now display with a
Revision History Number of "R1" at the bottom of this table. All new Revision History information entries
completed on or after 1/24/2013 will display as a row in the Revision History section of the LCD and numbering
will begin with "R2".
Revision
Revision
History
Revision History Explanation
Reason(s) for Change
History Date
Number
Revision Effective Date: 01/01/2013
HCPCS CODES AND MODIFIERS:
Added: E2378
• Provider
DOCUMENTATION REQUIREMENTS:
Education/Guidance
01/01/2013
R2
Revised: Proof of delivery
• Revisions Due To
POLICY SPECIFIC DOCUMENTATION
CPT/HCPCS Code Changes
REQUIREMENTS:
Changed: Narrative for same claim billing
requirement of accessories and base
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Associated Documents
Attachments N/A
Related Local Coverage Documents Article(s) A19846 - Wheelchair Options/Accessories - Policy Article - Effective
November 2013 opens in new window
Related National Coverage Documents N/A
Public Version(s) Updated on 03/07/2014 with effective dates 11/01/2013 - N/A Updated on 10/29/2013 with
effective dates 11/01/2013 - N/A Updated on 03/02/2013 with effective dates 01/01/2013 - 10/31/2013
Some older versions have been archived. Please visit the MCD Archive Site opens in new window to retrieve
them. Back to Top
Keywords
N/A Read the LCD Disclaimer opens in new window Back to Top
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