LCD: Centers for Medicare & Medicaid Services

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Contractor Information

Contractor Name ^{back to top}
NHIC, Corp.
Contractor Number ^{back to top}
16003
Contractor Type ^{back to top}
DME MAC

LCD Information

LCD ID Number ^{back to top}
L11473

LCD Title ^{back to top}
Wheelchair Options/Accessories

Contractor's Determination Number ^{back to top}
WCOA

AMA CPT / ADA CDT Copyright Statement ^{back to top}
CPT codes, descriptions and other data only are copyright 2009 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

CMS National Coverage Policy ^{back to top}
Pub. 100-3 (Medicare National Coverage Determinations Manual), Chapter 1, Sections 280.1, 280.3

Primary Geographic Jurisdiction ^{back to top}
Connecticut District of Columbia Delaware Massachusetts Maryland Maine New Hampshire New Jersey New York - Entire State Pennsylvania Rhode Island Vermont

Oversight Region ^{back to top}
Region I

DME Region LCD Covers ^{back to top}
Jurisdiction A

Original Determination Effective Date ^{back to top}
For services performed on or after 10/01/1993

Original Determination Ending Date ^{back to top}


Revision Effective Date ^{back to top}
For services performed on or after 04/01/2010

Revision Ending Date ^{back to top}


Indications and Limitations of Coverage and/or Medical Necessity ^{back to top}
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 medical policy, the criteria for "reasonable and necessary" 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 written signed and dated order must be received by the supplier before a claim is submitted. If the supplier bills for an item without first receiving the completed order, the item will be denied as not medically necessary. (See related Policy Article for information on order for power wheelchair accessories.) Options and accessories for wheelchairs are covered if the patient 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 medically necessary. ARM OF CHAIR: Adjustable arm height option (E0973, K0017, K0018, K0020) is covered if the patient requires an arm height that is different than that available using nonadjustable arms and the patient spends at least 2 hours per day in the wheelchair. An arm trough (E2209) is covered if the patient has quadriplegia, hemiplegia, or uncontrolled arm movements. FOOTREST/ LEGREST: Elevating legrests (E0990, K0046, K0047, K0053, K0195) are covered if: 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 an elevating legrest; or The patient meets the criteria for and has a reclining back on the wheelchair. NONSTANDARD SEAT FRAME DIMENSIONS: A nonstandard seat width and/or depth for a manual wheelchair (E2201-E2204) is covered only if the patient's physical dimensions justify the need. WHEELS/TIRES FOR MANUAL WHEELCHAIRS: A gear reduction drive wheel (E2227) is covered if all of the following criteria are met: The patient has been self-propelling in a manual wheelchair for at least one year; and The patient has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the need for the device in the patient’s home. The PT, OT, or physician may have no financial relationship with the supplier; and The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the patient. BATTERIES/ CHARGERS: Up to two batteries (E2361, E2363, E2365, E2371, K0731, K0733) at any one time are allowed if required for a power wheelchair. A non-sealed battery (E2360, E2362, E2364, E2372) will be denied as not medically necessary. A dual mode battery charger (E2367) is not medically necessary. When it is provided as a replacement, payment is based on the allowance for the least costly medically appropriate alternative, E2366. The usual maximum frequency of replacement for a lithium-based battery (E2397) is one every 3 years. Only one battery is allowed at any one time. POWER TILT AND/OR RECLINE SEATING SYSTEMS (E1002-E1010): A power seating system – tilt only, recline only, or combination tilt and recline – with or without power elevating legrests will be covered if criteria 1, 2, and 3 are met and if criterion 4, 5, or 6 is met: The patient meets all the coverage criteria for a power wheelchair described in the Power Mobility Devices LCD; 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 documents the patient’s seating and positioning needs. The PT, OT, or physician may have no financial relationship with the supplier; and The seating system is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in rehabilitation wheelchairs and who has direct, in-person involvement in the selection of the seating system for the patient; and 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. POWER WHEELCHAIR DRIVE CONTROL SYSTEMS: An attendant control is covered in place of a patient-operated drive control system if the patient meets coverage criteria for a wheelchair, is unable to operate a manual or power wheelchair and has a caregiver who is unable to operate a manual wheelchair but is able to operate a power wheelchair. OTHER POWER WHEELCHAIR ACCESSORIES: An electronic interface (E2351) to allow a speech generating device to be operated by the power wheelchair control interface is covered if the patient has a covered speech generating device. (Refer to the Speech Generating Devices LCD for details.) MISCELLANEOUS ACCESSORIES: Anti-rollback device (E0974) is covered if the patient self-propels and needs the device because of ramps. A safety belt/pelvic strap (E0978) is covered if the patient has weak upper body muscles, upper body instability or muscle spasticity which requires use of this item for proper positioning. One example (not all-inclusive) of a covered indication for swingaway, retractable, or removable hardware (E1028) would be to move the component out of the way so that a patient can perform a slide transfer to a chair or bed. A manual fully reclining back option (E1226) is covered if the patient has one or more of the following conditions: 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 the bed. If these criteria are not met, the manual reclining back will be denied as not medically necessary. For information concerning a push-rim activated power assist device for a manual wheelchair, refer to the Power Mobility Devices medical policy.

