L11451-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Wheelchair Options/Accessories (L11451)

Contractor Information

Contractor Name CGS Administrators, LLC

LCD Information

Document Information

LCD ID Number L11451

LCD Title Wheelchair Options/Accessories

Contractor's Determination Number WCOA

AMA CPT/ADA CDT Copyright Statement

Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

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Virginia

Virgin Islands West Virginia

Oversight Region Region IV

DME Region LCD Covers Jurisdiction C

Original Determination Effective Date

For services performed on or after 10/01/1993 Original Determination Ending Date

Revision Effective Date

For services performed on or after 01/01/2012

Revision Ending Date

CMS National Coverage Policy

Pub. 100-3 (Medicare National Coverage Determinations Manual), Chapter 1, Sections 280.1, 280.3 Indications and Limitations of Coverage and/or Medical Necessity

For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this local coverage determination, the criteria for "reasonable and necessary", based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following indications and limitations of coverage and/or medical necessity.

For an option or accessory for a manual wheelchair to be covered, a detailed written order (DWO) must be received by the supplier before a claim is submitted. If the supplier bills for an item without first receiving the completed DWO, the item will be denied as not reasonable and necessary. (See related Policy Article for information on order for power wheelchair accessories.)

Options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. Coverage criteria for specific items are described below.

If these criteria are not met, the item will be denied as not reasonable and necessary.

ARM OF CHAIR:

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

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

FOOTREST/ LEGREST:

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

1. The beneficiary has a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee; or

2. The beneficiary has significant edema of the lower extremities that requires an elevating legrest; or

3. The beneficiary meets the criteria for and has a reclining back on the wheelchair.

NONSTANDARD SEAT FRAME DIMENSIONS:

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

WHEELS/TIRES FOR MANUAL WHEELCHAIRS:

A gear reduction drive wheel (E2227) or a lever activated wheel drive (E0988) is covered if all of the following criteria are met:

1. The beneficiary has been self-propelling in a manual wheelchair for at least one year; and

2. The beneficiary has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the need for the device in the 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 beneficiary.

BATTERIES/ CHARGERS:

Up to two sealed batteries (E2359, E2361, E2363, E2365, E2371, K0733) at any one time are allowed if required for a power wheelchair.

A non-sealed battery (E2358, E2360, E2362, E2364, E2372) will be denied as not reasonable and necessary.

A single mode battery charger (E2366) is appropriate for charging a sealed lead acid battery. If a dual mode battery charger (E2367) is provided as a replacement, it will be denied as not reasonable and necessary.

The usual maximum frequency of replacement for a lithium-based battery (E2397) is one every 3 years. Only one battery is allowed at any one time.

POWER TILT AND/OR RECLINE SEATING SYSTEMS (E1002-E1010):

A power seating system – tilt only, recline only, or combination tilt and recline – with or without power elevating legrests will be covered if criteria 1, 2, and 3 are met and if criterion 4, 5, or 6 is met:

1. The beneficiary meets all the coverage criteria for a power wheelchair described in the Power Mobility Devices LCD; 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 of the beneficiary's seating and positioning needs. The PT, OT, or physician may have no financial relationship with the supplier; and

4. The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or

5. The beneficiary 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 reasonable and necessary.

POWER WHEELCHAIR DRIVE CONTROL SYSTEMS:

An attendant control is covered in place of a beneficiary-operated drive control system if the beneficiary meets coverage criteria for a wheelchair, is unable to operate a manual or power wheelchair and has a caregiver who is unable to operate a manual wheelchair but is able to operate a power wheelchair.

OTHER POWER WHEELCHAIR ACCESSORIES:

An electronic interface (E2351) to allow a speech generating device to be operated by the power wheelchair control interface is covered if the beneficiary has a covered speech generating device. (Refer to the Speech Generating Devices LCD for details.)

MISCELLANEOUS ACCESSORIES:

Anti-rollback device (E0974) is covered if the beneficiary self-propels and needs the device because of ramps.

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

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

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

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

2. The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to the bed.

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

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

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 statement issued, as required by payer policy, individual case

GY – Item or service statutorily excluded or does not meet the definition of any Medicare benefit

GZ - Item or service expected to be denied as not reasonable and necessary KC - Replacement of special power wheelchair interface

KX - Requirements specified in the medical policy have been met RB – Replacement of a part of DME furnished as part of a repair HCPCS CODES:

ARM OF CHAIR:

E0973 WHEELCHAIR ACCESSORY, ADJUSTABLE HEIGHT, DETACHABLE ARMREST, COMPLETE ASSEMBLY, EACH E2209 ACCESSORY, ARM TROUGH, WITH OR WITHOUT HAND SUPPORT, EACH

K0015 DETACHABLE, NON-ADJUSTABLE HEIGHT ARMREST, EACH K0017 DETACHABLE, ADJUSTABLE HEIGHT ARMREST, BASE, EACH

K0018 DETACHABLE, ADJUSTABLE HEIGHT ARMREST, UPPER PORTION, EACH K0019 ARM PAD, EACH

K0020 FIXED, ADJUSTABLE HEIGHT ARMREST, PAIR

FOOTREST/LEGREST:

