LCD/NCD Portal

L11443

 

MANUAL WHEELCHAIR BASES

 

MAWC

Region IV

DME Region

Jurisdiction C

 

02/28/2013

 

 

• For any item to be covered by Medicare, it must:

o be eligible for a defined Medicare benefit category

o be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member

o Meet all other applicable Medicare statutory and regulatory requirements.

 For the items addressed in this local coverage determination, the criteria for "reasonable and necessary", based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following indications and limitations of coverage and/or medical necessity.

• For an item to be covered by Medicare, a detailed written order (DWO) must be received by the supplier before a claim is submitted.

o If the supplier bills for an item addressed in this policy without first receiving the completed DWO, the item will be denied as not reasonable and necessary.

• A manual wheelchair is covered if:

o Criteria A, B, C, D, and E are met

o Criterion F or G is met.

• Additional coverage criteria for specific devices are listed below.

o The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. A mobility limitation is one that:

 Prevents the beneficiary from accomplishing an MRADL entirely, or

 Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL

 Prevents the beneficiary from completing an MRADL within a reasonable time frame.

o The beneficiary’s mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.

o The beneficiary’s home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided.

 Use of a manual wheelchair will significantly improve the beneficiary’s ability to participate in MRADLs and the beneficiary will use it on a regular basis in the home.

o The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in the home.

o The beneficiary has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair that is provided in the home during a typical day.

 Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function.

o The beneficiary has a caregiver who is available, willing, and able to provide assistance with the wheelchair.

• If the manual wheelchair will be used inside the home and the coverage criteria are not met, it will be denied as not reasonable and necessary.

• If the manual wheelchair will only be used outside the home, see related Policy Article for information concerning coverage.

• A standard hemi-wheelchair (K0002) is covered when the beneficiary requires a lower seat height (17" to 18") because of short stature or to enable the beneficiary to place his/her feet on the ground for propulsion.

• A lightweight wheelchair (K0003) is covered when a beneficiary:

o Cannot self-propel in a standard wheelchair in the home

o The beneficiary can and does self-propel in a lightweight wheelchair.

• A high strength lightweight wheelchair (K0004) is covered when a beneficiary meets the criteria in (1) and/or (2):

o The beneficiary self-propels the wheelchair while engaging in frequent activities in the home that cannot be performed in a standard or lightweight wheelchair.

o The beneficiary requires a seat width, depth, or height that cannot be accommodated in a standard, lightweight or hemi-wheelchair, and spends at least two hours per day in the wheelchair.

• A high strength lightweight wheelchair is rarely reasonable and necessary if the expected duration of need is less than three months (e.g., post-operative recovery).

• Coverage of an ultra-lightweight wheelchair (K0005) is determined on an individual consideration basis. If a K0005 wheelchair is provided and if there is insufficient information to support the need for this type of wheelchair, it will be denied as not reasonable and necessary.

• A heavy duty wheelchair (K0006) is covered if the beneficiary weighs more than 250 pounds or the beneficiary has severe spasticity.

• An extra heavy duty wheelchair (K0007) is covered if the beneficiary weighs more than 300 pounds.

• If a K0002, K0003, K0004, K0006, or K0007 wheelchair is provided and if the additional coverage criteria are not met, it will be denied as not reasonable and necessary.

• Payment is made for only one wheelchair at a time. Backup chairs are denied as not reasonable and necessary. One month's rental of a wheelchair is covered if a beneficiary-owned wheelchair is being repaired.

 

Coding Information

Bill Type Codes:

• Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service.

• Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type.

• Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

 

Revenue Codes:

• Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service.

• In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination.

• Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

 

 

CPT/HCPCS Codes

• The appearance of a code in this section does not necessarily indicate coverage.

 

 

HCPCS MODIFIERS:

 

• EY – No physician or other licensed health care provider order for this item or service

 

• GA – Waiver of liability issued as required by payer policy, individual case

 

• GY – Item or service statutorily excluded or doesn’t meet the definition of any Medicare benefit category

 

• GZ – Item or service expected to be denied as not reasonable and necessary

 

• KX - Requirements specified in the medical policy have been met

 

 

HCPCS CODES:

 

E1161 MANUAL ADULT SIZE WHEELCHAIR, INCLUDES TILT IN SPACE

E1229 WHEELCHAIR, PEDIATRIC SIZE, NOT OTHERWISE SPECIFIED

E1231 WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, RIGID, ADJUSTABLE, WITH SEATING SYSTEM

E1232 WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, ADJUSTABLE, WITH SEATING SYSTEM

