To Bill or Not to Bill?
A Guide to Billing Wheelchair Options & Accessories
Learning Objectives
• Identify at least 3 separately billable wheelchair
accessories for manual and power wheelchairs to help
maximize reimbursement
• Identify at least 2 appropriate medical justifications for
each separately billable wheelchair accessories
• Identify current and updated HCPCS coding
• Discuss coding for wheelchair options/accessories
when provided as a replacement item
Agenda
• Power Mobility
• Manual Wheelchairs
• Seating & Positioning
• Wheelchair Accessories
• Power Wheelchair Electronics
• Powered Seating
• Repair and Replacement
Power Mobility Devices
POV Basic Equipment Package
• Batteries
• Battery chargers
• Complete set of tires
• Tiller steering
• All accessories necessary for safe operation
• Non-expandable controller with proportional response to input
• Weight appropriate upholstery and seating system
PWC Basic Equipment Package
• Lap belt or safety belt. (Shoulder or chest harness/straps/vest
may be billed separately)
• Battery charger, single mode
• Complete set of tires and casters, any type
• Legrests. (Elevating legrests may be billed separately)
• Footrests/foot platform. (Angle adjustable footplates may be
billed separately with Group 3, 4 and 5 PWCs)
• Armrests. (Adjustable height arms may be billed separately)
• Weight specific components required for weight capacity
PWC Basic Equipment Package
• Any back width or seat width and depth. (Group 3 or 4 PWCs
with a sling/solid seat/back, may bill separately:
– For Standard Duty, seat width and/or depth greater than 20”
– For HD, seat width and/or depth greater than 22”
– For VHD, seat width and/or depth greater than 24”
– For EHD, no separate billing
• Controller and Input Device. (expandable controller, a
nonstandard joystick, or other alternative control device may be
billed separately)
Codes Included in Initial Group 1 and 2 PWC
E0971
E0978
E0981
E0982
E0995
E1225
E2366
E2367
E2368
E2369
E2370
E2374
E2375
E2376
E2381
E2382
E2383
E2384
E2385
E2386
E2387
E2388
E2389
E2390
E2391
E2392
E2393
E2394
E2395
E2396
K0015
K0017
K0018
K0019
K0020
K0037
K0040
K0041
K0042
K0043
K0044
K0045
K0046
K0047
K0051
K0052
K0098
Codes Included in Initial Group 3 and 4 PWC
E0971
E0978
E0981
E0982
E0995
E1225
E2366
E2367
E2368
E2369
E2370
E2374
E2375
E2376
E2381
E2382
E2383
E2384
E2385
E2386
E2387
E2388
E2389
E2390
E2391
E2392
E2393
E2394
E2395
E2396
K0015
K0017
K0018
K0019
K0020
K0037
K0041
K0042
K0043
K0044
K0045
K0046
K0047
K0051
K0052
K0098
Manual Wheelchair Bases
Standard Features
• The following features are included in the allowance for all adult
manual wheelchairs:
– Seat Width: 15” – 19”
– Seat Depth: 15” – 19”
– Arm Style: Fixed, swingaway, or detachable; fixed height
– Footrests: Fixed, swingaway, or detachable
Codes Included in Initial MWC
E0967
E0981
E0982
E0995
E2205
E2206
E2210
E2220
E2221
E2222
E2223
E2224
E2225
E2226
K0015
K0017
K0018
K0019
K0042
K0043
K0044
K0045
K0046
K0047
K0050
K0052
K0069
K0070
K0071
K0072
Seating & Positioning
• General Use
• Positioning
• Skin Protection
• Skin Protection & Positioning
General Use Wheelchair Seat Cushion
Justifications:
•
•
Covered for a patient that has a Medicare covered wheelchair
If the patient does not have a covered WC, the cushion will be denied as
not medically necessary.