E0951 HEEL LOOP/HOLDER, ANY TYPE, WITH OR WITHOUT ANKLE STRAP, EACH E0952 TOE LOOP/HOLDER, ANY TYPE, EACH

E0990 WHEELCHAIR ACCESSORY, ELEVATING LEG REST, COMPLETE ASSEMBLY, EACH E0995 WHEELCHAIR ACCESSORY, CALF REST/PAD, EACH

E1020 RESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCHAIR, ANY TYPE K0037 HIGH MOUNT FLIP-UP FOOTREST, EACH

K0038 LEG STRAP, EACH

K0039 LEG STRAP, H STYLE, EACH

K0040 ADJUSTABLE ANGLE FOOTPLATE, EACH K0041 LARGE SIZE FOOTPLATE, EACH

K0042 STANDARD SIZE FOOTPLATE, EACH

K0043 FOOTREST, LOWER EXTENSION TUBE, EACH K0044 FOOTREST, UPPER HANGER BRACKET, EACH K0045 FOOTREST, COMPLETE ASSEMBLY

K0046 ELEVATING LEGREST, LOWER EXTENSION TUBE, EACH K0047 ELEVATING LEGREST, UPPER HANGER BRACKET, EACH K0050 RATCHET ASSEMBLY

K0051 CAM RELEASE ASSEMBLY, FOOTREST OR LEGREST, EACH K0052 SWINGAWAY, DETACHABLE FOOTRESTS, EACH

K0053 ELEVATING FOOTRESTS, ARTICULATING (TELESCOPING), EACH

K0195 ELEVATING LEG RESTS, PAIR (FOR USE WITH CAPPED RENTAL WHEELCHAIR BASE)

NONSTANDARD SEAT FRAME DIMENSIONS:

E1011 MODIFICATION TO PEDIATRIC SIZE WHEELCHAIR, WIDTH ADJUSTMENT PACKAGE (NOT TO BE DISPENSED WITH INITIAL CHAIR)

E2201 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME, WIDTH GREATER THAN OR EQUAL TO 20 INCHES AND LESS THAN 24 INCHES

E2202 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME WIDTH, 24-27 INCHES

E2203 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 20 TO LESS THAN 22 INCHES E2204 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 22 TO 25 INCHES

K0056 SEAT HEIGHT LESS THAN 17" OR EQUAL TO OR GREATER THAN 21" FOR A HIGH STRENGTH, LIGHTWEIGHT, OR ULTRALIGHTWEIGHT WHEELCHAIR

REAR WHEELS FOR MANUAL WHEELCHAIRS:

E0961 MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK BRAKE EXTENSION (HANDLE), EACH E0967 MANUAL WHEELCHAIR ACCESSORY, HAND RIM WITH PROJECTIONS, ANY TYPE, EACH E0988 MANUAL WHEELCHAIR ACCESSORY, LEVER-ACTIVATED, WHEEL DRIVE, PAIR

E2205 MANUAL WHEELCHAIR ACCESSORY, HANDRIM WITHOUT PROJECTIONS (INCLUDES ERGONOMIC OR CONTOURED), ANY TYPE, REPLACEMENT ONLY, EACH

E2206 MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK ASSEMBLY, COMPLETE, EACH E2211 MANUAL WHEELCHAIR ACCESSORY, PNEUMATIC PROPULSION TIRE, ANY SIZE, EACH

E2212 MANUAL WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC PROPULSION TIRE, ANY SIZE, EACH

E2213 MANUAL WHEELCHAIR ACCESSORY, INSERT FOR PNEUMATIC PROPULSION TIRE (REMOVABLE), ANY TYPE, ANY SIZE, EACH

E2214 MANUAL WHEELCHAIR ACCESSORY, PNEUMATIC CASTER TIRE, ANY SIZE, EACH

E2215 MANUAL WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC CASTER TIRE, ANY SIZE, EACH E2216 MANUAL WHEELCHAIR ACCESSORY, FOAM FILLED PROPULSION TIRE, ANY SIZE, EACH E2217 MANUAL WHEELCHAIR ACCESSORY, FOAM FILLED CASTER TIRE, ANY SIZE, EACH

E2218 MANUAL WHEELCHAIR ACCESSORY, FOAM PROPULSION TIRE, ANY SIZE, EACH E2219 MANUAL WHEELCHAIR ACCESSORY, FOAM CASTER TIRE, ANY SIZE, EACH

E2220 MANUAL WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) PROPULSION TIRE, ANY SIZE, EACH

E2221 MANUAL WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE (REMOVABLE), ANY SIZE, EACH

E2222 MANUAL WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE WITH INTEGRATED WHEEL, ANY SIZE, EACH

E2224 MANUAL WHEELCHAIR ACCESSORY, PROPULSION WHEEL EXCLUDES TIRE, ANY SIZE, EACH

E2225 MANUAL WHEELCHAIR ACCESSORY, CASTER WHEEL EXCLUDES TIRE, ANY SIZE, REPLACEMENT ONLY, EACH

E2226 MANUAL WHEELCHAIR ACCESSORY, CASTER FORK, ANY SIZE, REPLACEMENT ONLY, EACH E2227 MANUAL WHEELCHAIR ACCESSORY, GEAR REDUCTION DRIVE WHEEL, EACH

E2228 MANUAL WHEELCHAIR ACCESSORY, WHEEL BRAKING SYSTEM AND LOCK, COMPLETE, EACH K0065 SPOKE PROTECTORS, EACH

K0069 REAR WHEEL ASSEMBLY, COMPLETE, WITH SOLID TIRE, SPOKES OR MOLDED, EACH K0070 REAR WHEEL ASSEMBLY, COMPLETE, WITH PNEUMATIC TIRE, SPOKES OR MOLDED, EACH K0071 FRONT CASTER ASSEMBLY, COMPLETE, WITH PNEUMATIC TIRE, EACH

K0072 FRONT CASTER ASSEMBLY, COMPLETE, WITH SEMI-PNEUMATIC TIRE, EACH K0073 CASTER PIN LOCK,EACH

K0077 FRONT CASTER ASSEMBLY, COMPLETE, WITH SOLID TIRE, EACH

BATTERIES/CHARGERS:

E2358 POWER WHEELCHAIR ACCESSORY, GROUP 34 NON-SEALED LEAD ACID BATTERY, EACH

E2359 POWER WHEELCHAIR ACCESSORY, GROUP 34 SEALED LEAD ACID BATTERY, EACH (E.G. GEL CELL, ABSORBED GLASSMAT)

E2360 POWER WHEELCHAIR ACCESSORY, 22 NF NON-SEALED LEAD ACID BATTERY, EACH

E2361 POWER WHEELCHAIR ACCESSORY, 22NF SEALED LEAD ACID BATTERY, EACH, (E.G. GEL CELL, ABSORBED GLASSMAT)

E2362 POWER WHEELCHAIR ACCESSORY, GROUP 24 NON-SEALED LEAD ACID BATTERY, EACH

E2363 POWER WHEELCHAIR ACCESSORY, GROUP 24 SEALED LEAD ACID BATTERY, EACH (E.G. GEL CELL, ABSORBED GLASSMAT)

E2364 POWER WHEELCHAIR ACCESSORY, U-1 NON-SEALED LEAD ACID BATTERY, EACH

E2365 POWER WHEELCHAIR ACCESSORY, U-1 SEALED LEAD ACID BATTERY, EACH (E.G. GEL CELL, ABSORBED GLASSMAT)

E2366 POWER WHEELCHAIR ACCESSORY, BATTERY CHARGER, SINGLE MODE, FOR USE WITH ONLY ONE BATTERY TYPE, SEALED OR NON-SEALED, EACH

E2367 POWER WHEELCHAIR ACCESSORY, BATTERY CHARGER, DUAL MODE, FOR USE WITH EITHER BATTERY TYPE, SEALED OR NON-SEALED, EACH

E2371 POWER WHEELCHAIR ACCESSORY, GROUP 27 SEALED LEAD ACID BATTERY, (E.G. GEL CELL, ABSORBED GLASSMAT), EACH

E2372 POWER WHEELCHAIR ACCESSORY, GROUP 27 NON-SEALED LEAD ACID BATTERY, EACH E2397 POWER WHEELCHAIR ACCESSORY, LITHIUM-BASED BATTERY, EACH

K0733 POWER WHEELCHAIR ACCESSORY, 12 TO 24 AMP HOUR SEALED LEAD ACID BATTERY, EACH (E.G., GEL CELL, ABSORBED GLASSMAT)

POWER SEATING SYSTEMS:

E1002 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, TILT ONLY

E1003 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITHOUT SHEAR REDUCTION

E1004 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITH MECHANICAL SHEAR REDUCTION

E1005 WHEELCHAIR ACCESSORY, POWER SEATNG SYSTEM, RECLINE ONLY, WITH POWER SHEAR REDUCTION

E1006 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITHOUT SHEAR REDUCTION

E1007 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITH MECHANICAL SHEAR REDUCTION

E1008 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITH POWER SHEAR REDUCTION

E1009 WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, MECHANICALLY LINKED LEG ELEVATION SYSTEM, INCLUDING PUSHROD AND LEG REST, EACH

E1010 WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, POWER LEG ELEVATION SYSTEM, INCLUDING LEG REST, PAIR

E2300 POWER WHEELCHAIR ACCESSORY, POWER SEAT ELEVATION SYSTEM E2301 POWER WHEELCHAIR ACCESSORY, POWER STANDING SYSTEM

POWER WHEELCHAIR ACCESSORY, ELECTRONIC CONNECTION BETWEEN WHEELCHAIR CONTROLLER AND E2310 ONE POWER SEATING SYSTEM MOTOR, INCLUDING ALL RELATED ELECTRONICS, INDICATOR FEATURE,

MECHANICAL FUNCTION SELECTION SWITCH, AND FIXED MOUNTING HARDWARE

POWER WHEELCHAIR ACCESSORY, ELECTRONIC CONNECTION BETWEEN WHEELCHAIR CONTROLLER AND E2311 TWO OR MORE POWER SEATING SYSTEM MOTORS, INCLUDING ALL RELATED ELECTRONICS, INDICATOR

FEATURE, MECHANICAL FUNCTION SELECTION SWITCH, AND FIXED MOUNTING HARDWARE

POWER WHEELCHAIR DRIVE CONTROL SYSTEMS:

E2312 POWER WHEELCHAIR ACCESSORY, HAND OR CHIN CONTROL INTERFACE, MINI-PROPORTIONAL REMOTE JOYSTICK, PROPORTIONAL, INCLUDING FIXED MOUNTING HARDWARE

E2313 POWER WHEELCHAIR ACCESSORY, HARNESS FOR UPGRADE TO EXPANDABLE CONTROLLER, INCLUDING ALL FASTENERS, CONNECTORS AND MOUNTING HARDWARE, EACH

POWER WHEELCHAIR ACCESSORY, HAND CONTROL INTERFACE, REMOTE JOYSTICK, NONPROPORTIONAL, E2321 INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, AND FIXED MOUNTING

HARDWARE

POWER WHEELCHAIR ACCESSORY, HAND CONTROL INTERFACE, MULTIPLE MECHANICAL SWITCHES, E2322 NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, AND FIXED

MOUNTING HARDWARE

E2323 POWER WHEELCHAIR ACCESSORY, SPECIALTY JOYSTICK HANDLE FOR HAND CONTROL INTERFACE, PREFABRICATED

E2324 POWER WHEELCHAIR ACCESSORY, CHIN CUP FOR CHIN CONTROL INTERFACE

E2325 POWER WHEELCHAIR ACCESSORY, SIP AND PUFF INTERFACE, NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, AND MANUAL SWINGAWAY MOUNTING HARDWARE

