The Centers for Medicare and Medicaid Services found that evidence is adequate to determine that mobility assistive equipment (MAE) is reasonable and necessary for members who have a personal mobility deficit sufficient to impair their participation in mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations within the home. Mobility assistive equipment includes, but is not limited to, canes, crutches, walkers, manual wheelchairs, power wheelchairs, and scooters.

Medicare Advantage Medical Policy Bulletin E-56 addresses the various wheelchair options and accessories available for wheelchairs.

For any item to be covered, 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 statutory and regulatory requirements.

For the items addressed in this medical policy, "reasonable and necessary" is defined by the following indications and limitations of coverage and/or medical necessity.

For an option or accessory for a manual wheelchair to be covered, a written signed and dated order must be received by the supplier before a claim is submitted. If the supplier bills for an item without first receiving the completed order, the item will be denied as not medically necessary.

Options and accessories for wheelchairs are covered if the patient has a wheelchair that meets 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 medically necessary.

ARM OF CHAIR:
Adjustable arm height option (E0973, K0017, K0018, K0020) is covered if the patient requires an arm height that is different than that available using nonadjustable arms and the patient spends at least 2 hours per day in the wheelchair.

An arm trough (E2209) is covered if the patient has quadriplegia, hemiplegia, or uncontrolled arm movements.

FOOTREST/ LEGREST:
Elevating legrests (E0990, K0046, K0047, K0053, K0195) are covered if:

1. The patient has a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee; or
2. The patient has significant edema of the lower extremities that requires an elevating legrest; or
3. The patient meets the criteria for and has a reclining back on the wheelchair.

NONSTANDARD SEAT FRAME DIMENSIONS:
A nonstandard seat width and/or depth for a manual wheelchair (E2201-E2204) is covered only if the patient's physical dimensions justify the need.

WHEELS/TIRES FOR MANUAL WHEELCHAIRS:
A gear reduction drive wheel (E2227) is covered if all of the following criteria are met:

1. The patient has been self-propelling in a manual wheelchair for at least one year; and
2. The patient 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 patient’s home. The PT, OT, or physician may have no financial relationship with the supplier; and
3. 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 patient.

BATTERIES/CHARGERS:
Up to two batteries (E2361, E2363, E2365, E2371, K0731, K0733) at any one time are allowed if required for a power wheelchair.

A non-sealed battery (E2360, E2362, E2364, E2372) will be denied as not medically necessary.

A dual mode battery charger (E2367) is not medically necessary. When it is provided as a replacement, payment is based on the allowance for the least costly medically appropriate alternative, E2366.

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:

1. The patient meets all the coverage criteria for a power wheelchair described in the Power Mobility Devices policy; and
2. 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 patient’s seating and positioning needs. The PT, OT, or physician may have no financial relationship with the supplier; and
3. 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 patient; and
4. The patient is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or
5. The patient utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed; or
6. 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 medically necessary.

POWER WHEELCHAIR DRIVE CONTROL SYSTEMS: 
An attendant control is covered in place of a patient-operated drive control system if the patient 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 patient has a covered speech generating device. Refer to Medicare Advantage Medical Policy Bulletin E-36 for additional information on Speech Generating Devices.

MISCELLANEOUS ACCESSORIES: 
Anti-rollback device (E0974) is covered if the patient self-propels and needs the device because of ramps.

A safety belt/pelvic strap (E0978) is covered if the patient has weak upper body muscles, upper body instability or muscle spasticity which requires use of this item for proper positioning.

One example (not all-inclusive) of a covered indication for swingaway, retractable, or removable hardware (E1028) would be to move the component out of the way so that a patient can perform a slide transfer to a chair or bed.

A manual fully reclining back option (E1226) is covered if the patient has one or more of the following conditions:

1. The patient is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or
2. The patient 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 medically necessary.

For information concerning a push-rim activated power assist device for a manual wheelchair, refer to the Power Mobility Devices medical policy.

Reasons for Noncoverage

For an option or accessory for a power wheelchair to be covered, a written signed and dated order must be received by the supplier prior to delivery of the item. If the supplier delivers the item prior to the receipt of a written order, it will be denied as non-covered. If the written order is not obtained prior to delivery, payment will not be made for that item even if a written order is subsequently obtained. If a similar item is subsequently provided by an unrelated supplier who has obtained a written order prior to delivery, it will be eligible for coverage.