HCPCS Codes
E2601: Width Less Than 22”, Any Depth
E2602: With 22” or Greater, Any Depth
Skin Protection
Justifications:
1.The patient has a Medicare covered WC, and
2.The patient has either of the following:
a. Current pressure ulcer or a past history of a pressure ulcer (707.03 707.05) on 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:
SCI resulting in quadriplegia or paraplegia, other spinal cord disease, MS, other
demyelinating disease, CP, anterior horn cell disease including ALS, post polio
paralysis, TBI resulting in quadriplegia, spina bifida, childhood cerebral
degeneration, Alzheimer’s disease, Parkinson’s disease
HCPCS codes
E2603: Width Less Than 22”, Any Depth
E2604: Width 22” or Greater, Any Depth
Positioning
Justifications:
1.The patient has a Medicare covered WC; and
2.The patient has any significant postural asymmetries that are
due to one of the diagnoses listed for skin protection or to one of
the following diagnoses:
Monoplegia of the lower limb, Hemiplegia (due to stroke, TBI, or other
etiology), MD, Torsion Dystonias, Spinocerebellar Disease
HCPCS codes:
E2605: Width Less than 22”, Any Depth
E2606: Width 22” or Greater, Any Depth
Skin Protection and Positioning
Justifications:
• A non-adjustable skin protection and positioning seat cushion, or
an adjustable skin protection and positioning seat cushion is
covered for a patient who meets the criteria for both a skin
protection and positioning seat cushion.
HCPCS codes
E2607: Width Less that 22”, Any Depth
E2608: Width 22” or Greater, Any Depth
General Use Wheelchair Back Cushion
Justifications:
• Covered for a patient who has a Medicare covered WC.
• If the patient does not have a covered w/c, then the cushion
will be denied as not medically necessary.
HCPCS codes
E2611: Width less than 22”, Any Height, Including Any Type Mounting Hardware
E2612: Width 22” or Greater, Any Height, Including Any Type Mounting Hardware
Positioning: Posterior/Lateral
Justifications:
Covered for a patient who meets both of the following criteria:
1. The patient has a Medicare covered WC; and
2. The patient has any significant postural asymmetries that are due to
one of the diagnoses listed under the justification criteria for a skin
protection cushion, or to one of the following diagnoses:
Monoplegia of the lower limb, Hemiplegia (due to stroke, TBI, or other etiology),MD,
Torsion Dystonias, Spinocerebellar Disease
HCPCS codes
E2615: Width Less Than 22”, Any Height, Including Any Type Mounting Hardware
E2616: Width 22” or Greater, Any Height, Including Any Type Mounting Hardware
Positioning: Planar with Lateral Supports
Justifications:
Covered for a patient who meets both of the following criteria:
1. The patient has a Medicare covered WC; and
2. The patient has any significant postural asymmetries that are due to
one of the diagnoses listed for skin protection or to one of the following
diagnoses:
Monoplegia of the lower limb, Hemiplegia (due to stroke, TBI, or other etiology), MD,
Torsion Dystonias, Spinocerebellar Disease
HCPCS Codes
E2620: Width Less than 22”, Any Height, Including Any Type Mounting Hardware
E2621: Width 22” or Greater, Any Height, Including Any Type Mounting Hardware
Custom Fabricated Seat Cushion and Back
Justifications:
HCPCS Codes
E2609: Seat Cushion
E2617: Back Cushion
A custom fabricated seat cushion is covered if criteria (1) and (3) are met.
A custom fabricated back cushion 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.
Wheelchair Cushion – Coding Guidelines
• No separate payment for solid seat/back inserts
(rigidizer)
• No separate payment for mounting hardware
• Seat/back cushions not PDAC verified must be billed
K0669.
• Pediatric size cushions and positioning accessories are
billed using same codes
• What to do for patients who do not have a qualifying
diagnosis?
Swingaway Hardware
Code: E1028, each
• Used for hardware that allows the following items to retract, swingaway or
be removed:
− headrests (E0955),
− lateral trunk or hip supports (E0956)
− medial thigh supports (E0957)
Justifications
– Allows accessories to swing away to allow close access to tables,
sinks and desks, giving the client increased independence in
performing MRADLs
– Permits safe transfers to bed and commodes.
Head Rests
Head rests
− Code: E0955
Coverage criteria:
− Diagnosis driven, or
− Patient has a covered manual or power tilt and/or recline
seating system.