E2326 POWER WHEELCHAIR ACCESSORY, BREATH TUBE KIT FOR SIP AND PUFF INTERFACE

POWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, MECHANICAL, PROPORTIONAL, E2327 INCLUDING ALL RELATED ELECTRONICS, MECHANICAL DIRECTION CHANGE SWITCH, AND FIXED

MOUNTING HARDWARE

E2328 POWER WHEELCHAIR ACCESSORY, HEAD CONTROL OR EXTREMITY CONTROL INTERFACE, ELECTRONIC, PROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS AND FIXED MOUNTING HARDWARE

POWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, CONTACT SWITCH MECHANISM,

E2329 NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, MECHANICAL DIRECTION CHANGE SWITCH, HEAD ARRAY, AND FIXED MOUNTING HARDWARE

POWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, PROXIMITY SWITCH MECHANISM,

E2330 NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, MECHANICAL DIRECTION CHANGE SWITCH, HEAD ARRAY, AND FIXED MOUNTING HARDWARE

E2331 POWER WHEELCHAIR ACCESSORY, ATTENDANT CONTROL, PROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS AND FIXED MOUNTING HARDWARE

E2373 POWER WHEELCHAIR ACCESSORY, HAND OR CHIN CONTROL INTERFACE, COMPACT REMOTE JOYSTICK, PROPORTIONAL, INCLUDING FIXED MOUNTING HARDWARE

POWER WHEELCHAIR ACCESSORY, HAND OR CHIN CONTROL INTERFACE, STANDARD REMOTE JOYSTICK E2374 (NOT INCLUDING CONTROLLER), PROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS AND FIXED

MOUNTING HARDWARE, REPLACEMENT ONLY

E2375 POWER WHEELCHAIR ACCESSORY, NON-EXPANDABLE CONTROLLER, INCLUDING ALL RELATED ELECTRONICS AND MOUNTING HARDWARE, REPLACEMENT ONLY

E2376 POWER WHEELCHAIR ACCESSORY, EXPANDABLE CONTROLLER, INCLUDING ALL RELATED ELECTRONICS AND MOUNTING HARDWARE, REPLACEMENT ONLY

E2377 POWER WHEELCHAIR ACCESSORY, EXPANDABLE CONTROLLER, INCLUDING ALL RELATED ELECTRONICS AND MOUNTING HARDWARE, UPGRADE PROVIDED AT INITIAL ISSUE

OTHER POWER WHEELCHAIR ACCESSORIES:

E1016 SHOCK ABSORBER FOR POWER WHEELCHAIR, EACH

E1018 HEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY DUTY POWER WHEELCHAIR, EACH

E2351 POWER WHEELCHAIR ACCESSORY, ELECTRONIC INTERFACE TO OPERATE SPEECH GENERATING DEVICE USING POWER WHEELCHAIR CONTROL INTERFACE

E2368 POWER WHEELCHAIR COMPONENT, DRIVE WHEEL MOTOR, REPLACEMENT ONLY E2369 POWER WHEELCHAIR COMPONENT, DRIVE WHEEL GEAR BOX, REPLACEMENT ONLY

E2370 POWER WHEELCHAIR COMPONENT, INTEGRATED DRIVE WHEEL MOTOR AND GEAR BOX COMBINATION, REPLACEMENT ONLY

E2381

POWER WHEELCHAIR ACCESSORY, PNEUMATIC DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT ONLY, EACH

E2382 POWER WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT ONLY, EACH

E2383 POWER WHEELCHAIR ACCESSORY, INSERT FOR PNEUMATIC DRIVE WHEEL TIRE (REMOVABLE), ANY TYPE, ANY SIZE, REPLACEMENT ONLY, EACH

E2384 POWER WHEELCHAIR ACCESSORY, PNEUMATIC CASTER TIRE, ANY SIZE, REPLACEMENT ONLY, EACH

E2385 POWER WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC CASTER TIRE, ANY SIZE, REPLACEMENT ONLY, EACH

E2386 POWER WHEELCHAIR ACCESSORY, FOAM FILLED DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT ONLY, EACH

E2387 POWER WHEELCHAIR ACCESSORY, FOAM FILLED CASTER TIRE, ANY SIZE, REPLACEMENT ONLY, EACH E2388 POWER WHEELCHAIR ACCESSORY, FOAM DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT ONLY, EACH E2389 POWER WHEELCHAIR ACCESSORY, FOAM CASTER TIRE, ANY SIZE, REPLACEMENT ONLY, EACH

E2390 POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT ONLY, EACH

E2391 POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE (REMOVABLE), ANY SIZE, REPLACEMENT ONLY, EACH

E2392 POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE WITH INTEGRATED WHEEL, ANY SIZE, REPLACEMENT ONLY, EACH

E2394 POWER WHEELCHAIR ACCESSORY, DRIVE WHEEL EXCLUDES TIRE, ANY SIZE, REPLACEMENT ONLY, EACH

E2395 POWER WHEELCHAIR ACCESSORY, CASTER WHEEL EXCLUDES TIRE, ANY SIZE, REPLACEMENT ONLY, EACH

E2396 POWER WHEELCHAIR ACCESSORY, CASTER FORK, ANY SIZE, REPLACEMENT ONLY, EACH K0098 DRIVE BELT FOR POWER WHEELCHAIR

MISCELLANEOUS ACCESSORIES:

A9270 NON-COVERED ITEM OR SERVICE

A9900 MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS CODE E0705 TRANSFER DEVICE, ANY TYPE, EACH

