Local Coverage Article

Wheelchair Options/Accessories - Policy Article

A52504

Expand All | Collapse All

Contractor Information

Article Information

General Information

Article ID
A52504
Original ICD-9 Article ID
A47229
A20284
A19829
A19846
Article Title
Wheelchair Options/Accessories - Policy Article
Article Type
Article
Original Effective Date
10/01/2015
Revision Effective Date
01/01/2020
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

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.

Current Dental Terminology © 2020 American Dental Association. All rights reserved.

Copyright © 2013 - 2021, the American Hospital Association, Chicago, Illinois. Reproduced by CMS with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB-04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312-893-6816. Making copies or utilizing the content of the UB-04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of UB-04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. To license the electronic data file of UB-04 Data Specifications, contact Tim Carlson at (312) 893-6816. You may also contact us at ub04@aha.org.

Article Guidance

Article Text

NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
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. Information provided in this policy article relates to determinations other than those based on Social Security Act §1862(a)(1)(A) provisions (i.e. “reasonable and necessary”).

Wheelchair options and accessories are covered under the Durable Medical Equipment benefit (Social Security Act §1861(s)(6)). In order for a beneficiary’s equipment to be eligible for reimbursement the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met.

The allowance for a power operated vehicle (POV) includes all options and accessories that are provided at the time of initial issue, including but not limited to batteries, battery chargers, seating systems, etc. If a beneficiary-owned POV meets coverage criteria, medically necessary replacement items are covered.

The allowance for a rollabout chair includes all options and accessories that are provided at the time of initial issue. The allowance for a transport chair includes all options and accessories that are provided at the time of initial issue except for elevating legrests (E0990, K0195). If a rollabout chair or transport chair are covered, medically necessary replacement items are covered.

An option/accessory that is beneficial primarily in allowing the beneficiary to perform leisure or recreational activities is non-covered.

If an option or accessory that is included in another code is billed separately, the claim line will be denied as not separately payable. (Refer to Coding Guidelines section for additional information on correct coding.)

BATTERIES/ CHARGERS:

A sealed battery (E2359, E2361, E2363, E2365, E2371, E2397, K0733) is separately payable from a power wheelchair base.

There is no additional/separate payment when a dual mode battery charger is provided at the time of initial issue of a power wheelchair.

A battery charger (E2366, E2367) is included in the allowance for a power wheelchair base.

POWER SEATING SYSTEMS:

A power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. If a wheelchair has an electrical connection device described by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or power standing feature, it will be denied as non-covered.

POWER WHEELCHAIR DRIVE CONTROL SYSTEMS:

If an attendant control (E2331) is provided in addition to a beneficiary-operated drive control system, it will be denied as non-covered. (See the related LCD for situations in which it is provided in place of a beneficiary-operated system.)

OTHER POWER WHEELCHAIR ACCESSORIES:

An electronic interface used to control lights or other electrical devices is non-covered because it is not primarily medical in nature.

The following features of a power wheelchair will be denied as non-covered: stair climbing (A9270), electronic balance (A9270), ability to elevate the seat by balancing on two wheels (A9270), and remote operation (A9270).

MISCELLANEOUS ACCESSORIES:

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

A manual standing system for a manual wheelchair (E2230) is non-covered (no benefit category) because it is not primarily medical in nature.

REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed. Reg Vol 217) 

Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated. The link will be located here once it is available.

Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.

If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD, it will be eligible for coverage.


POLICY SPECIFIC DOCUMENTATION REQUIREMENTS

In addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.

Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below.

MODIFIERS

KX, GA, GY, AND GZ MODIFIERS:

For accessories for a power mobility device (PMD), if the requirements related to a standard written order (SWO) for the PMD base and face-to-face encounter 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 the related 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.

CODING GUIDELINES

GENERAL:

Power Wheelchair Basic Equipment Package - Each power wheelchair code is required to include all these items on initial issue (i.e., no separate billing/payment at the time of initial issue, unless otherwise noted). The statement that an item may be separately billed does not necessarily indicate coverage.