Lateral Trunk Supports
Lateral trunk supports
− Code: E0956, each
Justifications:
– Client has lack of trunk control due to loss of muscle function,
abnormal tone or reflexes
– Needed to correct or accommodate scoliosis that may worsen and
cause respiratory, skin and digestive problems
– Needed to provide proximal control so client may function distally using
their upper extremities (ex. eating, driving, writing)
Medial Knee Support
Medial knee support
– Code: E0957, each
Justifications:
– Client is at risk for or has hip subluxation or dislocation and needs
support to hold joint in safest posture
– Client assumes an adduction pattern, due to tone, abduction breaks up
tone
– Client needs to maintain ROM for hygiene and toileting
Seat Positioning Strap
Seat positioning strap
− Code: E0978, each
− Included on power mobility devices
Justifications:
− Needed to provide proper positioning of the pelvis
− Client can’t maintain pelvic control assuming poor postures allowing
development of deformities and skin breakdown
− Client thrusts or extends and slides out of their seat
Chest Positioning Strap
Chest positioning strap
− Code: E0960, each
Justifications:
– Client has moderate to severe decrease in trunk control, can’t function
without added support
– Client can’t use tilt/recline due to primitive reflexes, needs chest
support to hold body up against gravity
– Client has rotational posture and needs pressure in the front of the
body for control
Wheelchair Accessories
Adjustable Height Arms
Codes
– E0973, each (detachable)
– K0020, pair (fixed)
Coverage criteria:
– Covered if patient requires arm height different than that
available using non-adjustable height arms
– Patient spends at least 2 hours per day in the WC
Adjustable Height Arms
Justifications:
– Standard arm is too high/low causing client to assume poor
positions to use arms as support
– Client needs the armrest to be a particular height for transfers
and weight shifts
– Client has poor shoulder integrity and arms need to be at a
particular height for support
Adjustable Angle Footplates
Code: K0040, each
Justifications:
– Needed because the client has a contracture to accommodate.
– Needed because the client has hamstring tightness that needs to be
accommodated, makes a STD 60 or 70 footrest a tighter or more open
angle.
– Needed because the client wears AFO’s and needs the footrest to
accommodate to the set angle.
– Needed to decrease the tone involved with thrusting from the chair.
Foot Positioning Options
Codes:
– Heel loops – E0951, each
– Toe loops – E0952, each
– Leg straps – K0038, each
– H-style straps – K0039, each
Justifications:
– Provides safety for the feet that fall off the footrests because of
tone, primitive reflexes or lack of control
– Prevents hyperflexion or extension at the knee
Large Size Footplates
Code: K0041, each
– Included on power mobility devices
Justifications:
– Needed to provide full contact and support of the foot to
control a tendency to go into a poor posture.
– Needed to provide full contact and support of the foot to
control primitive reflexes that start at the foot like positive
supporting reflex or extensor thrust.
Manual Elevating Legrests
Code: E0990, each (purchase)
Code: K0195, pair (capped rental)
Coverage criteria:
− Patient has musculoskeletal condition or the presence of a
cast/brace that prevents 90 degree flexion at the knee
− Patient has significant edema of the lower extremities that
requires having an ELR
− Patient meets the criteria for and has a reclining back on the
wheelchair
Manual Elevating Legrests
Justifications:
– Limited range of motion.
– Reduction of edema if combined with recline or tilt.
– Differs positioning for comfort.
– Client has BKA, splint or prosthesis which requires support in an
extended position.
Wheel Lock Extensions
Code: E0961, each
Justifications:
– Client does not have the strength, ROM or pattern of movement to apply
standard brakes.
– Poor balance keeps client from reaching a standard brake.
– Client is unable to grasp standard size brake.
– One Upper extremity is non-functional requiring the opposite to cross over
and apply the brakes.
Flat Free Tires
Code: E2213,each
Justifications:
– History of frequent repairs, more cost effective.
– Terrain has potential to cause frequent flats.
– Client travels far from home in chair and it would be a safety issue if
he/she got a flat.
– Client lives in a rural location and does not have easy access to the
supplier for repairs.
Shock Absorbers
Code: E1015, each (MWC)
Code: E1016, each (PWC)
Justifications:
– Needed to reduce spasticity caused by shock or vibration.