E0950 WHEELCHAIR ACCESSORY, TRAY, EACH

E0958 MANUAL WHEELCHAIR ACCESSORY, ONE-ARM DRIVE ATTACHMENT, EACH E0959 MANUAL WHEELCHAIR ACCESSORY, ADAPTER FOR AMPUTEE, EACH

E0971 MANUAL WHEELCHAIR ACCESSORY, ANTI-TIPPING DEVICE, EACH E0974 MANUAL WHEELCHAIR ACCESSORY, ANTI-ROLLBACK DEVICE, EACH

E0978 WHEELCHAIR ACCESSORY, POSITIONING BELT/SAFETY BELT/PELVIC STRAP, EACH E0981 WHEELCHAIR ACCESSORY, SEAT UPHOLSTERY, REPLACEMENT ONLY, EACH

E0982 WHEELCHAIR ACCESSORY, BACK UPHOLSTERY, REPLACEMENT ONLY, EACH E0985 WHEELCHAIR ACCESSORY, SEAT LIFT MECHANISM

E1014 RECLINING BACK, ADDITION TO PEDIATRIC SIZE WHEELCHAIR E1015 SHOCK ABSORBER FOR MANUAL WHEELCHAIR, EACH

E1017 HEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY DUTY MANUAL WHEELCHAIR, EACH

E1028 WHEELCHAIR ACCESSORY, MANUAL SWINGAWAY, RETRACTABLE OR REMOVABLE MOUNTING HARDWARE FOR JOYSTICK, OTHER CONTROL INTERFACE OR POSITIONING ACCESSORY

E1029 WHEELCHAIR ACCESSORY, VENTILATOR TRAY, FIXED E1030 WHEELCHAIR ACCESSORY, VENTILATOR TRAY, GIMBALED

E1225 WHEELCHAIR ACCESSORY, MANUAL SEMI-RECLINING BACK, (RECLINE GREATER THAN 15 DEGREES, BUT LESS THAN 80 DEGREES), EACH

E1226 WHEELCHAIR ACCESSORY, MANUAL FULLY RECLINING BACK, (RECLINE GREATER THAN 80 DEGREES), EACH

E2207 WHEELCHAIR ACCESSORY, CRUTCH AND CANE HOLDER, EACH E2208 WHEELCHAIR ACCESSORY, CYLINDER TANK CARRIER, EACH

E2210 WHEELCHAIR ACCESSORY, BEARINGS, ANY TYPE, REPLACEMENT ONLY, EACH E2230 MANUAL WHEELCHAIR ACCESSORY, MANUAL STANDING SYSTEM

E2295 MANUAL WHEELCHAIR ACCESSORY, FOR PEDIATRIC SIZE WHEELCHAIR, DYNAMIC SEATING FRAME, ALLOWS COORDINATED MOVEMENT OF MULTIPLE POSITIONING FEATURES

K0105 IV HANGER, EACH

K0108 WHEELCHAIR COMPONENT OR ACCESSORY, NOT OTHERWISE SPECIFIED

ICD-9 Codes that Support Medical Necessity

AsteriskNoteText

Diagnoses that Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity

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

Wheelchair options and accessories provided for a manual wheelchair base must meet the following requirements for dispensing and detailed written orders. See the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS SECTION below for prescription requirements for options and accessories provided for a power wheelchair base.

GENERAL (PIM 5.2.1)

All items billed to Medicare require a prescription. An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request. Items dispensed and/or billed that do not meet these prescription requirements and those below must be submitted with an EY modifier added to each affected HCPCS code.

DISPENSING ORDERS (PIM 5.2.2)

Equipment and supplies may be delivered upon receipt of a dispensing order except for those items that require a written order prior to delivery. A dispensing order may be verbal or written. The supplier must keep a record of the dispensing order on file. It must contain:

• Description of the item

• Beneficiary's name

• Prescribing Physician's name

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

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

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

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

The dispensing order must be available upon request.

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

DETAILED WRITTEN ORDERS (PIM 5.2.3)

A detailed written order (DWO) is required before billing. Someone other than the ordering physician may produce the DWO. However, the ordering physician must review the content and sign and date the document. It must contain:

• Beneficiary's name

• Physician's name

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

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

• Physician signature and signature date

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

Frequency of use information on orders must contain detailed instructions for use and specific amounts to be dispensed. Reimbursement shall be based on the specific utilization amount only. Orders that only state “PRN” or “as needed” utilization estimates for replacement frequency, use, or consumption are not acceptable. (PIM 5.9)

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

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

The DWO must be available upon request.

A prescription is not considered as part of the medical record. Medical information intended to demonstrate compliance with coverage criteria may be included on the prescription but must be corroborated by information contained in the medical record.

MEDICAL RECORD INFORMATION

GENERAL (PIM 5.7 -5.9)

The Indications and Limitations of Coverage and/or Medical Necessity section of this LCD contains numerous reasonable and necessary (R&N) requirements. The Nonmedical Necessity Coverage and Payment Rules section of the related Policy Article contains numerous non-reasonable and necessary, benefit category and statutory requirements that must be met in order for payment to be justified. Suppliers are reminded that:

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

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

Information contained directly in the contemporaneous medical record is the source required to justify payment except as noted elsewhere for prescriptions and CMNs. The medical record is not limited to physician’s office records but may include records from hospitals, nursing facilities, home health agencies, other healthcare professionals, etc. (not all-inclusive). Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves for the purpose of determining that an item is reasonable and necessary.