E1233 WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, RIGID, ADJUSTABLE, WITHOUT SEATING SYSTEM

E1234 WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, ADJUSTABLE, WITHOUT SEATING SYSTEM

E1235 WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITH SEATING SYSTEM

E1236 WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITH SEATING SYSTEM

E1237 WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITHOUT SEATING SYSTEM

E1238 WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITHOUT SEATING SYSTEM

K0001 STANDARD WHEELCHAIR

K0002 STANDARD HEMI (LOW SEAT) WHEELCHAIR

K0003 LIGHTWEIGHT WHEELCHAIR

K0004 HIGH STRENGTH, LIGHTWEIGHT WHEELCHAIR

K0005 ULTRALIGHTWEIGHT WHEELCHAIR

K0006 HEAVY DUTY WHEELCHAIR

K0007 EXTRA HEAVY DUTY WHEELCHAIR

K0009 OTHER MANUAL WHEELCHAIR/BASE

 

General Information

Documentations Requirements

• Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider."

• It is expected that the beneficiary's medical records will reflect the need for the care provided.

• The beneficiary's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports.

• This documentation must be available upon request.

 

 

• PRESCRIPTION (ORDER) REQUIREMENTS

 

• GENERAL (PIM 5.2.1)

o All items billed to Medicare require a prescription.

o 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.

o Items dispensed and/or billed that do not meet these prescription requirements and those below must be submitted with an EY modifier added to each affected HCPCS code.

 

• DISPENSING ORDERS (PIM 5.2.2)

o Equipment and supplies may be delivered upon receipt of a dispensing order except for those items that require a written order prior to delivery.

o A dispensing order may be verbal or written.

o The supplier must keep a record of the dispensing order on file. It must contain:

 Description of the item

 Beneficiary's name

 Prescribing Physician's name

 Date of the order and the start date, if the start date is different from the date of the order

 Physician signature (if a written order) or supplier signature (if verbal order)

o For the "Date of the order" described above, use the date the supplier is contacted by the physician (for verbal orders) or the date entered by the physician (for written dispensing orders).

o Signature and date stamps are not allowed. Signatures must comply with the CMS signature requirements outlined in PIM 3.3.2.4.

o The dispensing order must be available upon request.

o For items that are provided based on a dispensing order, the supplier must obtain a detailed written order before submitting a claim.

 

• DETAILED WRITTEN ORDERS (PIM 5.2.3)

o A detailed written order (DWO) is required before billing.

o Someone other than the ordering physician may produce the DWO.

o However, the ordering physician must review the content and sign and date the document.

o It must contain:

 Beneficiary's name

 Physician's name

 Date of the order and the start date, if start date is different from the date of the order

 Detailed description of the item(s) (see below for specific requirements for selected items)

 Physician signature and signature date

o For items provided on a periodic basis, including drugs, the written order must include:

 Item(s) to be dispensed

 Dosage or concentration, if applicable

 Route of Administration

 Frequency of use

 Duration of infusion, if applicable

 Quantity to be dispensed

 Number of refills

o For the "Date of the order" described above, use the date the supplier is contacted by the physician (for verbal orders) or the date entered by the physician (for written dispensing orders).

o Frequency of use information on orders must contain detailed instructions for use and specific amounts to be dispensed.

 Reimbursement shall be based on the specific utilization amount only.

 Orders that only state "PRN" or "as needed" utilization estimates for replacement frequency, use, or consumption are not acceptable. (PIM 5.9)

o The detailed description in the written order may be either a narrative description or a brand name/model number.

o Signature and date stamps are not allowed.

 Signatures must comply with the CMS signature requirements outlined in PIM 3.3.2.4.

o The DWO must be available upon request.

o A prescription is not considered as part of the medical record.

 Medical information intended to demonstrate compliance with coverage criteria may be included on the prescription but must be corroborated by information contained in the medical record.

 

 

• MEDICAL RECORD INFORMATION

 

• GENERAL (PIM 5.7 -5.9)

• The Indications and Limitations of Coverage and/or Medical Necessity section of this LCD contains numerous reasonable and necessary (R&N) requirements.

o The Nonmedical Necessity Coverage and Payment Rules section of the related Policy Article contains numerous non-reasonable and necessary, benefit category and statutory requirements that must be met in order for payment to be justified.

o Suppliers are reminded that:

 Supplier-produced records, even if signed by the ordering physician, and attestation letters (e.g. letters of medical necessity) are deemed not to be part of a medical record for Medicare payment purposes.

 Templates and forms, including CMS Certificates of Medical Necessity, are subject to corroboration with information in the medical record.