Coding Information

Bill Type Codes: ^{back to top}

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: ^{back to top}

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 ^{back to top}

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

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
L3964	SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED, ADJUSTABLE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
L3965	SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED, ADJUSTABLE RANCHO TYPE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
L3966	SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED, RECLINING, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
L3968	SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED, FRICTION ARM SUPPORT (FRICTION DAMPENING TO PROXIMAL AND DISTAL JOINTS), PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
L3969	SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPPORT, MONOSUSPENSION ARM AND HAND SUPPORT, OVERHEAD ELBOW FOREARM HAND SLING SUPPORT, YOKE TYPE SUSPENSION SUPPORT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
L3970	SEO, ADDITION TO MOBILE ARM SUPPORT, ELEVATING PROXIMAL ARM
L3972	SEO, ADDITION TO MOBILE ARM SUPPORT, OFFSET OR LATERAL ROCKER ARM WITH ELASTIC BALANCE CONTROL
L3974	SEO, ADDITION TO MOBILE ARM SUPPORT, SUPINATOR

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
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
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:

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
E2310	POWER WHEELCHAIR ACCESSORY, ELECTRONIC CONNECTION BETWEEN WHEELCHAIR CONTROLLER AND ONE POWER SEATING SYSTEM MOTOR, INCLUDING ALL RELATED ELECTRONICS, INDICATOR FEATURE, MECHANICAL FUNCTION SELECTION SWITCH, AND FIXED MOUNTING HARDWARE
E2311	POWER WHEELCHAIR ACCESSORY, ELECTRONIC CONNECTION BETWEEN WHEELCHAIR CONTROLLER AND TWO OR MORE POWER SEATING SYSTEM MOTORS, INCLUDING ALL RELATED ELECTRONICS, INDICATOR FEATURE, MECHANICAL FUNCTION SELECTION SWITCH, AND FIXED MOUNTING HARDWARE

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
E2321	POWER WHEELCHAIR ACCESSORY, HAND CONTROL INTERFACE, REMOTE JOYSTICK, NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, AND FIXED MOUNTING HARDWARE
E2322	POWER WHEELCHAIR ACCESSORY, HAND CONTROL INTERFACE, MULTIPLE MECHANICAL SWITCHES, 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
E2327	POWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, MECHANICAL, PROPORTIONAL, 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
E2329	POWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, CONTACT SWITCH MECHANISM, NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, MECHANICAL DIRECTION CHANGE SWITCH, HEAD ARRAY, AND FIXED MOUNTING HARDWARE
E2330	POWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, PROXIMITY SWITCH MECHANISM, NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, MECHANICAL DIRECTION CHANGE SWITCH, HEAD ARRAY, AND FIXED MOUNTING HARDWARE
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
E2374	POWER WHEELCHAIR ACCESSORY, HAND OR CHIN CONTROL INTERFACE, STANDARD REMOTE JOYSTICK (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, MOTOR, REPLACEMENT ONLY
E2369	POWER WHEELCHAIR COMPONENT, GEAR BOX, REPLACEMENT ONLY
E2370	POWER WHEELCHAIR COMPONENT, 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 ^{back to top}

Not specified.

Diagnoses that Support Medical Necessity ^{back to top}

Not specified.

ICD-9 Codes that DO NOT Support Medical Necessity ^{back to top}

Not specified.

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation ^{back to top}

Diagnoses that DO NOT Support Medical Necessity ^{back to top}

Not specified.

General Information

Documentation Requirements ^{back to top}

Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider." It is expected that the patient's medical records will reflect the need for the care provided. The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.

An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request.

For options and accessories provided at the time of initial issue of a power wheelchair, once the supplier has determined the specific power mobility device that is appropriate for the patient based on the physician's order, the supplier must prepare a written document (termed a detailed product description) that lists the wheelchair base and all options and accessories that will be separately billed. For the wheelchair base and each option/accessory, the supplier must enter all of the following:

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

If there is no fee schedule allowance, the supplier must enter “not applicable”. The physician must sign and date this detailed product description and the supplier must receive it prior to delivery of the PWC. A date stamp or equivalent must be used to document receipt date. The detailed product description must be available on request.

