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.

Options and accessories for wheelchairs are covered if:

1. The patient has a wheelchair that meets Medicare coverage criteria, and
2. 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.

An option/accessory that is beneficial primarily in allowing the patient to perform leisure or recreational activities is not covered. Network providers can bill the member for these denied items.

If an option or accessory that is included in another code is billed separately, the claim line will be denied as not separately payable. Network providers cannot bill the member separately for these services.

Anti-rollback Device:  An anti-rollback device (E0974) is covered if the patient propels himself/herself and needs the device because of ramps.

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.

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

• The patient is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or
• The patient utilizes intermittent catheterization for bladder management
  and is unable to independently transfer from the wheelchair to bed.

If these criteria are not met, the manual reclining back will be denied as not medically necessary.

Manually Operated Reclining Back:  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.

Batteries/Chargers:  A sealed battery (E2361, E2363, E2365, E2371, K0733) is separately payable from the wheelchair base (K0010-K0014, K0813-K0816, K0820-K0831, K0835-K0843, K0848-K0864, K0868-K0871, K0877-K0880, K0884-K0886, K0890, K0891). Up to two batteries at any one time are allowed if required for a power wheelchair. Requests for more than two batteries at one time will be considered not medically necessary. 

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

A battery charger (E2366) 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). A dual mode battery charger (E2367) is not medically necessary. When it is provided as a replacement, payment will be denied.

Electronic Interface: Code E2351 describes an electronic interface used with a speech generating device. An electronic interface 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.

NOTE:

Refer to Medicare Advantage Medical Policy Bulletin E-36 for additional information on speech generating devices.

An electronic interface used to control lights or other electrical devices is not covered because it is not primarily medical in nature. 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). A network provider can bill the patient for these non-covered items.

Footrest/Legrest:  Elevating legrests (E0990, K0046, K0047, K0053, K0195) are covered if:

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

Elevating legrests that are used with a wheelchair that is purchased or owned by the member are coded E0990. This code is per legrest.  

Leg Elevation Feature

• 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.

Motor and/or Gearbox (Power Wheelchair):  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.

Non-Standard 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 separately billed. Codes E2201-E2204 describe seat widths and/or depths of 20 inches or more for manual wheelchairs. 

A non-standard seat width and/or depth for a manual wheelchair (E2201-E2204) is covered only if the patient’s dimensions justify the need.

For power wheelchairs, there is no separate billing for nonstandard seat frame dimensions. The allowance for the power wheelchair base code includes any seat size (width, depth, or height) that is provided. Code K0108 may not be used 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.

Power Operated Vehicles (POV): 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.

Power Seating Systems

A power seating system – tilt only, recline only, or combination tilt and recline – with or without power elevating legrests will be covered if the following criteria are met:

• The patient meets all the coverage criteria for a PWC described in Medicare Advantage Medical Policy Bulletin E-60, Power Mobility Devices; 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 of the patient’s seating and positioning needs. The PT, OT, or physician may have no financial relationship with the supplier.

  In addition, one of the following criteria must also be met:
  

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

For claims with dates of service on or after April 1, 2008, the specialty evaluation required for patients receiving a power tilt and/or recline seating system must be performed by a RESNA-certified Assistive Technology Practitioner (ATP) specializing in wheelchairs or a physician who is board-certified in Physical Medicine and Rehabilitation. The ATP or physician may not have any financial relationship with the supplier. In addition, the power seating system must be provided by a RESNA-certified Assistive Technology Supplier (ATS) specializing in wheelchairs.

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 power seat elevation feature (E2300) and power standing feature (E2301) are not 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 not covered. Network providers can bill the member for items that are not primarily medical in nature.

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.

Power Wheelchair Drive Control Systems: An attendant control (E2331) 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. If an attendant control (E2331) is provided in addition to a patient-operated drive control system, it will be denied as noncovered. 

Rollabout Chair: The allowance for a rollabout chair includes all options and accessories that are provided at the time of initial issue. Accessories provided at the time of initial issue of a rollabout chair are not separately billable. 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.

Safety Belt/Pelvic Strap: 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.

Sheer Reduction Feature: 

• A mechanical sheer 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.

Swing-away, Retractable or Removable Hardware: Code E1028 is used for swingaway hardware used with remote joysticks or touchpads, swingaway or flip-down hardware for head control interfaces E2327-E2330, and 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 Medicare Advantage Medical Policy Bulletin E-55, Wheelchair Seating, for information concerning uses of E1028 for positioning accessories.)

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

Swingaway, retractable, or removable hardware (E1028) is noncovered if the primary indication for its use is to allow the patient to move close to desks or other surfaces. If it is ordered for this indication, a GY modifier must be added to the code.

Switch: 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 non-mechanical. 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 non-mechanical 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.

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.