The allowance for a power operated vehicle (POV) includes all options and accessories that are provided at the time of initial issue, including but not limited to batteries, battery chargers, seating systems, etc. If a patient-owned POV meets coverage criteria, medically necessary replacement items are covered.

The allowance for a rollabout chair includes all options and accessories that are provided at the time of initial issue. The allowance for a transport chair includes all options and accessories that are provided at the time of initial issue except for elevating legrests (E0990, K0195). If a rollabout chair or transport chair are covered, medically necessary replacement items are covered.

An option/accessory that is beneficial primarily in allowing the patient to perform leisure or recreational activities is non-covered. The provider can bill the member for the non-covered device.

If an option or accessory that is included in another code is billed separately, the claim line will be denied as not separately payable. (Refer to Coding Guidelines section for additional information on correct coding.)

BATTERIES/ CHARGERS:
A sealed battery (E2361, E2363, E2365, E2371, E2397, K0733) is separately payable from a power wheelchair base.

There is no additional/separate payment when a dual mode battery charger is provided at the time of initial issue of a power wheelchair.

A battery charger (E2366, E2367) is included in the allowance for a power wheelchair base (K0010-K0014, K0813-K0816, K0820-K0831, K0835-K0843, K0848-K0864, K0868-K0871, K0877-K0880, K0884-K0886, K0890, K0891).

POWER SEATING SYSTEMS:
A power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. If a wheelchair has an electrical connection device described by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or power standing feature, it will be denied as non-covered. The provider can bill the member for the non-covered device.

POWER WHEELCHAIR DRIVE CONTROL SYSTEMS: 
If an attendant control (E2331) is provided in addition to a patient-operated drive control system, it will be denied as non-covered. The provider can bill the member for the non-covered device. (See the related policy for situations in which it is provided in place of a patient-operated system.)

OTHER POWER WHEELCHAIR ACCESSORIES:
An electronic interface used to control lights or other electrical devices is non-covered because it is not primarily medical in nature. The provider can bill the member for the non-covered device.

The following features of a power wheelchair will be denied as non-covered: stair climbing (A9270), electronic balance (A9270), ability to elevate the seat by balancing on two wheels (A9270), and remote operation (A9270). The provider cannot bill the member for the non-covered device.

MISCELLANEOUS ACCESSORIES:
Swingaway, retractable, or removable hardware (E1028) is non-covered if the primary indication for its use is to allow the patient to move close to desks or other surfaces. The provider can bill the member for the non-covered device. If it is ordered for this indication, a GY modifier must be added to the code.

A manual standing system for a manual wheelchair (E2230) is non-covered because it is not primarily medical in nature. The provider can bill the member for the manual standing system.

Documentation Requirements

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.

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 patient based on the physician's order, the supplier must prepare a written document (termed a detailed product description) that lists the wheelchair base and all options and accessories that will be separately billed. For the wheelchair base and each option/accessory, the supplier must enter all of the following:

• HCPCS code
• Narrative description of the item
• Manufacturer name and model name/number
• Supplier’s charge
• Medicare fee schedule allowance

If there is no fee schedule allowance, the supplier must enter “not applicable.” The physician must sign and date this detailed product description and the supplier must receive it prior to delivery of the PWC. A date stamp or equivalent must be used to document 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 lists each item which will be billed separately and which is signed and dated by the physician. In these situations, the supplier's charges and allowances do not need to be included. 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.

For manual wheelchair accessories, there must be a detailed written order which lists each item which will be billed separately and which is signed and dated by the physician and must be received by the supplier before the claim is submitted.

If a manual wheelchair accessory is billed before a signed and dated order is received by the supplier, it must be submitted with an EY modifier after 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 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 policies have been met and (b) any specific coverage criteria for the accessory in this policy 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 Pre-Service Denial Notice or the GZ modifier if they have not obtained a Pre-Service Denial Notice. Services submitted witha GA modifier will be denied as not medically necessary and are billable to the member.  Services submitted with a GZ modifier will be denied as not medically necessary and are not billable to the member.

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 patient's medical record and be available on request. This documentation might include information on why the patient needs the item, the patient's diagnosis, the patient's abilities and limitations as they relate to the equipment (e.g., degree of independence/dependence, frequency and nature of the activities the patient performs, etc.), the duration of the condition, the expected prognosis, and past experience using similar equipment.

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

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.