  • Lap belt or safety belt. Shoulder harness/straps or chest straps/vest may be billed separately.

  • Battery charger, single mode

  • Complete set of tires and casters, any type

  • Legrests. There is no separate billing/payment if fixed, swingaway, or detachable non-elevating legrests with or without calf pad are provided. Elevating legrests may be billed separately.

  • Footrests/foot platform. There is no separate billing/payment if fixed, swingaway, or detachable footrests or a foot platform without angle adjustment are provided. There is no separate billing for angle adjustable footplates with Group 1 or 2 PWCs. Angle adjustable footplates may be billed separately with Group 3, 4 and 5 PWCs.

  • Armrests. There is no separate billing/ payment if fixed, swingaway, or detachable non-adjustable height armrests with arm pad are provided (K0015). Adjustable height armrests (E0973, K0020) may be billed separately.

  • Any weight specific components (braces, bars, upholstery, brackets, motors, gears, etc.) as required by beneficiary weight capacity.

  • Any seat width and depth. Exception: For Group 3 and 4 PWCs with a sling/solid seat/back, the following may be billed separately:

    • For Standard Duty, seat width and/or depth greater than 20 inches;

    • For Heavy Duty, seat width and/or depth greater than 22 inches;

    • For Very Heavy Duty, seat width and/or depth greater than 24 inches;

    • For Extra Heavy Duty, no separate billing

  • Any back width. Exception: For Group 3 and 4 PWCs with a sling/solid seat/back, the following may be billed separately:

    • For Standard Duty, back width greater than 20 inches;

    • For Heavy Duty, back width greater than 22 inches;

    • For Very Heavy Duty, back width greater than 24 inches;

    • For Extra Heavy Duty, no separate billing

  • Controller and Input Device. There is no separate billing/payment if a non-expandable controller and a standard proportional joystick (integrated or remote) is provided. An expandable controller, a nonstandard joystick (i.e., non-proportional or mini, compact or short throw proportional), or other alternative control device may be billed separately.

Power Operated Vehicle (POV) Basic Equipment Package - Each POV is to include all these items on initial issue (i.e., no separate billing/payment at time of initial issue):

  • Lap belt or safety belt. Shoulder harness/straps or chest straps/vest may be billed separately

  • Battery or batteries required for operation

  • Battery charger, single mode

  • Weight appropriate upholstery and seating system

  • Tiller steering

  • Non-expandable controller with proportional response to input

  • Complete set of tires

  • All accessories needed for safe operation

A table at the end of this section defines the bundling guidelines for wheelchair bases and options/accessories. Codes listed in Column II are not separately payable from the wheelchair base and must not be billed separately at the time of initial purchase or rental of the wheelchair.

A replacement option/accessory for POV is billed using a wheelchair option/accessory code. All options and accessories provided at the time of initial issue of a POV are not separately billable.

Accessories provided at the time of initial issue of a rollabout chair are not separately billable. Accessories provided with the initial issue of a transport chair are not separately billable with the exception of elevating legrests (E0990, K0195). A replacement accessory for a rollabout or transport chair is billed using code E1399.

The RB modifier is used when an option or accessory is provided as a replacement for the same part which has been worn or damaged (e.g., replacing a tire of the same type). The RB modifier must not be used for an upgrade subsequent to providing the wheelchair base (e.g., replacing a standard seat of a power wheelchair with a power seating system). The RB modifier must not be used if the accessory is provided at the same time as the wheelchair base, even if the option/accessory is the same as one that the beneficiary had on a prior wheelchair. (See section on Power Wheelchair Drive Control Systems for instructions on the use of the KC replacement modifier.)

Miscellaneous options, accessories, or replacement parts for wheelchairs that do not have a specific HCPCS code and are not included in another code should be coded K0108. If multiple miscellaneous accessories are provided, each should be billed on a separate claim line using code K0108. When billing more than one line item with code K0108, ensure that the additional information can be matched to the appropriate line item on the claim. It is also helpful to reference the line item to the submitted charge. If a supplier chooses to bill separately for a component that is included in another code, code A9900 must be used.