– Allows the client with poor trunk control to maintain better alignment which is
important for posture and skin integrity
– Provides better endurance for sitting because of decreased pain.
– Provides better endurance for pushing the chair because the chair does not meet
as much resistance on uneven terrain.
– Needed because client transfers from a high surface and needs to cushion the
shock to his/her buttocks due to poor or at risk skin integrity.
Manual Fully Reclining Back
Code: E1226
Coverage criteria:
• Patient spends at least 2 hours per day in the wheelchair and
has 1 or more of the following conditions/needs:
– Quadriplegia
– Fixed hip angle
– Trunk or LE casts/braces require recline for positioning needs
– Excess extensor tone of the trunk muscles
– Rests in recumbent position 2+ times/day and transfers are difficult
Manual Fully Reclining Back
Justifications:
– Patient needs to weight shift due to skin breakdown
– Patient needs to lie flat to empty their bladder
– Patient breathes better in recline position
– Patient needs to control severe lower extremity edema
– Patient needs to lie flat for transfers
Rear Anti-Tipper
Code: E0971, each
Justifications:
– Client rocks in their chair, unsafe without anti-tippers
– Client has extreme extensor tone
– Client often comes down hard into chair during transfers causing chair to tip
backwards
– Client utilizes a ramp and is unable to compensate by bringing weight
forward
Nonstandard Seat Frame - MWC
Codes:
– E2201 – width 20” to 22”
– E2202 – width 24” to 27”
– E2203 – depth 20” to 21”
– E2204 – depth 22” to 25”
Justifications:
– Patient’s physical size justifies the need for extended seat width or depth.
Power Wheelchair Electronics
Electronics Terminology
• Interface - mechanism that controls the movement of a power wheelchair.
Examples of interfaces include: joystick, sip and puff, chin control, head
control, etc.
• Proportional Interface - the direction and amount of movement by the
patient controls the direction and speed of the wheelchair. One example of
a proportional interface is a standard joystick.
• Non-Proportional Interface - involves a number of switches. Selecting a
particular switch determines the direction of the wheelchair, but the speed
is pre-programmed. One example of a non-proportional interface is a sipand-puff mechanism.
• Controller - the microprocessor and other related electronics that receive
and interpret input from the drive control interface and convert that input
into power output which controls speed and direction. A high power wire
harness connects the controller to the motor and gears.
Electronics Terminology
• Switch - an electronic device which turns power to a particular
function either "on" or "off". The switch may be either mechanical
or non-mechanical.
– Mechanical switches require physical contact to be activated.
Examples include: toggle, button, ribbon, etc.
– Non-mechanical switches do not require physical contact to be
activated. Examples include: proximity, infrared, etc.
– Some codes include multiple switches. Each switch may have its own
external component, may be integrated into a single external
component or may be integrated into the driver control without an
external component.
Electronics Terminology
• Stop Switch - allows for an emergency stop when a wheelchair with a nonproportional interface is operating in the latched mode. May be referred
to as a kill switch.
• Direction Change Switch - allows a switch to initiate forward movement
one time and backward movement another time.
• Function Selection Switch - allows the patient to determine what
operation is being controlled by the interface at any particular time.
Operations may include: drive forward, drive backward, tilt forward, recline
backward, etc.
• Integrated Proportional Joystick and Controller - an electronics
package in which a joystick and controller electronics are in a single box,
which is mounted on the arm of the wheelchair.
Power Wheelchair Electronics
• E2312 - PWC accessory, hand or chin control
interface, mini-proportional remote joystick,
proportional, including fixed mounting hardware
– Separately billable in addition to an expandable
controller both at initial issue and with replacement of the
expandable controller
– Activated by approx. 25 grams of force
– Has max excursion 5 mm from neutral
– Can only be used with an expandable controller.
– Used for hand, chin or by other body part control (e.g.,
tongue, lip, finger tip)
– No separate billing for control buttons, displays,
switches, or fixed mounting hardware, regardless of the
body part used to activate the joystick.