Services that do not meet the medical necessity criteria on this policy will be considered not medically necessary. A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Power Wheelchair Basic Equipment Package - Each power wheelchair code is required to include all these items on initial issue (i.e., no separate billing/payment at the time of initial issue, unless otherwise noted). The statement that an item may be separately billed does not necessarily indicate coverage.

• Lap belt or safety belt. Shoulder harness/straps or chest straps/vest may be billed separately.
• Battery charger, single mode
• Complete set of tires and casters, any type
• Legrests. There is no separate billing/payment if fixed, swingaway, or detachable non-elevating legrests with or without calf pad are provided. Elevating legrests may be billed separately.
• Footrests/foot platform. There is no separate billing/payment if fixed, swingaway, or detachable footrests or a foot platform without angle adjustment are provided. There is no separate billing for angle adjustable footplates with Group 1 or 2 PWCs. Angle adjustable footplates may be billed separately with Group 3, 4 and 5 PWCs.
• Armrests. There is no separate billing/ payment if fixed, swingaway, or detachable non-adjustable height armrests with arm pad are provided. Adjustable height armrests may be billed separately.
• Any weight specific components (braces, bars, upholstery, brackets, motors, gears, etc.) as required by patient weight capacity.
• Any seat width and depth. Exception: For Group 3 and 4 PWCs with a sling/solid seat/back, the following may be billed separately:
  • 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;
  • For Extra Heavy Duty, no separate billing
• Any back width. Exception: For Group 3 and 4 PWCs with a sling/solid seat/back, the following may be billed separately:
  • 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;
  • For Extra Heavy Duty, no separate billing
• Controller and Input Device. There is no separate billing/payment if a non-expandable controller and a standard proportional joystick (integrated or remote) is provided. An expandable controller, a nonstandard joystick (i.e., nonproportional or mini, compact or short throw proportional), or other alternative control device may be billed separately.

Power Operated Vehicle (POV) Basic Equipment Package - Each POV is to include all these items on initial issue (i.e., no separate billing/payment at time of initial issue):

• Battery or batteries required for operation
• Battery charger, single mode
• Weight appropriate upholstery and seating system
• Tiller steering
• Non-expandable controller with proportional response to input
• Complete set of tires
• All accessories needed for safe operation.

A table at the end of this section defines the bundling guidelines for wheelchair bases and options/accessories. Codes listed in Column II are not separately payable from the wheelchair base and must not be billed separately at the time of initial purchase or rental of the wheelchair.

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

Accessories provided at the time of initial issue of a rollabout chair are not separately billable. Accessories provided with the initial issue of a transport chair are not separately billable with the exception of elevating legrests (E0990, K0195). A replacement accessory for a rollabout or transport chair is billed using code E1399.

The RB modifier is used when an option or accessory is provided as a replacement for the same part which has been worn or damaged (e.g., replacing a tire of the same type). The RB modifier must not be used for an upgrade subsequent to providing the wheelchair base (e.g., replacing a standard seat of a power wheelchair with a power seating system). The RB modifier must not be used if the accessory is provided at the same time as the wheelchair base, even if the option/accessory is the same as one that the patient had on a prior wheelchair. (See section on Power Wheelchair Drive Control Systems for instructions on the use of the KC replacement modifier.)

Miscellaneous options, accessories, or replacement parts for wheelchairs that do not have a specific HCPCS code and are not included in another code should be coded K0108. If multiple miscellaneous accessories are provided, each should be billed on a separate claim line using code K0108. When billing more than one line item with code K0108, ensure that the additional information can be matched to the appropriate line item on the claim. It is also helpful to reference the line item to the submitted charge. If a supplier chooses to bill separately for a component that is included in another code, code A9900 must be used.

The right (RT) and left (LT) modifiers must be used when appropriate. If bilateral items (left and right) are provided as a purchase and the unit of service of the code is “each,” bill both items on the same claim line using the LTRT modifiers and 2 units of service. If bilateral items are provided as a rental and the unit of service is “each”, bill the items on two separate claim lines with the RT modifier on one line and the LT modifier on the other. If bilateral items are provided as a purchase or rental and the unit of service is “pair,” bill both items on the same claim line using the LTRT modifiers and 1 unit of service.

Codes E0968, E0969, E0970, E0980, E0994, E1227, E1228, E1296-E1298, and E2340-E2343 are not valid for claim submission.

Suppliers should contact the Pricing, Data Analysis, and Coding (PDAC) contractor for guidance on correct coding.