The right (RT) and left (LT) modifiers must be used when appropriate. Effective for claims with dates of service (DOS) on or after 3/1/2019, if bilateral items (left and right) are provided as a purchase and the unit of service of the code is “each”, bill each item on two separate claim lines using the RT and LT modifiers and 1 unit of service (UOS) on each claim line. Do not use the RTLT modifier on the same claim line and billed with 2 UOS. Claims for purchased items billed without modifiers RT and/or LT, or with RTLT on the same claim line and 2 UOS, will be rejected as incorrect coding. If bilateral items are provided as a rental and the UOS is “each”, bill the items on two separate claim lines with the RT modifier on one line and the LT modifier on the other. If bilateral items are provided and the unit of service is “pair”, the LT and RT modifiers do not need to be reported.

Codes E0968, E0969, E0970, E0980, E0994, E1227, E1228, E1296, E1297, E1298, and E2340, E2341, E2342, E2343 are not valid for claim submission.

FOOTREST/ LEGREST:

A footbox, E0954, is a padded box designed to position a beneficiary’s foot. This item comes in multiple configurations, i.e., it may be for a single foot or for both feet. Regardless of configuration, the unit of service (UOS) is per foot. E0954 includes both prefabricated and custom fabricated products. The code also includes all mounting hardware. 

Elevating legrests that are used with a wheelchair that is purchased or owned by the beneficiary are coded E0990. This code is per legrest. Elevating legrests that are used with a capped rental wheelchair base are coded K0195. This code is per pair of legrests.

NONSTANDARD SEAT FRAME DIMENSIONS:

For all adult manual wheelchairs (E1161, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0008, K0009), payment for seat widths and/or seat depths of 15-19 inches is included in the payment for the base code. These seat dimensions should not be billed separately. Codes E2201, E2202, E2203, E2204 describe seat widths and/or depths of 20 inches or more for manual wheelchairs.

For power wheelchairs, there is no separate billing for nonstandard seat frame dimensions (width, depth, or height) with the following exceptions: For Group 3 and 4 power wheelchairs, with a sling/solid seat/back, the following items may be billed separately using code K0108:

  • For Standard Duty, seat width and/or depth greater than 20 inches;

  • For Heavy Duty, seat width and/or depth greater than 22 inches;

  • For Very Heavy Duty, seat width and/or depth greater than 24 inches;

  • For Extra Heavy Duty, no separate billing

For Group 3 and 4 PWCs with a sling/solid seat/back, the following items may be billed separately using code K0108:

  • For Standard Duty, back width greater than 20 inches;

  • For Heavy Duty, back width greater than 22 inches;

  • For Very Heavy Duty, back width greater than 24 inches;

  • For Extra Heavy Duty, no separate billing

Code K0108 may not be billed for nonstandard dimensions of a power tilt and/or recline seating system (E1002, E1003, E1004, E1005, E1006, E1007, E1008). The definition of those codes includes any frame width and depth.

WHEELS/TIRES FOR MANUAL WHEELCHAIRS:

A propulsion wheel is a large wheel which can be used by a beneficiary to propel the wheelchair with his/her arms.

A caster is a small wheel that is in contact with the ground during normal operation of the wheelchair and which cannot be used for arm propulsion. This includes rear tires on tilt-in-space wheelchairs that are not used for arm propulsion.

A lever activated drive (E0988) is an alternative drive mechanism for propulsion of a manual wheelchair. It includes a user-powered lever-arm mechanism attached to one or both wheel hub(s). The lever activates adjustable-ratio gears and has the capability to shift between forward, reverse and braking.

A pneumatic tire (E2211, E2214) is a rubber tire which is used in conjunction with a separate tube (E2212, E2215) which is filled with air.

A flat free insert (E2213) is a removable ring of firm material that is placed inside of a pneumatic tire to allow the wheelchair to continue to move if the pneumatic tire is punctured. This code may not be used for a foam filled tire.

A foam filled tire (E2216, E2217) is one in which a rubber tire shell has been filled with foam which is non-removable.

