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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}

L15845

LCD Title ^{back to top}
Wheelchair Seating

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

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}


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 07/01/2004

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, "reasonable and necessary" is defined by the following indications and limitations of coverage and/or medical necessity. A general use seat cushion (E2601,E2602) and a general use wheelchair back cushion (E2611-E2612) is covered for a patient who has a manual wheelchair or a power wheelchair with a sling/solid seat/back which meets Medicare coverage criteria. If the patient does not have a covered wheelchair, then the cushion will be denied as not medically necessary. If the patient has a POV or a power wheelchair with a captain's chair seat, the cushion will be denied as not medically necessary. If a general use seat and/or back cushion is provided with a power wheelchair with a sling/solid seat/back, total payment for those items (cushion(s) plus the wheelchair) will be based on the allowance for the least costly medically appropriate alternative – e.g., the code for the comparable power wheelchair with Captain's Chair, if that code exists. (See Power Mobility Device policy for additional information.) If the patient has a POV or a power wheelchair with a captain's chair seat, a separate seat and/or back cushion will be denied as not medically necessary. A skin protection seat cushion (E2603, E2604, K0734, K0735) is covered for a patient who meets both of the following criteria: The patient has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the patient meets Medicare coverage criteria for it; and The patient has either of the following: Current pressure ulcer (ICD-9-CM codes 707.03, 707.04, 707.05) or past history of a pressure ulcer (707.03, 707.04, 707.05) on the area of contact with the seating surface; or Absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift due to one of the following diagnoses: spinal cord injury resulting in quadriplegia or paraplegia (344.00-344.1), other spinal cord disease (336.0-336.3), multiple sclerosis (340), other demyelinating disease (341.0-341.9), cerebral palsy (343.0-343.9), anterior horn cell diseases including amyotrophic lateral sclerosis (335.0-335.21, 335.23-335.9), post polio paralysis (138), traumatic brain injury resulting in quadriplegia (344.09), spina bifida (741.00-741.93), childhood cerebral degeneration (330.0-330.9), Alzheimer's disease (331.0), Parkinson's disease (332.0),muscular dystrophy (359.0, 359.1), hemiplegia (342.00 – 342.92, 438.20-438.22), Huntignton’s chorea (333.4), idiopathic torsion dystonia (333.6), athetoid cerebral palsy (333.71). A positioning seat cushion (E2605, E2606), positioning back cushion (E2613-E2616, E2620, E2621), and positioning accessory (E0955-E0957, E0960) is covered for a patient who meets both of the following criteria: The patient has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the patient meets Medicare coverage criteria for it; and The patient has any significant postural asymmetries that are due to one of the diagnoses listed in criterion 2b above or to one of the following diagnoses: monoplegia of the lower limb (344.30-344.32, 438.40-438.42) due to stroke, traumatic brain injury, or other etiology, spinocerebellar disease (334.0-334.9), above knee leg amputation (897.2-897.7), osteogenesis imperfecta (756.51), transverse myelitis (323.82). A headrest (E0955) is also covered when the patient has a covered manual tilt-in-space, manual semi or fully reclining back on a manual wheelchair, a manual fully reclining back on a power wheelchair, or power tilt and/or recline power seating system. If the patient has a POV or a power wheelchair with a captain's chair seat, a headrest or other positioning accessory will be denied as not medically necessary. A combination skin protection and positioning seat cushion (E2607, E2608, K0736, K0737) is covered for a patient who meets the criteria for both a skin protection seat cushion and a positioning seat cushion. If a skin protection seat cushion, positioning seat cushion, or combination skin protection and positioning seat cushion is provided for a patient who does not meet the stated coverage criteria, but the coverage criteria for another type of cushion are met, payment will be based on the allowance for the least costly medically appropriate alternative; if the criteria for a another type of seat cushion are not met, the provided cushion will be denied as not medically necessary. If a positioning back cushion is provided for a patient who does not meet the stated coverage criteria, but the coverage criteria for a general use back cushion are met, payment will be based on the allowance for the least costly medically appropriate alternative, E2611 or E2612; if the criteria for a general use back cushion are not met, the provided cushion will be denied as not medically necessary. If a positioning accessory is provided and the criteria are not met, the item will be denied as not medically necessary. A custom fabricated seat cushion (E2609) is covered if criteria (1) and (3) are met. A custom fabricated back cushion (E2617) is covered if criteria (2) and (3) are met: Patient meets all of the criteria for a prefabricated skin protection seat cushion or positioning seat cushion; Patient meets all of the criteria for a prefabricated positioning back cushion; There is a comprehensive written evaluation by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), which clearly explains why a prefabricated seating system is not sufficient to meet the patient’s seating and positioning needs. The PT or OT may have no financial relationship with the supplier. If a custom fabricated cushion is provided for a patient who does not meet the stated coverage criteria, but the coverage criteria for another type of cushion are met, payment will be based on the allowance for the least costly medically appropriate alternative; if the criteria for another type of cushion are not met, the custom fabricated cushion will be denied as not medically necessary. A seat or back cushion that is provided for use with a transport chair (E1037, E1038) will be denied as not medically necessary. The effectiveness of a powered seat cushion (E2610) has not been established. Claims for a powered seat cushion will be denied as not medically necessary. A prefabricated seat cushion, a prefabricated positioning back cushion, or a brand name custom fabricated seat or back cushion which has not received a written coding verification from the Pricing, Data Analysis and Coding (PDAC) contractor or which does not meet the criteria stated in the Coding Guidelines section (see Policy Article) will be denied as not medically necessary.