FOOTREST/LEGREST:
Elevating legrests that are used with a wheelchair that is purchased or owned by the member are coded E0990. This code is per legrest. Elevating legrests that are used with a capped rental wheelchair base are coded K0195. This code is per pair of legrests.

NONSTANDARD SEAT FRAME DIMENSIONS:
For all adult manual wheelchairs (E1161, K0001-K0009), payment for seat widths and/or seat depths of 15-19 inches is included in the payment for the base code. These seat dimensions should not be billed separately. Codes E2201-E2204 describe seat widths and/or depths of 20 inches or more for manual wheelchairs.

For power wheelchairs, there is no separate billing for nonstandard seat frame dimensions (width, depth, or height) with the following exceptions: For Group 3 and 4 power wheelchairs, with a sling/solid seat/back, the following items may be billed separately using code K0108:

• 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;
• For Extra Heavy Duty, no separate billing.

For Group 3 and 4 PWCs with a sling/solid seat/back, the following items may be billed separately using code K0108:

• 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;
• For Extra Heavy Duty, no separate billing.

Code K0108 may not be billed for nonstandard dimensions of a power tilt and/or recline seating system (E1002-E1008). The definition of those codes includes any frame width and depth.

WHEELS/TIRES FOR MANUAL WHEELCHAIRS: 
A propulsion wheel is a large wheel which can be used by a beneficiary to propel the wheelchair with his/her arms.

A caster is a small wheel that is in contact with the ground during normal operation of the wheelchair and which cannot be used for arm propulsion. This includes rear tires on tilt-in-space wheelchairs that are not used for arm propulsion.

A pneumatic tire (E2211, E2214) is a rubber tire which is used in conjunction with a separate tube (E2212, E2215) which is filled with air.

A flat free insert (E2213) is a removable ring of firm material that is placed inside of a pneumatic tire to allow the wheelchair to continue to move if the pneumatic tire is punctured. This code may not be used for a foam filled tire.

A foam filled tire (E2216, E2217) is one in which a rubber tire shell has been filled with foam which is nonremovable.

A foam tire (E2218, E2219) is one which is made entirely of self-skinning urethane.

A solid tire (E2220, E2221, E2222) is one which is made of hard plastic or rubber.

A gear reduction drive wheel (E2227) is one that has more than one gear ratio option. Pushing on the rim allows the user to manually shift between the gears in order to provide additional leverage to assist propulsion of a manual wheelchair.

A wheel braking and lock system (E2228) is a caliper or disc type braking system that permits the controlled slowing of a manual wheelchair or the controlled descent on inclines. It also has full wheel lock capability.

A rear wheel assembly (K0069, K0070) includes a wheel rim plus a tire. For pneumatic tires, it also includes the tire tube, but not a flat free insert.

A caster assembly (K0071, K0072, K0077) includes a caster fork, wheel rim, and tire.

For information concerning a push-rim activated power assist device for a manual wheelchair, refer to the Power Mobility Devices Medical Policy Bulletin E-60.

POWER SEATING SYSTEMS:
A power tilt seating system (E1002) includes: a solid seat platform and a solid back; any frame width and depth; detachable or flip-up fixed height or adjustable height armrests; fixed or swingaway detachable legrests; fixed or flip-up footplates; a motor and related electronics with or without variable speed programmability; a switch control which is independent of the power wheelchair drive control interface; any hardware that is needed to attach the seating system to the wheelchair base. It does not include a headrest. It must have the following features: ability to tilt to greater than or equal to 45 degrees from horizontal; back height of at least 20 inches; ability for the supplier to adjust the seat to back angle; ability to support patient weight of at least 250 pounds.

A power recline seating system (E1003-E1005) includes: a solid seat platform and a solid back; any frame width and depth; detachable or flip-up fixed height or adjustable height arm rests; fixed or swingaway detachable legrests; fixed or flip-up footplates; a motor and related electronics with or without variable speed programmability; a switch control which is independent of the power wheelchair drive control interface; any hardware that is needed to attach the seating system to the wheelchair base. It does not include a headrest. It must have the following features: ability to recline to greater than or equal to 150 degrees from horizontal; back height of at least 20 inches; ability to support patient weight of at least 250 pounds.