CONTINUED USE

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

Suppliers are responsible for monitoring utilization of DMEPOS rental items and supplies. No monitoring of purchased items or capped rental items that have converted to a purchase is required. Suppliers must discontinue billing Medicare when rental items or ongoing supply items are no longer being used by the beneficiary.

Beneficiary medical records or supplier records may be used to confirm that a DMEPOS item continues to be used by the beneficiary. Any of the following may serve as documentation that an item submitted for reimbursement continues to be used by the beneficiary:

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

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

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

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

CONTINUED MEDICAL NEED

For all DMEPOS items, the initial justification for medical need is established at the time the item(s) is first ordered; therefore, beneficiary medical records demonstrating that the item is reasonable and necessary are created just prior to, or at the time of, the creation of the initial prescription. For purchased items, initial months of a rental item or for initial months of ongoing supplies or drugs, information justifying reimbursement will come from this initial time period. Entries in the beneficiary’s medical record must have been created prior to, or at the time of, the initial DOS to establish whether the initial reimbursement was justified based upon the applicable coverage policy.

For ongoing supplies and rental DME items, in addition to information described above that justifies the initial provision of the item(s) and/or supplies, there must be information in the beneficiary’s medical record to support that the item continues to be used by the beneficiary and remains reasonable and necessary. Information used to justify continued medical need must be timely for the DOS under review. Any of the following may serve as documentation justifying continued medical need:

• A recent order by the treating physician for refills

• A recent change in prescription

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

• Timely documentation in the beneficiary’s medical record showing usage of the item.

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

PROOF OF DELIVERY (PIM 4.26, 5.8)

Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD documentation in their files. For medical review purposes, POD serves to assist in determining correct coding and billing information for claims submitted for Medicare reimbursement. Regardless of the method of delivery, the contractor must be able to determine from delivery documentation that the supplier properly coded the item(s), that the item(s) delivered are the same item(s) submitted for Medicare reimbursement and that the item(s) are intended for, and received by, a specific Medicare beneficiary.

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

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

Proof of delivery documentation must be available to the Medicare contractor on request. All services that do not have appropriate proof of delivery from the supplier will be denied and overpayments will be requested. Suppliers who consistently fail to provide documentation to support their services may be referred to the OIG for imposition of Civil Monetary Penalties or other administrative sanctions.

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

1. Delivery directly to the beneficiary or authorized representative

2. Delivery via shipping or delivery service

3. Delivery of items to a nursing facility on behalf of the beneficiary

Method 1—Direct Delivery to the Beneficiary by the Supplier

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

• Beneficiary’s name

• Delivery address

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

• Quantity delivered

• Date delivered

• Beneficiary (or designee) signature and date of signature

The date of signature on the delivery slip must be the date that the DMEPOS item was received by the beneficiary or designee. In instances where the supplies are delivered directly by the supplier, the date the beneficiary received the DMEPOS supply must be the date of service on the claim.

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

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

• Beneficiary’s name

• Delivery address

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

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

• Quantity delivered

• Date delivered

• Evidence of delivery

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

Suppliers may also utilize a return postage-paid delivery invoice from the beneficiary or designee as a POD. This type of POD record must contain the information specified above.

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

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

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.

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

For options and accessories provided at the time of initial issue of a power wheelchair, once the supplier has determined the specific power mobility device that is appropriate for the beneficiary based on the physician's 7- element order, the supplier must prepare a written document (termed a detailed product description). This detailed product description (DPD) must comply with the requirements for a detailed written order as outlined in the Supplier Manual and CMS’ Program Integrity Manual (Internet-Only Manual, Pub. 100-8), Chapter 5.

Regardless of the form of the description, there must be sufficient detail to identify the item(s) in order to determine that the item(s) dispensed is properly coded.

The physician must sign and date the detailed product description and the supplier must receive it prior to delivery of the PWC or POV. A date stamp or equivalent must be used to document the supplier receipt date. The detailed product description must be available on request.

For items provided for a power mobility device other than at the time of initial issue, there must be a detailed written order which is signed and dated by the physician. This order must be received by the supplier prior to delivery.

If a power wheelchair accessory is delivered before a signed and dated order has been received by the supplier, it must be submitted with an EY modifier added to each affected HCPCS code.

KX, GA, GY, AND GZ MODIFIERS:

For accessories for a power mobility device, if the requirements related to a 7-element order and face-to-face examination in the Power Mobility Devices Policy Article have not been met, the GY modifier must be added to the codes for all accessories.

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

If the conditions for use of the GY modifier are not met, the KX modifier must be added to the code for the accessory only if (a) the coverage criteria that are specified in the Manual Wheelchair Bases or Power Mobility Devices LCD have been met and (b) any specific coverage criteria for the accessory in this LCD have been met. If the coverage criteria are not met, the KX modifier must not be used.

If the conditions for use of the GY modifier are not met and if the requirements for use of the KX modifier are not met, the GA or GZ modifier must be added to a claim line for the accessory. When there is an expectation of a medical necessity denial, suppliers must enter the GA modifier on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or the GZ modifier if they have not obtained a valid ABN.

If the GY modifier is used, the KX, GA, and GZ modifiers should not be used.

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

MISCELLANEOUS:

The medical necessity for all options and accessories must be documented in the beneficiary’s medical record and be available on request. This documentation might include information on why the beneficiary needs the item, the beneficiary’s diagnosis, the beneficiary’s abilities and limitations as they relate to the equipment (e.g., degree of independence/dependence, frequency and nature of the activities the beneficiary performs, etc.), the duration of the condition, the expected prognosis, and past experience using similar equipment.

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

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

Appendices PIM citations above denote references to CMS Program Integrity Manual, Internet Only Manual 100-8.