For items provided for a power mobility device other than at the time of initial issue, there must be a detailed written order which lists each item which will be billed separately and which is signed and dated by the physician. In these situations, the supplier's charges and Medicare allowances do not need to be included. This order must be received by the supplier prior to delivery.

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

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

If a manual wheelchair accessory is billed before a signed and dated order is received by the supplier, it must be submitted with an EY modifier after each affected HCPCS code.

KX, GA, GY, AND GZ MODIFIERS:

For accessories for a power mobility device, if the requirements related to a 7-element order and face-to-face examination in the Power Mobility Devices Policy 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 patient's medical record and be available on request. This documentation might include information on why the patient needs the item, the patient's diagnosis, the patient's abilities and limitations as they relate to the equipment (e.g., degree of independence/dependence, frequency and nature of the activities the patient performs, etc.), the duration of the condition, the expected prognosis, and past experience using similar equipment.

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

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

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

Appendices ^{back to top}

Utilization Guidelines ^{back to top}

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

Sources of Information and Basis for Decision ^{back to top}

Reserved for future use

Advisory Committee Meeting Notes ^{back to top}

Start Date of Comment Period ^{back to top}

09/14/2005

End Date of Comment Period ^{back to top}

10/31/2005

Start Date of Notice Period ^{back to top}

08/15/2006

Revision History Number ^{back to top}

WCC011

Revision History Explanation ^{back to top}

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: 01/01/2009
INDICATIONS AND LIMITATIONS OF COVERAGE:
Changed: Terminology from Assistive Technology Supplier/ Practitioner to Assistive Technology Professional.
HCPCS CODES AND MODIFIERS:
Added: E2230, E2295 (to Miscellaneous Accessories section), RB modifier.
Revised: KX modifier.
Deleted: RP modifier.

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 NHIC (16003) LCD L11473 from DME PSC TriCenturion (77011) LCD L11473.

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 AND MODIFIERS:
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 AND MODIFIERS:
Added: E2373-E2377, E2381-E2396
Revised: E0967, E2209
Deleted: K0090-K0097, K0099

Revision Effective Date: 11/15/2006
Implementation of the 10/1/2006 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: Push-rim activated power assist devices are addressed in the Power Mobility Devices policy.
HCPCS CODES AND MODIFIERS:
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 05/01/2006.
HCPCS CODES AND MODIFIERS:
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 TriCenturion (77011) from DMERC Tricenturion (77011).

Revision Effective Device: 01/01/2006
HCPCS CODES AND MODIFIERS:
Added: E0705, E2207-E2226, E2371, E2372
Revised: E0971
Discontinued: E0972, K0064, K0066-K0068, K0074-K0076, 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 05/01/2006.
Revised: Coverage criteria form manual reclining back effective 05/01/2006.
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 Modifier, 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/ 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: 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:
Revised: Manual references.
INDICATIONS AND LIMITATIONS OF COVERAGE:
Added: Coverage guidelines for electrical connection devices for power seating systems (E2310, E2311) and electronic connection device for speech generating device (E2351).
Stated: The following items are noncovered: power seat elevation feature (E2300), power standing feature, electronic interface for lights/ other electrical devices.
Stated: A solid seat insert (E0992) is not separately payable.
Revised: Coverage criteria for nonstandard seat width and depth (E2201-E2204, E2340-E2343).
CODING GUIDELINES:
Revised: Guidelines for use of RP modifier.
Revised List of codes that are invalid for claim submission to the DMERC.
Added: Definitions for many new codes.
APPENDICES:
Added: Correct coding guidelines for: power tilt and/or recline systems, E1009, E1010, E2325.
Revised: 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:
Added: Standard language concerning coverage of items without an order.
Revised/Added: Statements concerning coverage of batteries and POV accessories that were previously published in a DMERC bulletin.
CODING GUIDELNES:
Moved: Definitions section to this section.
Revised: Definition of code K0116.
Added: Previously published statement concerning coding of POV accessories.
Clarified: Billing of bilateral items.
DOCUMENTATION REQUIREMENTS:
Addsed: Standard language concerning use of EY modifier for items without an order.
Revised: Standard language concerning use of CMNs.
APPENDICES:
Added: POVs and new adult tilt-in-space and pediatric wheelchair codes to the table.
Added: 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.

Reason for Change ^{back to top}

Last Reviewed On Date ^{back to top}

Medicare Coverage Database

LCD for Wheelchair Options/Accessories (L11473)