A power tilt and recline seating system (E1006-E1008) includes: a solid seat platform and a solid back; any frame width and depth; detachable or flip-up fixed height or adjustable height armrests; fixed or swingaway detachable legrests; fixed or flip-up footplates; two motors and related electronics with or without variable speed programmability; a switch control which is independent of the power wheelchair drive control interface; any hardware that is needed to attach the seating system to the wheelchair base. It does not include a headrest. It must have the following features: ability to tilt to greater than or equal to 45 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 patient weight of at least 250 pounds.

A mechanical shear reduction feature (E1004 and E1007) consists of two separate back panels. As the posterior back panel reclines or raises there is a mechanical linkage between the two panels which allows the patient's back to stay in contact with the anterior panel without sliding along that panel.

A power shear reduction feature (E1005 and E1008) consists of two separate back panels. As the posterior back panel reclines or raises there is a separate motor which controls the linkage between the two panels and allows the patient's back to stay in contact with the anterior panel without sliding along that panel.

A mechanically linked leg elevation feature (E1009) involves a pushrod which connects the legrest to a power recline seating system. With this feature, when the back reclines, the legrest elevates; when the back raises, the legrest lowers.

A power leg elevation feature (E1010) involves a dedicated motor and related electronics with or without variable speed programmability which allows the legrest to be raised and lowered independently of the recline and/or tilt of the seating system. It includes a switch control which may or may not be integrated with the power tilt and/or recline control(s). It includes either articulating or non-articulating legrests. The unit of service of code E1010 is a pair.

A power seat elevation system (E2300) includes: a motor and related electronics with or without variable speed programmability; a switch control which is independent of the power wheelchair drive control interface; any hardware that is needed to attach the seating system to the wheelchair base. It must provide a seat elevation of at least 6 inches.

A power standing system (E2301) includes: a solid seat platform and a solid back; detachable or flip-up fixed height armrests; hinged legrests; anterior knee supports; fixed or flip-up footplates; a motor and related electronics with or without variable speed programmability; a basic switch control which is independent of the power wheelchair drive control interface; any hardware that is needed to attach the seating system to the wheelchair base. It does not include a headrest. It must have the following features: ability to move the patient to a standing position; ability to support patient weight of at least 250 pounds.

Codes E2310 and E2311 describe the electronic components that allow the patient to control two or more of the following motors from a single interface (e.g., proportional joystick, touchpad, or nonproportional interface): power wheelchair drive, power tilt, power recline, power shear reduction, power leg elevation, power seat elevation, power standing. It includes a function selection switch which allows the patient to select the motor that is being controlled and an indicator feature to visually show which function has been selected. When the wheelchair drive function has been selected, the indicator feature may also show the direction that has been selected (forward, reverse, left, right). This indicator feature may be in a separate display box or may be integrated into the wheelchair interface. Payment for the code includes an allowance for fixed mounting hardware for the control box and for the display box (if present).

POWER WHEELCHAIR DRIVE CONTROL SYSTEMS:
The term interface in the code narrative and definitions describes the mechanism for controlling the movement of a power wheelchair. Examples of interfaces include, but are not limited to, joystick, sip and puff, chin control, head control, etc. (Note: In the Power Mobility Devices policy, the term "control input device" is used instead of "interface.")

A proportional interface is one in which the direction and amount of movement by the member controls the direction and speed of the wheelchair. One example of a proportional interface is a standard joystick.

A nonproportional interface is one which 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 nonproportional interface is a sip-and-puff mechanism.

The term controller describes the microprocessor and other related electronics that receive and interpret input from the joystick (or other 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.

A non-expandable controller has the following features:

• May have the ability to control up to 2 power seating actuators through the drive control (for example, seat elevator and single actuator power elevating legrests). (Note: Control of the power seating actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.)
• Can accommodate only an integral joystick or a standard proportional remote joystick.
• May allow for the incorporation of an attendant control.

An expandable controller is capable of accommodating one or more of the following additional functions:

• Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.)
• Non-proportional input devices (e.g., sip and puff, head array, etc.)
• Operate 3 or more powered seating actuators through the drive control. (Note: Control of the power seating actuators though the Control Input Device would require the use of an additional component, E2310 or 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

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.

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 E2312 is separately billable in addition to an expandable controller both at initial issue and with complete replacement of the expandable controller. However, if individual components of the harness are replaced, code K0108 should be used.