Utilization Guidelines Refer to Indications and Limitations of Coverage and/or Medical Necessity.

Sources of Information and Basis for Decision Advisory Committee Meeting Notes

Start Date of Comment Period 09/14/2005

End Date of Comment Period 10/31/2005

Start Date of Notice Period 08/15/2006

Revision History Number 013

Revision History Explanation Revision Effective Date: 01/01/2012 INDICATIONS AND LIMITATIONS OF COVERAGE:

Revised: Order requirement Added:E0988, E2358, E2359 HCPCS CODES AND MODIFIERS: Added:E0988, E2358, E2359

Replaced: “Patient” with “beneficiary”

DOCUMENTATION REQUIREMENTS:(Note: The effective date above is not applicable to this section. These revised and added requirements are existing Medicare requirements which are now included in the LCD for easy reference)

Revised: Prescription requirements

Added: General medical record information requirements, continued use and continued need requirements, and proof of delivery requirements

11/21/2011 - The following CPT/HCPCS codes were deleted: L3964 was deleted from Group 1

L3965 was deleted from Group 1 L3966 was deleted from Group 1 L3968 was deleted from Group 1 L3969 was deleted from Group 1 L3970 was deleted from Group 1 L3972 was deleted from Group 1 L3974 was deleted from Group 1

08/05/2011 - The Jurisdiction C contractor adopted a new business name. This LCD revision only includes the change from CIGNA Government Services to CGS Administrators, LLC. No coverage information was included in this revision and no provider action is needed regarding this revision.

Revision Effective Date: 06/01/2011 DOCUMENTATION REQUIREMENTS:

Revised: Language for detailed product description

Revision Effective Date: 02/04/2011 INDICATIONS AND LIMITATIONS OF COVERAGE:

Deleted: Least costly alternative language for dual mode battery chargers HCPCS CODES AND MODIFIERS:

Revised: GA modifier

Revision Effective Date: 04/01/2010 HCPCS CODES AND MODIFIERS:

Added: GA, GZ

Deleted: E2223, E2393, E2399 (effective 01/01/2010) DOCUMENTATION REQUIREMENTS:

Revised: Requirements for the detailed product description

Added: Instructions for use of the GA, GY, and GZ modifiers Revised: Requirements for use of the KX modifier

Revision Effective Date: 11/05/2009

CPT/HCPCS code E2223 was deleted from group 4 CPT/HCPCS code E2399 was deleted from group 7 CPT/HCPCS code E2393 was deleted from group 8

Revision Effective Date: 01/01/2009 INDICATIONS AND LIMITATIONS OF COVERAGE;

Changed: Terminology from Assistive Technology Supplier/ Practitioner to Assistive Technology Professional HCPCS MODIFIERS:

Added: RB modifier Revised: KX modifier Deleted: RP modifier HCPCS CODES:

Added: E2230, E2295 (to Miscellaneous Accessories section)

Revision Effective Date: 04/01/2008 INDICATIONS AND LIMITATIONS OF COVERAGE;

Revised: Statements about the requirements for ATS or ATP involvement in the selection of power tilt and/or recline seating systems

03/01/2008 - In accordance with Section 911 of the Medicare Modernization Act, this policy was transitioned to DME MAC CIGNA Government Services (18003) LCD L11517 from DME PSC TrustSolutions (77012).

Revision Effective Date: 01/01/2008 INDICATIONS AND LIMITATIONS OF COVERAGE:

Added: Coverage criteria for gear reduction wheel for manual wheelchair (E2227) Added: Replacement guidelines for lithium-based battery (E2397)

HCPCS CODES:

Added: E2227, E2228, E2312, E2313, E2397 Revised: E0705, E2205, E2373

06/01/2007 - In accordance with Section 911 of the Medicare Modernization Act of 2003, Virginia and West Virginia were transitioned from DME PSC TriCenturion (77011) to DME PSC TrustSolutions (77012).

Revision Effective Date: 01/01/2007 HCPCS CODES:

Added: E2373-E2377, E2381-E2396

Revised: E0967, E2209 Deleted: K0090-K0097, K0099

Revision Effective Date: 11/15/2006

Implementation of the 10/01/2006 LCD revision has been delayed. DOCUMENTATION REQUIREMENTS:

Revised instructions for detailed product description.

Revision Effective Date: 10/01/2006 INDICATIONS AND LIMITATIONS OF COVERAGE:

Deleted codes for nonstandard seat frame dimensions for power wheelchairs. Added coverage criteria for power tilt and/or recline power seating systems. Removed code reference for attendant control.

Noted that push-rim activated power assist devices are addressed in the Power Mobility Devices policy. HCPCS CODES:

Added: KX

Removed: E0986, E2320, E2340-E2343 DOCUMENTATION REQUIREMENTS:

Added requirement for detailed product description for items provided at the time of issue of a power wheelchair. Added instructions for use of the GY and KX modifiers.

Revision Effective Date: 07/01/2006 INDICATIONS AND LIMITATIONS OF COVERAGE:

Added new battery code, K0733

Deleted criteria for reclining backs for dates of service prior to 5/1/2006.

HCPCS CODES:

Added: K0733

ADVISORY COMMITTEE NOTES:

Deleted statement which applied to changes made in a previous version.

03/01/2006 - In accordance with Section 911 of the Medicare Modernization Act of 2003, this policy was transitioned to DME PSC TrustSolutions (77012) from DMERC Palmetto GBA (00885).