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 healthcare 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 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:

SEAT CUSHIONS:

E2601	GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH
E2602	GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH
E2603	SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH
E2604	SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH
E2605	POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH
E2606	POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH
E2607	SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH
E2608	SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH
E2609	CUSTOM FABRICATED WHEELCHAIR SEAT CUSHION, ANY SIZE
E2610	WHEELCHAIR SEAT CUSHION, POWERED
K0734	SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES, ANY DEPTH
K0735	SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22 INCHES OR GREATER, ANY DEPTH
K0736	SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES, ANY DEPTH
K0737	SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22 INCHES OR GREATER, ANY DEPTH

BACK CUSHIONS:

E2611	GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE
E2612	GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE
E2613	POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE
E2614	POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE
E2615	POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE
E2616	POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE
E2617	CUSTOM FABRICATED WHEELCHAIR BACK CUSHION, ANY SIZE, INCLUDING ANY TYPE MOUNTING HARDWARE
E2620	POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE
E2621	POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE

POSITIONING ACCESSORIES:

E0955	WHEELCHAIR ACCESSORY, HEADREST, CUSHIONED, ANY TYPE, INCLUDING FIXED MOUNTING HARDWARE, EACH
E0956	WHEELCHAIR ACCESSORY, LATERAL TRUNK OR HIP SUPPORT, ANY TYPE, INCLUDING FIXED MOUNTING HARDWARE, EACH
E0957	WHEELCHAIR ACCESSORY, MEDIAL THIGH SUPPORT, ANY TYPE, INCLUDING FIXED MOUNTING HARDWARE, EACH
E0960	WHEELCHAIR ACCESSORY, SHOULDER HARNESS/STRAPS OR CHEST STRAP, INCLUDING ANY TYPE MOUNTING HARDWARE
E0966	MANUAL WHEELCHAIR ACCESSORY, HEADREST EXTENSION, EACH
E1028	WHEELCHAIR ACCESSORY, MANUAL SWINGAWAY, RETRACTABLE OR REMOVABLE MOUNTING HARDWARE FOR JOYSTICK, OTHER CONTROL INTERFACE OR POSITIONING ACCESSORY

MISCELLANEOUS:

A9900	MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS CODE
E0992	MANUAL WHEELCHAIR ACCESSORY, SOLID SEAT INSERT
E2231	MANUAL WHEELCHAIR ACCESSORY, SOLID SEAT SUPPORT BASE (REPLACES SLING SEAT), INCLUDES ANY TYPE MOUNTING HARDWARE
E2291	BACK, PLANAR, FOR PEDIATRIC SIZE WHEELCHAIR INCLUDING FIXED ATTACHING HARDWARE
E2292	SEAT, PLANAR, FOR PEDIATRIC SIZE WHEELCHAIR INCLUDING FIXED ATTACHING HARDWARE
E2293	BACK, CONTOURED, FOR PEDIATRIC SIZE WHEELCHAIR INCLUDING FIXED ATTACHING HARDWARE
E2294	SEAT, CONTOURED, FOR PEDIATRIC SIZE WHEELCHAIR INCLUDING FIXED ATTACHING HARDWARE
E2619	REPLACEMENT COVER FOR WHEELCHAIR SEAT CUSHION OR BACK CUSHION, EACH
K0108	WHEELCHAIR COMPONENT OR ACCESSORY, NOT OTHERWISE SPECIFIED
K0669	WHEELCHAIR ACCESSORY, WHEELCHAIR SEAT OR BACK CUSHION, DOES NOT MEET SPECIFIC CODE CRITERIA OR NO WRITTEN CODING VERIFICATION FROM DME PDAC

ICD-9 Codes that Support Medical Necessity ^{back to top}

The presence of an ICD-9 code listed in this section is not sufficient by itself to assure coverage. Refer to the section on Indications and Limitation of Coverage and/or Medical Necessity for other coverage criteria and payment information.

For HCPCS codes E2603, E2604, K0734, K0735:

138	LATE EFFECTS OF ACUTE POLIOMYELITIS
330.0 - 330.9	LEUKODYSTROPHY - UNSPECIFIED CEREBRAL DEGENERATION IN CHILDHOOD
331.0	ALZHEIMER'S DISEASE
332.0	PARALYSIS AGITANS
333.4	HUNTINGTON'S CHOREA
333.6	GENETIC TORSION DYSTONIA
333.71	ATHETOID CEREBRAL PALSY
335.0 - 335.21	WERDNIG-HOFFMANN DISEASE - PROGRESSIVE MUSCULAR ATROPHY
335.23 - 335.9	PSEUDOBULBAR PALSY - ANTERIOR HORN CELL DISEASE UNSPECIFIED
336.0 - 336.3	SYRINGOMYELIA AND SYRINGOBULBIA - MYELOPATHY IN OTHER DISEASES CLASSIFIED ELSEWHERE
340	MULTIPLE SCLEROSIS
341.0 - 341.9	NEUROMYELITIS OPTICA - DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED
342.00 - 342.92	FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE - UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE
343.0 - 343.9	CONGENITAL DIPLEGIA - INFANTILE CEREBRAL PALSY UNSPECIFIED
344.00 - 344.1	QUADRIPLEGIA UNSPECIFIED - PARAPLEGIA
359.0	CONGENITAL HEREDITARY MUSCULAR DYSTROPHY
359.1	HEREDITARY PROGRESSIVE MUSCULAR DYSTROPHY
438.20 - 438.22	HEMIPLEGIA AFFECTING UNSPECIFIED SIDE - HEMIPLEGIA AFFECTING NONDOMINANT SIDE
707.03 - 707.05	PRESSURE ULCER, LOWER BACK - PRESSURE ULCER, BUTTOCK
741.00 - 741.93	SPINA BIFIDA UNSPECIFIED REGION WITH HYDROCEPHALUS - SPINA BIFIDA LUMBAR REGION WITHOUT HYDROCEPHALUS

For HCPCS codes E0956-E0957, E0960, E2605, E2606, E2613-E2617, E2620, and E2621:

138	LATE EFFECTS OF ACUTE POLIOMYELITIS
323.82	OTHER CAUSES OF MYELITIS
330.0 - 330.9	LEUKODYSTROPHY - UNSPECIFIED CEREBRAL DEGENERATION IN CHILDHOOD
331.0	ALZHEIMER'S DISEASE
332.0	PARALYSIS AGITANS
333.4	HUNTINGTON'S CHOREA
333.6	GENETIC TORSION DYSTONIA
333.71	ATHETOID CEREBRAL PALSY
334.0 - 334.9	FRIEDREICH'S ATAXIA - SPINOCEREBELLAR DISEASE UNSPECIFIED
335.0 - 335.21	WERDNIG-HOFFMANN DISEASE - PROGRESSIVE MUSCULAR ATROPHY
335.23 - 335.9	PSEUDOBULBAR PALSY - ANTERIOR HORN CELL DISEASE UNSPECIFIED
336.0 - 336.3	SYRINGOMYELIA AND SYRINGOBULBIA - MYELOPATHY IN OTHER DISEASES CLASSIFIED ELSEWHERE
340	MULTIPLE SCLEROSIS
341.0 - 341.9	NEUROMYELITIS OPTICA - DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED
342.00 - 342.92	FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE - UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE
343.0 - 343.9	CONGENITAL DIPLEGIA - INFANTILE CEREBRAL PALSY UNSPECIFIED
344.00 - 344.1	QUADRIPLEGIA UNSPECIFIED - PARAPLEGIA
344.30 - 344.32	MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE - MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE
359.0	CONGENITAL HEREDITARY MUSCULAR DYSTROPHY
359.1	HEREDITARY PROGRESSIVE MUSCULAR DYSTROPHY
438.20 - 438.22	HEMIPLEGIA AFFECTING UNSPECIFIED SIDE - HEMIPLEGIA AFFECTING NONDOMINANT SIDE
438.40 - 438.42	MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE - MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE
741.00 - 741.93	SPINA BIFIDA UNSPECIFIED REGION WITH HYDROCEPHALUS - SPINA BIFIDA LUMBAR REGION WITHOUT HYDROCEPHALUS
756.51	OSTEOGENESIS IMPERFECTA
897.2 - 897.7	TRAUMATIC AMPUTATION OF LEG(S) (COMPLETE) (PARTIAL) UNILATERAL AT OR ABOVE KNEE WITHOUT COMPLICATION - TRAUMATIC AMPUTATION OF LEG(S) (COMPLETE) (PARTIAL) BILATERAL (ANY LEVEL) COMPLICATED

For HCPCS codes E2607, E2608, K0736, K0737, either 1) One of the following ICD-9 codes:

138	LATE EFFECTS OF ACUTE POLIOMYELITIS
330.0 - 330.9	LEUKODYSTROPHY - UNSPECIFIED CEREBRAL DEGENERATION IN CHILDHOOD
331.0	ALZHEIMER'S DISEASE
332.0	PARALYSIS AGITANS
333.4	HUNTINGTON'S CHOREA
333.6	GENETIC TORSION DYSTONIA
333.71	ATHETOID CEREBRAL PALSY
335.0 - 335.21	WERDNIG-HOFFMANN DISEASE - PROGRESSIVE MUSCULAR ATROPHY
335.23 - 335.9	PSEUDOBULBAR PALSY - ANTERIOR HORN CELL DISEASE UNSPECIFIED
336.0 - 336.3	SYRINGOMYELIA AND SYRINGOBULBIA - MYELOPATHY IN OTHER DISEASES CLASSIFIED ELSEWHERE
340	MULTIPLE SCLEROSIS
341.0 - 341.9	NEUROMYELITIS OPTICA - DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED
342.00 - 342.92	FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE - UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE
343.0 - 343.9	CONGENITAL DIPLEGIA - INFANTILE CEREBRAL PALSY UNSPECIFIED
344.00 - 344.1	QUADRIPLEGIA UNSPECIFIED - PARAPLEGIA
359.0	CONGENITAL HEREDITARY MUSCULAR DYSTROPHY
359.1	HEREDITARY PROGRESSIVE MUSCULAR DYSTROPHY
438.20 - 438.22	HEMIPLEGIA AFFECTING UNSPECIFIED SIDE - HEMIPLEGIA AFFECTING NONDOMINANT SIDE
741.00 - 741.93	SPINA BIFIDA UNSPECIFIED REGION WITH HYDROCEPHALUS - SPINA BIFIDA LUMBAR REGION WITHOUT HYDROCEPHALUS