A switch is an electronic device which turns power to a particular function either "on" or "off." The external component of a switch may be either mechanical or nonmechanical. Mechanical switches involve physical contact in order to be activated. Examples of the external components of mechanical switches include, but are not limited to, toggle, button, ribbon, etc. Examples of the external components of nonmechanical switches include, but are not limited to, proximity, infrared, etc. Some of the codes include multiple switches. In those situations, each functional switch may have its own external component or multiple functional switches may be integrated into a single external switch component or multiple functional switches may be integrated into the wheelchair control interface without having a distinct external switch component.

A stop switch allows for an emergency stop when a wheelchair with a nonproportional interface is operating in the latched mode. (Latched mode is when the wheelchair continues to move without the patient having to continually activate the interface.) This switch is sometimes referred to as a kill switch.

A direction change switch allows the patient to change the direction that is controlled by another separate switch or by a mechanical proportional head control interface. For example, it allows a switch to initiate forward movement one time and backward movement another time.

A function selection switch allows the patient to determine what operation is being controlled by the interface at any particular time. Operations may include, but are not limited to, drive forward, drive backward, tilt forward, recline backward, etc.

An integrated proportional joystick and controller is an electronics package in which a joystick and controller electronics are in a single box, which is mounted on the arm of the wheelchair.

The interfaces described by codes E2312, E2321, E2322, E2325, E2327-E2330, and E2373-E2377 must have programmable control parameters for speed adjustment, tremor dampening, acceleration control, and braking.

A remote joystick is one in which the joystick is in one box that is typically mounted on the arm of the wheelchair and the controller electronics are located in a different box that is typically located under the seat of the wheelchair. The joystick is connected to the controller through a low power wire harness. A remote joystick may be used for either hand control, chin control, or attendant control.

A standard proportional remote joystick is one which requires approximately 340 grams of force to activate and which has an excursion (length of throw) of approximately 25 mm from neutral position. It can be used with a non-expandable or an expandable controller. There is no separate billing for a standard proportional remote joystick when it is provided at the time of initial issue of a power wheelchair whether it is used for hand or chin control by the patient or whether it is used as an attendant control in place of a patient-operated drive control interface.

A mini-proportional (short throw) remote joystick (E2312) is one which can be activated by a very low force (approximately 25 grams) and which has a very short displacement (a maximum excursion of approximately 5 mm from neutral). It can only be used with an expandable controller. It can be used for hand or chin control or control by other body part (e.g., tongue, lip, finger tip, etc.) There is no separate billing for control buttons, displays, switches, etc. There is no separate billing for fixed mounting hardware, regardless of the body part used to activate the joystick.

A compact proportional remote joystick (E2373) is one which has a maximum excursion of about 15 mm from neutral position but requires approximately 340 grams of force to activate. It can only be used with an expandable controller. It can be used for hand or chin control or control by other body part (e.g., foot, amputee stump, etc.) There is no separate billing for control buttons, displays, switches, etc. There is no separate billing for fixed mounting hardware, regardless of the body part used to activate the joystick.

A touchpad is an interface similar to the pad-type mouse found on portable computers. It is billed with code K0108.

Code E2321 is used for a nonproportional remote joystick, regardless of whether it is used for hand or chin control.

When code E2312, E2321, E2373, or E2374 is used for a chin control interface, the chin cup is billed separately with code E2324.

Code E2322 describes a system of 3-5 mechanical switches which are activated by the patient touching the switch. The switch that is 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.

Code E2323 includes prefabricated joystick handles that have shapes other than a straight stick - e.g., U shape or T shape - or that have some other nonstandard feature - e.g., flexible shaft.

A sip and puff interface (E2325) 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. E2325 does not include the breath tube kit which is described by code E2326.

A proportional, mechanical head control interface (E2327) is one in which 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.

A proportional, electronic head control interface (E2328) is one in which a member's head movements are sensed by a box placed behind the member's head. The direction and amount of movement of the patient's head (which does not come in contact with the box) control the direction and speed of the wheelchair. A proportional, electronic extremity control interface (E2328) is one in which the direction and amount of movement of the patient's arm or leg control the direction and speed of the wheelchair.

A nonproportional, contact switch head control interface (E2329) is one in which a member activates one of three mechanical switches placed around the back and sides of their head. These switches are activated by pressure of the head against the switch. The switch that is selected determines the direction of the wheelchair. A mechanical stop switch and a mechanical direction change switch is included in the allowance for the code.