 Information contained directly in the contemporaneous medical record is the source required to justify payment except as noted elsewhere for prescriptions and CMNs.

 The medical record is not limited to physician's office records but may include records from hospitals, nursing facilities, home health agencies, other healthcare professionals, etc. (not all-inclusive).

 Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves for the purpose of determining that an item is reasonable and necessary.

 

• CONTINUED USE

o Continued use describes the ongoing utilization of supplies or a rental item by a beneficiary.

o Suppliers are responsible for monitoring utilization of DMEPOS rental items and supplies.

 No monitoring of purchased items or capped rental items that have converted to a purchase is required.

 Suppliers must discontinue billing Medicare when rental items or ongoing supply items are no longer being used by the beneficiary.

o Beneficiary medical records or supplier records may be used to confirm that a DMEPOS item continues to be used by the beneficiary.

 Any of the following may serve as documentation that an item submitted for reimbursement continues to be used by the beneficiary:

 Timely documentation in the beneficiary's medical record showing usage of the item, related option/accessories and supplies.

 Supplier records documenting the request for refill/replacement of supplies in compliance with the Refill Documentation Requirements This is deemed to be sufficient to document continued use for the base item, as well.

 Supplier records documenting beneficiary confirmation of continued use of a rental item

 Timely documentation is defined as a record in the preceding 12 months unless otherwise specified elsewhere in this policy.

 

• CONTINUED MEDICAL NEED

o For all DMEPOS items, the initial justification for medical need is established at the time the item(s) is first ordered.

 Therefore, beneficiary medical records demonstrating that the item is reasonable and necessary are created just prior to, or at the time of, the creation of the initial prescription.

 For purchased items, initial months of a rental item or for initial months of ongoing supplies or drugs, information justifying reimbursement will come from this initial time period.

 Entries in the beneficiary's medical record must have been created prior to, or at the time of, the initial DOS to establish whether the initial reimbursement was justified based upon the applicable coverage policy.

o For ongoing supplies and rental DME items, in addition to information described above that justifies the initial provision of the item(s) and/or supplies, there must be information in the beneficiary's medical record to support that the item continues to be used by the beneficiary and remains reasonable and necessary.

 Information used to justify continued medical need must be timely for the DOS under review.

 Any of the following may serve as documentation justifying continued medical need:

 A recent order by the treating physician for refills

 A recent change in prescription

 A properly completed CMN or DIF with an appropriate length of need specified

 Timely documentation in the beneficiary's medical record showing usage of the item.

 Timely documentation is defined as a record in the preceding 12 months unless otherwise specified elsewhere in the policy.

 

• PROOF OF DELIVERY (PIM 4.26, 5.8)

o Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD documentation in their files.

 For medical review purposes, POD serves to assist in determining correct coding and billing information for claims submitted for Medicare reimbursement.

 Regardless of the method of delivery, the contractor must be able to determine from delivery documentation that the supplier properly coded the item(s), that the item(s) delivered are the same item(s) submitted for Medicare reimbursement and that the item(s) are intended for, and received by, a specific Medicare beneficiary.

o Suppliers, their employees, or anyone else having a financial interest in the delivery of the item are prohibited from signing and accepting an item on behalf of a beneficiary (i.e., acting as a designee on behalf of the beneficiary).

 The signature and date the beneficiary or designee accepted delivery must be legible.

o For the purpose of the delivery methods noted below, designee is defined as "Any person who can sign and accept the delivery of durable medical equipment on behalf of the beneficiary."

o Proof of delivery documentation must be available to the Medicare contractor on request.

 All services that do not have appropriate proof of delivery from the supplier will be denied and overpayments will be requested.

 Suppliers who consistently fail to provide documentation to support their services may be referred to the OIG for imposition of Civil Monetary Penalties or other administrative sanctions.

o Suppliers are required to maintain POD documentation in their files. There are three methods of delivery:

 Delivery directly to the beneficiary or authorized representative

 Delivery via shipping or delivery service

 Delivery of items to a nursing facility on behalf of the beneficiary

 

• Method 1—Direct Delivery to the Beneficiary by the Supplier

o Suppliers may deliver directly to the beneficiary or the designee. In this case, POD to a beneficiary must be a signed and dated delivery slip.

o The POD record must include:

 Beneficiary's name

 Delivery address

 Sufficiently detailed description to identify the item(s) being delivered (e.g., brand name, serial number, narrative description)

 Quantity delivered

 Date delivered

 Beneficiary (or designee) signature and date of signature

o The date of signature on the delivery slip must be the date that the DMEPOS item was received by the beneficiary or designee.