Or 2) A combination of ICD-9 code 707.03, 707.04, or 707.05 AND one of the following ICD-9 codes:

323.82	OTHER CAUSES OF MYELITIS
334.0 - 334.9	FRIEDREICH'S ATAXIA - SPINOCEREBELLAR DISEASE UNSPECIFIED
344.30 - 344.32	MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE - MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE
438.40 - 438.42	MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE - MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE
756.51	OSTEOGENESIS IMPERFECTA
897.2 - 897.7	TRAUMATIC AMPUTATION OF LEG(S) (COMPLETE) (PARTIAL) UNILATERAL AT OR ABOVE KNEE WITHOUT COMPLICATION - TRAUMATIC AMPUTATION OF LEG(S) (COMPLETE) (PARTIAL) BILATERAL (ANY LEVEL) COMPLICATED

For HCPCS code E2609

138	LATE EFFECTS OF ACUTE POLIOMYELITIS
323.82	OTHER CAUSES OF MYELITIS
330.0 - 330.9	LEUKODYSTROPHY - UNSPECIFIED CEREBRAL DEGENERATION IN CHILDHOOD
331.0	ALZHEIMER'S DISEASE
332.0	PARALYSIS AGITANS
333.4	HUNTINGTON'S CHOREA
333.6	GENETIC TORSION DYSTONIA
333.71	ATHETOID CEREBRAL PALSY
334.0 - 334.9	FRIEDREICH'S ATAXIA - SPINOCEREBELLAR DISEASE UNSPECIFIED
335.0 - 335.21	WERDNIG-HOFFMANN DISEASE - PROGRESSIVE MUSCULAR ATROPHY
335.23 - 335.9	PSEUDOBULBAR PALSY - ANTERIOR HORN CELL DISEASE UNSPECIFIED
336.0 - 336.3	SYRINGOMYELIA AND SYRINGOBULBIA - MYELOPATHY IN OTHER DISEASES CLASSIFIED ELSEWHERE
340	MULTIPLE SCLEROSIS
341.0 - 341.9	NEUROMYELITIS OPTICA - DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED
342.00 - 342.92	FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE - UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE
343.0 - 343.9	CONGENITAL DIPLEGIA - INFANTILE CEREBRAL PALSY UNSPECIFIED
344.00 - 344.1	QUADRIPLEGIA UNSPECIFIED - PARAPLEGIA
344.30 - 344.32	MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE - MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE
359.0	CONGENITAL HEREDITARY MUSCULAR DYSTROPHY
359.1	HEREDITARY PROGRESSIVE MUSCULAR DYSTROPHY
438.20 - 438.22	HEMIPLEGIA AFFECTING UNSPECIFIED SIDE - HEMIPLEGIA AFFECTING NONDOMINANT SIDE
438.40 - 438.42	MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE - MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE
707.03 - 707.05	PRESSURE ULCER, LOWER BACK - PRESSURE ULCER, BUTTOCK
741.00 - 741.93	SPINA BIFIDA UNSPECIFIED REGION WITH HYDROCEPHALUS - SPINA BIFIDA LUMBAR REGION WITHOUT HYDROCEPHALUS
756.51	OSTEOGENESIS IMPERFECTA
897.2 - 897.7	TRAUMATIC AMPUTATION OF LEG(S) (COMPLETE) (PARTIAL) UNILATERAL AT OR ABOVE KNEE WITHOUT COMPLICATION - TRAUMATIC AMPUTATION OF LEG(S) (COMPLETE) (PARTIAL) BILATERAL (ANY LEVEL) COMPLICATED