Power Wheelchair Electronics
• E2313 - PWC accessory, harness for upgrade to
expandable controller, including all fasteners,
connectors and mounting hardware, each
– Includes all the wires, fuse boxes, fuses, circuits, switches and all the
necessary fasteners, connectors, and mounting hardware required for
the operation of an expandable controller.
Power Wheelchair Electronics
• E2321 - PWC accessory, hand
control interface, remote joystick,
non-proportional, including all related
electronics, mechanical stop switch,
and fixed mounting hardware.
– Used for a non-proportional remote
joystick used for either a hand or chin
control.
Power Wheelchair Electronics
• E2322 - PWC accessory, hand control
interface, multiple mechanical switches,
non-proportional, including all related
electronics, mechanical stop switch, and
fixed mounting hardware
– Describes a system of 3-5 mechanical
switches activated by the patient touching
the switch. The switch selected determines
the direction of the wheelchair.
– A mechanical stop switch and a mechanical
direction change switch, if provided, are
included in the allowance for the code.
Power Wheelchair Electronics
• E2323 - PWC accessory, specialty
joystick handle for hand control
interface, prefabricated
– Includes handles with a shape other than
a straight stick (i.e. U-shape or T-shape)
– Handles that have other nonstandard
features (i.e. flexible shaft)
Power Wheelchair Electronics
• E2324 - PWC accessory, chin cup
for chin control interface
– When code E2312, E2321, E2373,
or E2374 is used for a chin control
interface, the chin cup is billed
separately with code E2324.
Power Wheelchair Electronics
• E2325 - PWC accessory, sip and puff
interface, non-proportional, including all
related electronics, mechanical stop
switch, and manual swingaway
mounting hardware
– A sip and puff interface is a nonproportional interface in which the patient
holds a tube in their mouth and controls
the wheelchair by either sucking in (sip) or
blowing out (puff). A mechanical stop
switch is included in the allowance for the
code.
Power Wheelchair Electronics
• E2326 - PWC accessory, breath
tube kit for sip and puff interface
– Billed in addition to E2325 when a sip n
puff interface is provided.
Power Wheelchair Electronics
• E2327 - PWC accessory, head control
interface, mechanical, proportional,
includes all related electronics, mechanical
direction change switch, and fixed
mounting hardware
– A headrest is attached to a joystick-like device.
– The direction and amount of movement of the
patient's head pressing on the headrest control
the direction and speed of the wheelchair.
– A mechanical direction control switch is
included in the code.
Power Wheelchair Electronics
• E2328 - PWC accessory, head control or
extremity control interface, electronic,
proportional, including all related electronics
and fixed mounting hardware
– A patient's head or extremity movements are
sensed by a box placed behind the patient's head
or extremity.
– The direction and amount of movement of the
patient's head or extremity control the direction and
speed of the wheelchair
Power Wheelchair Electronics
• E2329 - PWC accessory, head control interface, contact switch
mechanism, non-proportional, including all related electronics,
mechanical stop switch, mechanical direction change switch,
head array, and fixed mounting hardware
– A patient activates one of three mechanical switches placed around the
back and sides of the head by pressure of the head against the switch.
– The switch selected determines the direction of the wheelchair.
– A mechanical stop switch and direction change switch are included in
the allowance for the code.
Power Wheelchair Electronics
• E2330 - PWC 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
– The patient activates one of three switches
placed around the back and sides of their head.
– The switches are activated by movement of the
head toward the switch, the head does not
actually touch the switch.
– The switch selected determines the direction of
the wheelchair.
– A mechanical stop switch and direction change
switch is included in the allowance for the code.
Power Wheelchair Electronics
• E2331 - PWC accessory, attendant control,
proportional, including all related electronics and
fixed mounting hardware
– Allows a caregiver to drive the WC instead of the patient
– This code is limited to proportional control devices,
usually a joystick mounted on the rear canes of the WC
– An attendant control is covered in place of a patientoperated driver control if the patient meets coverage
criteria for a WC, is unable to operate a MWC or PWC
and has a caregiver who is unable to operate a MWC
but is able to operate a PWC.
– If an attendant control is provided in addition to a patient
operated driver control, it is denied as non-covered.