 In instances where the supplies are delivered directly by the supplier, the date the beneficiary received the DMEPOS supply must be the date of service on the claim.

 

• Method 2—Delivery via Shipping or Delivery Service Directly to a Beneficiary

o If the supplier utilizes a shipping service or mail order, the POD documentation must be a complete record tracking the item(s) from the DMEPOS supplier to the beneficiary. An example of acceptable proof of delivery would include both the supplier's own detailed shipping invoice and the delivery service's tracking information. The supplier's record must be linked to the delivery service record by some clear method like the delivery service's package identification number or supplier's invoice number for the package sent to the beneficiary. The POD record must include:

 Beneficiary's name

 Delivery address

 Delivery service's package identification number, supplier invoice number or alternative method that links the supplier's delivery documents with the delivery service's records.

 Sufficiently detailed description to identify the item(s) being delivered (e.g., brand name, serial number, narrative description)

 Quantity delivered

 Date delivered

 Evidence of delivery

o If a supplier utilizes a shipping service or mail order, suppliers must use the shipping date as the date of service on the claim.

o Suppliers may also utilize a return postage-paid delivery invoice from the beneficiary or designee as a POD.

 This type of POD record must contain the information specified above.

 

• Method 3—Delivery to Nursing Facility on Behalf of a Beneficiary

o When a supplier delivers items directly to a nursing facility, the documentation described for Method 1 (see above) is required.

o When a delivery service or mail order is used to deliver the item to a nursing facility, the documentation described for Method 2 (see above) is required.

o Regardless the method of delivery, for those beneficiaries that are residents of a nursing facility, information from the nursing facility showing that the item(s) delivered for the beneficiary's use were actually provided to and used by the beneficiary must be available upon request.

 

 

• POLICY SPECIFIC DOCUMENTATION REQUIREMENTS

o Information showing that the coverage criteria in the Indications and Limitations of and/or Medical Necessity section have been met must be present in the beneficiary’s medical record.

 Information about whether the beneficiary’s home can accommodate the wheelchair (Criterion C), also called the home assessment, must be fully documented in the medical record or elsewhere by the supplier.

 For manual wheelchairs, the home assessment may be done directly by visiting the beneficiary’s home or indirectly based upon information provided by the beneficiary or their designee.

 When the home assessment is based upon indirectly obtained information, the supplier must, at the time of delivery, verify that the item delivered meets the requirements specified in criterion C.

 Issues such as the physical layout of the home, surfaces to be traversed, and obstacles must be addressed by and documented in the home assessment.

 Information from the beneficiary’s medical record and the supplier’s records must be available upon request.

o Manual wheelchairs described by codes E1161, E1231-E1234, K0005 and K0009 are eligible for Advance Determination of Medicare Coverage (ADMC).

 Refer to the ADMC chapter in the Supplier Manual for details concerning the ADMC process.

o If documentation of the medical necessity for a K0005 wheelchair is requested, it must include a description of the beneficiary’s routine activities.

 This may include the types of activities the beneficiary frequently encounters and whether the beneficiary is fully independent in the use of the wheelchair.

 Describe the features of the K0005 base which are needed compared to the K0004 base.

 

• REPAIR/REPLACEMENT (BPM Ch 15, §100.2)

o A new physician’s order is not needed for repairs.

o The supplier must maintain detailed records describing the need for and nature of all repairs including a detailed explanation of the justification for any component or part replaced as well as the labor time.

 

• KX, GA, GY, AND GZ MODIFIERS:

o Suppliers must add a KX modifier to the code for the manual wheelchair base only if all of the coverage criteria in the Indications and Limitations of Coverage section of this policy have been met and evidence of such is retained in the supplier’s files and available to the DME MAC upon request.

 If the coverage criteria are not met, the KX modifier must not be used.

o If all of the coverage criteria in the Indications and Limitations of Coverage and/or Medical

 Necessity section have not been met, the GA or GZ modifier must be added to the code.

 When there is an expectation of a medical necessity denial, suppliers must enter the GA modifier on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or the GZ modifier if they have not obtained a valid ABN.

o If the wheelchair is only to be used for mobility outside the home, the GY modifier must be added to the code.

o Claim lines billed without a KX, GA, GY, or GZ modifier will be rejected as missing information.

o Refer to the Supplier Manual for more information on documentation requirements.

 

Sources of Information and Basis for Decision

 

A25580 - Manual Wheelchair Bases - Policy Article - Effective May 2012

 

Local Coverage Determination (LCD) for Manual Wheelchair Bases (L11443)