For HCPCS codes E0955, E2601, E2602, E2611, E2612, and E2619:
Not Specified

For codes E2610 and K0669:
None

Diagnoses that Support Medical Necessity ^{back to top}

Refer to previous section.

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

For the specific HCPCS codes indicated above, all ICD-9 codes that are not specified in the preceding section.

For HCPCS codes E2610 and K0669, all ICD-9 codes

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

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

For the specific HCPCS codes indicated above, all diagnoses that are not specified in the precious section.

For HCPCS codes E2610 and K0669, all diagnoses.

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 cushions and positioning accessories provided at the time of initial issue of a power wheelchair, the supplier must include all of the following elements on the detailed product description that lists the wheelchair base and all options and accessories that will be separately billed:

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

For cushions and positioning accessories provided for a manual wheelchair, 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 of the item.

Items delivered before a signed written order has been received by the supplier must be submitted with an EY modifier added to each affected HCPCS code.

The ICD-9 code which justifies the need for these items must be included on the claim.

KX MODIFIER:

For a skin protection seat cushion (E2603, E2604, K0734, K0735), a KX modifier must be added to the code only if either criterion (a), (b), or (c) is met:

If there is a past history of or current pressure ulcer in the area of contact with the seating surface; or
If there is absent or impaired sensation in the area of contact with the seating surface due to one of the diagnoses listed as a covered diagnosis; or
If there is an inability to carry out a functional weight shift due to one of the diagnoses listed as a covered diagnosis.

For a positioning seat cushion (E2605, E2606), positioning back cushion (E2613-E2616, E2620, E2621), or positioning accessory (E0956-E0957, E0960), a KX modifier must be added to the code only if the patient has significant postural asymmetries due to one of the diagnoses listed as a covered diagnosis.

For a headrest (E0955), a KX modifier must be added to the code only if one of the coverage criteria specified in the Indications and Limitations of Coverage section has been met.

For a combination skin protection and positioning seat cushion (E2607, E2608, K0736, K0737), a KX modifier must be added to the code only if criterion (a) or (b) or (c) is met and criterion (d) is met:

If there is a past history or current pressure ulcer in the area of contact with the seating surface; or
If there is absent or impaired sensation in the area of contact with the seating surface due one of the diagnoses listed as a covered diagnosis for skin protection cushions (except 707.03, 707.04, 707.05); or
If there is an inability to carry out a functional weight shift due one of the diagnoses listed as a covered diagnosis for skin protection cushions (except 707.03, 707.04, 707.05); and
If the patient has significant postural asymmetries due to one of the diagnoses listed as a covered diagnosis for positioning cushions.

For a custom fabricated seat or back cushion (E2609, E2617), a KX modifier must be added to the code only if criterion (a) is met and criterion (b), (c), or (d) is met:

For E2609 or E2617, there is a comprehensive written evaluation by a licensed/certified medical professional, such as a PT or OT (who has no financial relationship with the supplier) which explains why a prefabricated seating system is not sufficient to meet the patient’s seating and positioning needs; and
For E2609, there is a past history of or current pressure ulcer in the area of contact with the seating surface; or
For E2609, there is absent or impaired sensation in the area of contact with the seating surface or an inability to carry out a functional weight shift due to one of the diagnoses listed as a covered diagnosis for skin protection cushions; or
For E2609 or E2617, the patient has significant postural asymmetries due to one of the diagnoses listed as a covered diagnosis for positioning cushions.