Revision Effective Date: 01/01/2006 HCPCS CODES AND MODIFIERS:

Added: E0705, E2207-E2226, E2371, E2372

Revised: E0971

Discontinued: E0972, K0064, K0066-K0068, K0074-K0076, K0077, K0078, K0102, K0104, K0106, K0452 INDICATIONS AND LIMITATIONS OF COVERAGE:

Moved statement concerning orders for power wheelchair accessories to the Policy Article. Revised general coverage criteria to reflect changes in the NCD.

Updated section with HCPCS code changes.

Added coverage criteria for attendant control of power wheelchair.

Added noncoverage statement for non-sealed batteries, effective 5/1/06. Revised coverage criteria form manual reclining back effective 5/1/06.

Deleted noncoverage statement for a cane and crutch holder. DOCUMENTATION REQUIREMENTS:

Revised instructions for EY modifier. Eliminated use of the CMN.

Revised documentation requirements for replacement items. Deleted instructions for billing E2399 and K0108.

Revision Effective Date: 04/01/2005 HCPCS CODES AND MODIFIERS:

Added: KC, E2205, E2206, E2368, E2369, E2370

Revised: E0951, E0952, E0967, E0978, E0986, E1010, E1011, E1014, E1225, E1226

Discontinued: K0059, K0060, K0061, K0081 DOCUMENTATION REQUIREMENTS:

Specified documentation when billing K0108 for nonstandard power wheelchair seat dimensions or when billing E2399.

Revision Effective Date: 07/01/2004

LMRP converted to LCD and Policy Article format. HCPCS CODES AND MODIFIERS:

Discontinued: E0192, E0962-E0965, E1012, E1013, E1025-E1027, K0023, K0024, K0114-K0116. See Wheelchair

Seating policy.

Moved: E0966, E0992 See Wheelchair Seating policy.

Removed E1028 from the Power Drive Control section. It remains in the Miscellaneous section. INDICATIONS AND LIMITATIONS OF COVERAGE:

Removed coverage criteria for wheelchair seat and back cushions and related items. These are now addressed in the Wheelchair Seating policy.

Corrected the code range for nonstandard dimensions for power wheelchairs. Deleted coverage criteria for one arm drive attachment (E0958).

Moved non-medical necessity coverage and payment rules to the related Policy Article. DOCUMENTATION REQUIREMENTS:

Moved GY modifier instructions to Policy Article. Deleted references to discontinued codes.

Revision Effective Date: 01/01/2004 HCPCS CODES AND MODIFIERS:

Added: A9270, A9900, E0950-E0952, E0955-E0957, E0959-E0961, E0966, E0967, E0972-E0974, E0978, E0981, E0982, E0985, E0986, E0990, E0992, E0995, E1002-E1010, E1028-E1030, E1225, E1226, E2201-E2204, E2300, E2301, E2310, E2311, E2320-E2331, E2340-E2343, E2351, E2360-E2367, E2399, RP

Discontinued: K0016, K0022, K0025-K0033, K0035, K0036, K0048, K0049, K0054, K0055, K0057, K0058, K0062, K0063, K0079, K0080, K0082-K0089, K0100, K0103, K0107

Revised: E0958

CMS NATIONAL COVERAGE POLICY:Revises manual references.

INDICATIONS AND LIMITATIONS OF COVERAGE: Adds coverage guidelines for electrical connection devices for power seating systems (E2310, E2311) and electronic connection device for speech generating device (E2351). States that the following items are noncovered: power seat elevation feature (E2300), power standing feature, electronic interface for lights/ other electrical devices.

States that a solid seat insert (E0992) is not separately payable.

Revises coverage criteria for nonstandard seat width and depth (E2201-E2204, E2340-E2343).

CODING GUIDELINES:Revises guidelines for use of RP modifier.Revises list of codes that are invalid for claim submission to the DMERC.

Adds definitions for many new codes.

APPENDICES:Adds correct coding guidelines for: power tilt and/or recline systems, E1009, E1010, E2325.Revises correct coding guidelines for: manual wheelchair bases, power wheelchair bases, E0990, K0053, K0195.

Revision Effective Date: 04/01/2003 HCPCS CODES AND MODIFIERS:

Added: E0951, E0958, E0971, E1011-E1018, E1020, E1025-E1027, EY

Discontinued: K0021, K0034, K0101 Revised: K0082-K0089

INDICATIONS AND LIMITATIONS OF COVERAGE:

Adds standard language concerning coverage of items without an order.

Revises/adds statements concerning coverage of batteries and POV accessories that were previously published in a DMERC bulletin.

CODING GUIDELNES:

Moves Definitions section to this section. Revises the definition of code K0116.

Adds previously published statement concerning coding of POV accessories. Clarifies the billing of bilateral items.

DOCUMENTATION REQUIREMENTS:

Adds standard language concerning use of EY modifier for items without an order. Revises standard language concerning use of CMNs.

APPENDICES:

Adds POVs and new adult tilt-in-space and pediatric wheelchair codes to the table.

Adds anti-tipping device (E0971) and wheel locks (K0081) to the accessories that are included in the allowance for power wheelchairs.

The revision dates listed below are the dates the revisions were published and not necessarily the effective dates for the revisions.

03/01/1998 – Added "for wheelchair" to description for HCPCS code E0192. 06/01/1997 – Added HCPCS codes. Revised all sections of the policy.

10/01/1995 – Added codes K0053 and K0195 to statement in the Indications section as follows: “Elevating legrests (K0046-K0048, K0053, K0195) are covered if…”

04/01/1995 – Removed codes K0067, K0074, and K0094 from columns in Attachment 2 – Correct coding guidelines.

11/25/2012 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

E1020 descriptor was changed in Group 2 E2368 descriptor was changed in Group 8 E2369 descriptor was changed in Group 8 E2370 descriptor was changed in Group 8

Reason for Change