Power Wheelchair Electronics
• E2373 - PWC accessory, hand or chin
control interface, compact remote joystick,
proportional, including fixed mounting
hardware
– Has a max excursion of 15 mm from neutral
– Requires approx. 340 grams of force to activate
– Can only be used with an expandable controller
– Can be used for hand, chin or other body part
(e.g., foot, amputee stump, etc.)
– No separate billing for control buttons, displays,
switches, or fixed mount hardware regardless
of the body part used to activate the joystick.
Power Wheelchair Electronics
• E2374 - PWC accessory, hand or chin control interface, standard remote
joystick (not including controller), proportional, including all related
electronics and fixed mounting hardware, replacement only
– Joystick is typically mounted on the arm of the wheelchair and the controller is
located under the seat of the wheelchair
– The joystick is connected to the controller through a low power wire harness
– May be used for either hand control, chin control, or attendant control
– Requires approx 340 grams of force to activate
– Has an excursion of 25 mm from neutral
– Can be used with a non-expandable or an expandable controller
– There is no separate billing for an E2374 joystick when it is provided at the time of
initial issue of a PWC
Power Wheelchair Electronics
• E2375 - PWC accessory, non-expandable controller, including all
related electronics and mounting hardware, replacement only
– A non-expandable controller has the following features:
• Has the ability to control up to 2 power seating actuators through
the drive control (requires the use of E2310-E2311.)
• Can accommodate only an integrated joystick or a standard
proportional remote joystick.
• May allow for the incorporation of an attendant control.
Power Wheelchair Electronics
• E2376 - PWC accessory, expandable controller, including all
related electronics and mounting hardware, replacement only
– May only be used for replacement of an expandable controller.
• E2377 - PWC accessory, expandable controller, including all
related electronics and mounting hardware, upgrade provided at
initial issue
– Used if an expandable controller is provided at the time of initial issue
for power wheelchairs capable of being upgraded to an expandable
controller (K0835 -K0891).
Power Wheelchair Electronics
• An expandable controller is capable of accommodating one or more of the
following additional functions:
– Other types of proportional input devices (e.g., mini or low-force joysticks, touchpads,
chin control, head control, etc.)
– Non-proportional input devices (e.g., sip and puff, head array)
– Operate 3 or more powered seating actuators through the drive control. (requires the
use of E2310-E2311.)
• An expandable controller may also be able to operate one or more of the
following:
– A separate display (i.e., for alternate control devices)
– Other electronic devices (e.g., control of an augmentative speech device or computer
through the chair's drive control)
– An attendant control
Power Wheelchair Electronics
• K0108 - PWC accessory, not otherwise classified interface,
including all related electronics and any type mounting hardware
(E2399 was deleted 01/01/2010)
– Appropriately used at the time of initial issue only when:
• the drive control interface provided is not included in the base code and there is no
specific E code which describes it.
– Appropriately used at the time of replacement only when:
• An integrated joystick and controller box are being replaced due to damage
• An interface other than a remote joystick (e.g. sip and puff, head control) is being
replaced but the controller is not being replaced; or
• There is no specific E code which describes the type of drive control interface
system which is provided.
Power Wheelchair Electronics
• E1028 - Swingaway, retractable,
removable hardware.
• Used for:
– remote joysticks or touchpads,
– head control interfaces E2327-E2330, and
– an indicator display box related to the multimotor electronic connection codes E2310 or
E2311.
• Code E1028 is not used with a sip and puff
interface because it is included in the
allowance for E2325.
Miscellaneous Switches - K0108
Electronic Switches
Mechanical Switches
• Fiber Optic Switch
• Egg Switch
• Mini Fiber Optic Switch
• Lip Switch
• Proximity Switch
• Wobble Switches
• Adjustable Proximity Switch
• Pneumatic Switches
• Adjustable Beam Switch
• Microlite Switches
• Motion Concepts Push Buttons
• Motion Concepts Single Toggle
Powered Seating
Tilt
Recline
Combination Tilt & Recline
Seat Elevation
Standing
Powered Seating Coverage Criteria
A power tilt, recline or tilt and recline, with or w/o power ELRs, is covered if 1
and 2 are met and if one of 3, 4 or 5 are met:
1. The patient meets all the coverage criteria for a power wheelchair; and
2. A specialty evaluation by a licensed/certified medical professional, such
as a PT/OT or physician of the patient’s seating and positioning needs;
and
3. The patient is at high risk for development of a pressure ulcer and is
unable to perform a functional weight shift; or
4. The patient utilizes intermittent catheterization for bladder management
and is unable to independently transfer from the wheelchair to bed; or
5. The power seating system is needed to manage increased tone or
spasticity.