In addition to meeting the specific requirements listed above, for all seat and back cushions and positioning accessories, the KX modifier must be added to the code only if the item is being used with a wheelchair that meets coverage criteria specified in the Manual Wheelchair Bases or Power Mobility Devices LCD.

GA, GY, AND GZ MODIFIERS:

For a cushion or positioning accessory that is used with 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 items.

For items 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 items.

In all of the situations above describing use of the KX modifier, if all of the specific coverage criteria have not been met or if the wheelchair that it is being used with does not meet the coverage criteria in the Manual Wheelchair Bases or Power Mobility Devices LCD, the GA or GZ modifier must be added to a claim line for the seat or back cushion or positioning 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:

When billing for a custom fabricated cushion (E2609, E2617), the claim must include the manufacturer and model name/ number of the product (if applicable), or if not, a detailed description of the product that was provided.

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

Appendices ^{back to top}

Utilization Guidelines ^{back to top}

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

Advisory Committee Meeting Notes ^{back to top}

Start Date of Comment Period ^{back to top}

12/03/2001

End Date of Comment Period ^{back to top}

01/21/2002

Start Date of Notice Period ^{back to top}

03/01/2004

Revision History Number ^{back to top}

WCS011

Revision History Explanation ^{back to top}

Revision Effective Date: 04/01/2010
HCPCS CODES AND MODIFIERS:
Added: GY
Revised: GA
DOCUMENTATION REQUIREMENTS:
Added: Requirements for use of the GY modifier.
Revised: Requirements for detailed product description.
Revised: Requirements for use of the KX modifier.
Revised: Requirements for use of GA and GZ modifiers.

Revision Effective Date: 12/01/2009
INDICATIONS AND LIMITATIONS OF COVERAGE:
Added: Hemiplegia, Huntington’s chorea, idiopathic torsion dystonia, and cerebral palsy to the list of covered conditions for skin protection seat cushions.
Added: Above knee amputations, osteogenesis imperfecta, and transverse myelitis to the list of covered conditions for positioning seat and back cushions and positioning accessories.
ICD-9 CODES THAT SUPPORT MEDICAL NECESSITY:
Added: Corresponding ICD-9 codes.
Moved: 359.0, 359.1 from second group of codes to the first group of codes for E2607, E2608, K0736, K0737.
HCPCS MODIFIERS:
Added: GA, GZ
Revised: KX modifier.
DOCUMENTATION REQUIREMENTS:
Added: Instructions for use of GA and GZ modifiers.

Revision Effective Date: 01/01/2009
INDICATIONS AND LIMITATIONS OF COVERAGE:
Replaced: Reference to SADMERC with PDAC.
HCPCS CODES AND MODIFIERS:
Added: E2231
Revised: K0669

03/01/2008 - In accordance with Section 911 of the Medicare Modernization Act, this policy was transitioned to DME MAC NHIC (16003) LCD L15845 from DME PSC TriCenturion (77011) LCD L15845.

Revision Effective Date: 01/01/2008
INDICATIONS AND LIMITATIONS OF COVERAGE:
Added: Muscular dystrophy to the list of covered diagnoses for prefabricated skin protection and combination skin protection and positioning seat cushions.
Removed: Instructions concerning solid seat support base (E2618).
HCPCS CODES AND MODIFIERS:
Added: K0108
Deleted: E2618
ICD-9 CODES THAT SUPPORT MEDICAL NECESSITY:
Added: Muscular dystrophy (359.0, 359.1) to the list of covered diagnoses for prefabricated skin protection and combination skin protection and positioning seat cushions.
Removed: E2618

Revision Effective Date: 07/01/2007
INDICATIONS AND LIMITATIONS OF COVERAGE:
Removed: Duplicate paragraph.