• A stop switch allows for an emergency stop when a wheelchair with a non-proportional 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.

Transport Chair:  See “Rollabout Chair”

Ventilator Tray: 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.

Wheels/Tires for Manual Wheelchairs: A propulsion wheel is a large wheel which can be used by a member to propel the wheelchair with his/her arms.

Services that do not meet the medical necessity criteria on this policy will be considered not medically necessary. Effective January 26, 2009, 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.

The following features of a power wheelchair are noncovered: stair climbing (A9270), electronic balance (A9270), ability to elevate the seat by balancing on two wheels (A9270), remote operation (A9270).

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 specific base (procedure code and either a narrative description of the item or the manufacturer name/model) and all options and accessories that will be separately billed. 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 other than at the time of initial issue of a power wheelchair, there must be a detailed written order which lists each item which will be separately billed and which is signed and dated by the physician. For manual wheelchair accessories, this order must be received by the supplier before the claim is submitted. For power wheelchair accessories, this order must be received prior to delivery.

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, it must be submitted with an EY modifier added to each affected procedure code. The item will be denied as not medically necessary.

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 must be submitted with an EY modifier added to each affected procedure code. The item will be denied as noncovered. 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.

For accessories provided at the same time as a power wheelchair, if the requirements related to a face-to-face examination have not been met, the GY modifier must be added to the codes for all accessories provided at the same time.  (For information on the requirements related to a face-to-face examination, see Medicare Advantage Policy E-60, Power Mobility Devices.)

For accessories provided with a power wheelchair that is only needed for mobility outside the home, the GY modifier must be added to the codes for all accessories.

For a power wheelchair, if the coverage criteria that are specified in Medicare Advantage Medical Policy Bulletin E-60 (Power Mobility Devices) have been met, a KX modifier must be added to the codes for all accessories provided at the same time. If the coverage criteria are not met, the KX modifier must not be used.

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.

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.

Invalid Code: Codes E0969,  E0970, E0980, E0994, E1227, E1296, E1297, E1298, E2340, E2341, E2342, E2343 are invalid codes.

Maintenance:  Codes E1340 and K0462 should only be used to bill for maintenance and service for an item for which the initial claim was paid.

Modifiers:

• KC Modifier: The KC modifier (replacement of special power wheelchair interface) is used in the following situation:
  1. Due to a change in the patient’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 patient had a drive control interface described by codes E2321, E2322, E2325, or E2327-E2330 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 should not be reported at the time of initial issue of a wheelchair.

  The KC modifier specifically states “replacement”, therefore, the RP modifier is not required. The KC modifier is not used when billing code E2399.

• RP Modifier: The RP modifier is used when an option or accessory is provided either as a replacement for the same part which has been worn or damaged (e.g., replacing a tire of the same type) or as an upgrade subsequent to providing the wheelchair base (e.g., replacing a standard seat of a power wheelchair with a power seating system). In both of these situations, the new item is placed on the existing wheelchair base. The RP 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.  

  When billing option/accessory codes as a replacement (modifier RP), documentation of the medical necessity for the item, make and model name of the wheelchair base it is being added to, and the initial date of service of the wheelchair must be available upon request.

• RT/LT Modifiers: The right (RT) and left (LT) modifiers must be used when appropriate. 

NOC Codes: Miscellaneous options, accessories, or replacement parts for wheelchairs that do not have a specific procedure 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 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. 

Replacements: 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 purchase of the wheelchair must be submitted with the claim.

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.

General

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):

• Lap belt or safety belt (E0978)
• Battery charger single mode (E2366)
• Complete set of tires and casters, any type (E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2393, E2394, E2395, E2396) 
• Legrests. There is no separate billing/payment if fixed or swingaway detachable non-elevating legrests with/without calf pad (K0051, K0052, E0995) are provided. Elevating legrests may be billed separately. 
• Fixed/swingaway detachable footrests with/without angle adjustment footplate/platform (K0037, K0040, K0041, K0042, K0043, K0044, K0045, K0052)
• Armrests. There is no separate billing/payment if fixed/swingaway detachable non-adjustable armrests with arm pad (K0015, K0019, K0020) are provided. Adjustable height armrests may be billed separately.
• Upholstery for seat and back of proper strength and type for patient weight capacity of the power wheelchair (E0981, E0982)
• Weight specific components per patient weight capacity
• Controller and Input Device. There is no separate billing/payment if a non-expandable controller and proportional input device (integrated or remote) is provided. If a code specifies an expandable controller as an option (but not a requirement) at the time of initial issue, it may be separately billed.

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 replacement option/accessory for a power operated vehicle (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.

A replacement accessory for a rollabout or transport chair is billed using code E1399.

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.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

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

LCD for Wheelchair Options/Accessories - L11473

CMS Transmittal 823, CR 4253

MLN Matters Number: MM4253