E1002 – E1008 Bundling Rules
E0973
K0015
K0017
K0018
K0019
K0020
K0042
K0043
K0044
K0045
K0046
K0047
K0050
K0051
K0052
Power Tilt (E1002)
Justifications:
• Weight Shift:
– Need to weight shift because they have or are at great risk for skin breakdown.
• Tone Management:
– Can’t use recline because the stretch on the muscles triggers more spasticity.
• Respiratory:
– Needed because client breathes better in tilt position allowing lung expansion.
• Vision:
– Due to severe deformity tilt is required to correct the clients visual field
• Hypotension:
– Needed for client to accommodate to BP changes without losing consciousness.
• Trunk Control
– Allows the person to sit upright due to lack of trunk muscle strength.
• Swallowing:
– Needs tilt to reduce tone around the esophagus to allow independent swallowing.
Power Recline (E1004)
Justifications:
• Weight Shift:
– Need to weight shift because they have or are at great risk for skin breakdown
− They need more weight redistribution than tilt, tilt does not provide enough relief.
• Toileting:
– Toileting and bladder emptying needs to happen in the chair and they need to lie flat
to empty their bladder.
• Respiratory:
− Needed because client breathes better because the recline allows lung expansion.
• Transfers:
− Client needs to lie flat to transfer (vent dependent, poor neck control, etc)
• Circulation:
− Needed to control lower extremity edema.
Power Tilt/Recline (E1007)
Justifications:
• Clients skin is so fragile they need the combination of tilt and
recline to decrease the effects of shearing and to increase
weight distribution over the largest surface area possible.
• Need tilt as primary weight shift to control spasticity and posture,
but need recline so they may empty their bladder or transfer flat.
• Power tilt/recline is needed for pain relief.
• Severe lower extremity edema and this the only way to get their
lower extremities over their heart.
Controlling Power Seating through Driver Control
“One Power Seating System Motor”
“Two or More Power Seating System Motors”
Controlling Power Seating through Driver Control
• E2310 - PWC 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 - PWC 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
– Payment includes:
• Function selection switch - allows the patient to select the motor that is being
controlled
• Indicator feature - shows which function has been selected. May be in a separate
display box or integrated into the wheelchair interface.
• Fixed mounting hardware for the control and display box (if present).
Controlling Power Seating through Driver Control
Justifications:
• Allows the client to control the tilt/recline mechanism through the drive
controller independently
• Allows the seating system to be speed controlled to:
– decrease the effects of spasticity or abnormal reflexes
– allow the client to control upper extremities
• Allows the seating system to be programmed to limit tilt/recline angles
because
– the client gets disoriented when they tilt or recline too far back
– the client can not go into a full upright position due to poor trunk control
• Allows the tilt and recline control to be programmed to work in a specific
order/direction because the client can only use specific movements in a tilt
or recline position
Repair and Replacement
Repair Policy Update
• Effective November 4, 2014
• If Medicare paid for the base equipment initially, medical necessity for the
base equipment has been established
• Contractors are to only review the necessity of the repair and make a
payment determination
• The necessity of the repair must be addressed in either the physician's or
the supplier's records.
• Medical Records are not required to address the medical necessity of the
base equipment but shall address the continued medical necessity of the
item being repaired. Documentation is considered timely when it is on
record during the preceding 12 months
• Medicare contractors shall not require a face-to-face examination for
repair of items already covered and paid for by Medicare.
Change Request 8864
• Effective 01/05/2015
• Provides instructions for CB wheelchair accessories furnished for use
with non-CB bid wheelchair bases to beneficiaries residing in a CBA.
• Suppliers with claims that have been incorrectly paid or denied will need
to submit appeal requests to the DME MAC's Reopening department.