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: 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:
Added: Least costly alternative statement regarding general use cushions.
Revised: Coverage criteria for all seat/back cushions and positioning accessories to identify their coverage with specific types of power mobility devices.
Revised: Statement concerning coverage of a headrest.
Revised: Wording which describes the clinician who performs the evaluation for a custom fabricated cushion.
Added: Statement concerning coverage of a seat cushion solid support base (E2618).
ICD-9 CODES THAT SUPPORT MEDICAL NECESSITY:
Substituted: ICD-9 333.71 for 333.7 in three of the diagnosis sets.
DOCUMENTATION REQUIREMENTS:
Added: Requirement for detailed product description for items provided at the time of issue of a power wheelchair.
Revised: Wording which describes the clinician who performs the evaluation for a custom fabricated cushion.

Revision Effective Date: 07/01/2006
INDICATIONS AND LIMITATIONS OF COVERAGE:
Substituted: New codes for adjustable seat cushions.
HCPCS CODES:
Added: K0734, K0735, K0736, K0737
Discontinued: K0108
ICD-9 CODES THAT SUPPORT MEDICAL NECESSITY;
Substituted: New codes for adjustable seat cushions.
Corrected by deleting A9900 in last group.
DOCUMENTATION REQUIREMENTS:
Substituted: New codes for adjustable seat cushions.
Removed: Claim submission requirements for K0108.

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 Date: 10/01/2005
INDICATIONS AND LIMITATIONS OF COVERAGE:
Revised: Coverage criteria for headrests (E0955).
ICD-9 CODES THAT SUPPORT MEDICAL NECESSITY
Eliminated: Listing of ICD-9 codes for headrests.
DOCUMENTATION REQUIREMENTS:
Revised: KX modifier requirements for headrests.
Eliminated: Statement that additional documentation may be submitted with a claim if the KX modifier is not used.
SOURCES OF INFORMATION AND BASIS FOR DECISION:
Deleted: List of references.

Revision Effective Date: 04/01/2005
HCPCS CODES AND MODIFIERS:
Added: E2291-E2294

Revision Effective Date: 01/01/2005
INDICATIONS AND LIMITATIONS OF COVERAGE:
Added: References to codes E2620, E2621.
Replaced: K codes with new E codes.
Added: Statements related to adjustable seat cushions.
HCPCS CODES:
Added: Codes E2620, E2621, E2618.
Replaced: K codes with new E codes (E2601-E2617, E2619).
ICD-9 CODES SUPPORTING MEDICAL NECESSITY:
Added: Codes E2620, E2621.
Replaced: K codes with new E codes.
Corrected: Diagnosis set for codes E2607 and E2608.
Added: Statements related to adjustable seat cushions.
DOCUMENTATION REQUIREMENTS:
Added: References to codes E2620, E2621.
Replaced: K codes with new E codes.
Revised: Item (d) under the KX modifier requirements for codes E2607 and E2608.
Added: Statements related to adjustable seat cushions.
Added: Claim submission requirements for custom fabricated cushions.
Revised: Claim submission requirements for K0108.

Revision Effective Date: 10/01/2004
INDICATIONS AND LIMITATIONS OF COVERAGE:
Revised: Acceptable diagnosis codes for decubitus ulcers.
ICD-9 CODES SUPPORTING MEDICAL NECESSITY:
Changed: Acceptable ICD-9 codes for decubitus ulcers from 707.0 to 707.03, 707.04, 707.05.
Corrected: Diagnosis set for K0658 to match the narrative description in the Indications and Limitations of Coverage section.
DOCUMENTATION REQUIREMENTS:
Revised: General requirements in paragraph 1.
Corrected: Code range for positioning accessories.
Revised: Acceptable diagnosis codes for decubitus ulcers.

Revision Effective Date: 07/01/2004
HCPCS CODES:
Added: E0966
DOCUMENTATION REQUIREMENTS:
Revised: Criteria for use of the KX modifier for combination skin protection and positioning seat cushions.

Reason for Change ^{back to top}

Last Reviewed On Date ^{back to top}

Medicare Coverage Database

LCD for Wheelchair Seating (L15845)