A nonproportional, proximity switch head control interface (E2330) is one in which a member activates one of three switches placed around the back and sides of their head. These switches are activated by movement of the head toward the switch, though the head does not touch the switch. The switch that is selected determines the direction of the wheelchair. A mechanical stop switch and a mechanical direction change switch is included in the allowance for the code.

An attendant control is one which allows a caregiver to drive the wheelchair instead of the member. The attendant control is usually mounted on one of the rear canes of the wheelchair. This code is limited to proportional control devices, usually a joystick. Code E2331 is used when an attendant control is provided in addition to a patient-operated drive control interface.

Codes E2374-E2376 describe components of drive control systems. They may only be used for replacements other than at the time of initial issue.

Code K0108 is appropriately used at the time of initial issue only when the drive control interface that is provided is not included in the base code and there is no specific E code which describes it. Code K0108 is appropriately used at the time of replacement in the following situations:

1. An integrated proportional joystick and controller box are being replaced due to damage; or
2. 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
3. There is no specific E code which describes the type of drive control interface system which is provided.

The KC modifier (replacement of special power wheelchair interface) is used in the following situations:

1. Due to a change in the member's condition an integrated joystick and controller is being replaced by another drive control interface - e.g., remote joystick, head control, sip and puff, etc.; or
2. The member had a drive control interface described by codes E2321-E2322, E2325, E2327-E2330, or E2373 and both the interface (e.g., joystick, head control, sip and puff) and the controller electronics are being replaced due to irreparable damage.

The KC modifier would never be used at the time of initial issue of a wheelchair. The KC modifier specifically states replacement, therefore, the RB modifier is not required.

OTHER POWER WHEELCHAIR ACCESSORIES: 
A drive wheel is one which is directly controlled by the motor of the power wheelchair. It may be either a rear wheel, mid wheel, or front wheel, depending on the model of the power wheelchair.

A caster is a smaller wheel that is in contact with the ground during normal operation of the wheelchair and which not directly controlled by the motor. It may be in the front and/or rear, depending on the location of the drive wheel.

A pneumatic tire (E2381, E2384) is a rubber tire which is used in conjunction with a separate tube (E2382, E2385) which is filled with air.

A flat free insert (E2383) is a removable ring of firm material that is placed inside of a pneumatic tire to allow the wheelchair to continue to move if the pneumatic tire is punctured. This code may not be used for a foam filled tire.

A foam filled tire (E2386, E2387) is one in which a rubber tire shell has been filled with foam which is nonremovable.

A foam tire (E2388, E2389) is one which is made entirely of self-skinning urethane.

A solid tire (E2390, E2391, E2392) is one which is made of hard plastic or rubber.

All types of tires and wheels are included in the code for a power mobility base. Codes E2381-E2396 may only be used for replacements other than at the time of initial issue.

Code E2351 describes an electronic interface used with a speech generating device. An electronic interface that is used to allow lights or other electrical devices to be operated using the power wheelchair control interface must be billed with code A9270 (non-covered item). The provider cannot bill the member for the non-covered device.

Codes E2368-E2370 are for a replacement motor and/or gearbox. These codes are not used at the time of initial issue. If the item is a rebuilt component, the UE (used DME) modifier must be added to the code.

MISCELLANEOUS: 
Code E1028 is used for:

1. Swingaway hardware used with remote joysticks or touchpads,
2. Swingaway or flip-down hardware for head control interfaces E2327-E2330, and
3. 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 used with a sip and puff interface (E2325) because swingaway hardware is included in the allowance for that code. See Wheelchair Seating Policy Article for information concerning uses of E1028 for positioning accessories.

Code E1029 describes a ventilator tray which is attached in a fixed position to the wheelchair base or back. Code E1030 describes a ventilator tray which is attached to the seat back and is articulated so that the tray will remain horizontal when the seat back is raised or lowered.

Code E1225 describes a manually operated reclining back that can recline greater than 15 degrees but less than 80 degrees. Code E1226 describes a manually operated reclining back that reclines 80 degrees or greater.

A Column II code is included in the allowance for the corresponding Column I code when provided at the same time. When multiple codes are listed in column I, all the codes in column II relate to each code in column I.

Provider News

08/2010, Wheelchair options and accessories FreedomBlue coverage criteria to change January 3, 2011

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 patient's medical records will reflect the need for the care provided. The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.

Medicare National Coverage Determinations Manual, Pub. 100-3, Chapter 1, Sections 280.1, 280.3

CMS Transmittal 823, CR 4253

MLN Matters Number: MM4253