• If multiple claims are involved, you may submit a single reopening
request for all affected claims via spreadsheet.
• A separate spreadsheet should be submitted for each PTAN.
• Each spreadsheet must include the PTAN, beneficiary's name, Health Insurance
Claim Number (HICN), and claim control number (CCN).
• If it has been more than one year since the claim was processed, request
a waiver to timely filing. The reason for appeal/reopening should state
"KY Modifier Processing Issues Resolved Under CR 8864."
Repair Rules
• Repairs definition
– To fix or mend and to put the equipment back in working condition after damage or
wear
• Covered when necessary to make the equipment serviceable
• If expense exceeds estimated expense of purchasing or renting another
item for the remaining period of medical need, no payment can be made
for the amount of the excess
• Not covered for previously denied/non-covered equipment or equipment in
the frequent and substantial servicing category
• Not covered during 13 month capped rental period
• No Medicare payment for travel time or equipment pickup and/or delivery
• A new CMN and/or physician’s order is not required
Repairs: Coding and Modifiers
• K0108 - Wheelchair component or accessory, not otherwise specified
• When billing code K0108 the following information is required:
‒ If multiple miscellaneous accessories are provided, each should be billed on a
separate claim line using code K0108
‒ Description of the item, brand name, make/model, and part number (use
abbreviations when needed).
• The brand name can be abbreviated by using just the first 5 letters.
• Do not abbreviate the model/part number
Repairs: Coding and Modifiers
• K0739 - Repair or non-routine service for durable medical equipment other
than oxygen requiring the skill of a technician, labor component, per 15
minutes
• One unit of service = 15 minutes
• Claims for repairs must include narrative information itemizing each repair
and the time taken for each repair
• Claims for replacement items and labor (K0739) must also include
information in the NTE 2300 segment
– Example: “RPRs to PT owned IVC Pronto M51 K0011 PWC PUR 041613”
Repairs: Coding and Modifiers
• RB: Replacement of a part of DME furnished as part of a repair
– Indicates replacement parts of DMEPOS furnished as part of the service for repairing
the DMEPOS item (base equipment/device)
• When billing for the replacement of an accessory, there must be specific
information notated in the NTE 2300 segment of the electronic claim
–
–
–
–
Description of the base piece of equipment
HCPCS code
Date of purchase of the base piece of equipment
“PT OWNED INVACARE ATM TAKE ALONG CHAIR PWC PUR 111612”
• Each claim line for each replacement part must include a description of the
reason why the item is being replaced
– These details should be notated in the NTE 2400 segment of the electronic claim
– Example: “RPL K0019 BBR” or “RPL arm pad destroyed”
Repairs: Additional Information
Equipment
Part Repaired/Replaced
Units of Service
PWC
Batteries
2
PWC
Joystick
2
PWC
Charger
2
PWC
Motors
2/3
PWC
Shroud
2
PWC/MWC
Wheel/Tire
1
PWC/MWC
Armrest/Pad
1
MWC
Anti-tipper
1
Replacement Rules
• Replacement of DME may occur in cases of loss, irreparable
damage or irreparable wear
– Irreparable Damage
• Specific accident or a natural disaster
• Equipment may be replaced in cases of loss or irreparable damage
• New order/CMN required
– Irreparable Wear
• Deterioration sustained from day-to-day usage over time
• Replacement due to irreparable wear takes into consideration the reasonable
useful lifetime of the equipment
• New order/CMN required
Replacement Rules
• Useful Lifetime
– Determined through program instructions
– In absence of specific instructions, contractors may determine the
reasonable useful lifetime of equipment but in no case can it be less
than 5 years
– Computation is based on when the equipment was delivered
– Replacement due to wear is not covered during the reasonable useful
lifetime
• Medicare will cover repair up to the cost of replacement, but not the actual
replacement
• RA: Replacement of a DME item
– Denotes instances where an item is furnished as a replacement for the
same item which has been lost, stolen or irreparably damaged
Thank You For Your Time!
Jim Stephenson
Rehab Reimbursement and Coding Manager
Invacare Corporation
jstephenson@invacare.com
www.invacare.com