A foam tire (E2218, E2219) is one which is made entirely of self-skinning urethane.

A replacement only solid tire (E2220, E2221, E2222) is one which is made of hard plastic or rubber.

A gear reduction drive wheel (E2227) is one that has more than one gear ratio option. Pushing on the rim allows the user to manually shift between the gears in order to provide additional leverage to assist propulsion of a manual wheelchair.

A wheel braking and lock system (E2228) is a caliper or disc type braking system that permits the controlled slowing of a manual wheelchair or the controlled descent on inclines. It also has full wheel lock capability.

A replacement only rear wheel assembly (K0069, K0070) includes a wheel rim plus a tire. For pneumatic tires, it also includes the tire tube, but not a flat free insert.

A replacement only caster assembly (K0071, K0072, K0077) includes a caster fork, wheel rim, and tire.

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

POWER SEATING SYSTEMS:

A power tilt seating system (E1002) includes: a solid seat platform and a solid back; any frame width and depth; detachable or flip-up fixed height or adjustable height armrests; fixed or swingaway detachable legrests; fixed or flip-up footplates; a motor and related electronics with or without variable speed programmability; a switch control which is independent of the power wheelchair drive control interface; any hardware that is needed to attach the seating system to the wheelchair base. It does not include a headrest. It must have the following features: ability to tilt to greater than or equal to 20 degrees from horizontal; back height of at least 20 inches; ability for the supplier to adjust the seat to back angle; ability to support beneficiary weight of at least 250 pounds.

A power recline seating system (E1003, E1004, E1005) includes: a solid seat platform and a solid back; any frame width and depth; detachable or flip-up fixed height or adjustable height arm rests; fixed or swingaway detachable legrests; fixed or flip-up footplates; a motor and related electronics with or without variable speed programmability; a switch control which is independent of the power wheelchair drive control interface; any hardware that is needed to attach the seating system to the wheelchair base. It does not include a headrest. It must have the following features: ability to recline to greater than or equal to 150 degrees from horizontal; back height of at least 20 inches; ability to support beneficiary weight of at least 250 pounds.

A power tilt and recline seating system (E1006, E1007, E1008) includes: a solid seat platform and a solid back; any frame width and depth; detachable or flip-up fixed height or adjustable height armrests; fixed or swingaway detachable legrests; fixed or flip-up footplates; two motors and related electronics with or without variable speed programmability; a switch control which is independent of the power wheelchair drive control interface; any hardware that is needed to attach the seating system to the wheelchair base. It does not include a headrest. It must have the following features: ability to tilt to greater than or equal to 20 degrees from horizontal; ability to recline to greater than or equal to 150 degrees from horizontal; back height of at least 20 inches; ability to support beneficiary weight of at least 250 pounds.

Coding for a power tilt system (E1002), power recline system (E1003, E1004 and E1005), and tilt/recline system (E1006, E1007 and E1008) are all-inclusive. Usage of K0108 to bill for additional heavy duty or bariatric features is considered unbundling and is not allowed.

A power tilt seating system or power tilt and recline seating system which does not achieve a tilt of greater than or equal to 20 degrees is considered to be the same as the standard seat included in the base wheelchair. Codes E1002, E1003, E1004, E1005, E1006, E1007, E1008 must not be used to describe a power tilt seating system or a power tilt and recline seating system which does not achieve a tilt of greater than or equal to 20 degrees. These seating systems must be coded as A9900 and are not separately payable.

A mechanical shear reduction feature (E1004 and E1007) consists of two separate back panels. As the posterior back panel reclines or raises there is a mechanical linkage between the two panels which allows the beneficiary's back to stay in contact with the anterior panel without sliding along that panel.

A power shear reduction feature (E1005 and E1008) consists of two separate back panels. As the posterior back panel reclines or raises there is a separate motor which controls the linkage between the two panels and allows the beneficiary's back to stay in contact with the anterior panel without sliding along that panel.

A mechanically linked leg elevation feature (E1009) involves a pushrod which connects the legrest to a power recline seating system. With this feature, when the back reclines, the legrest elevates; when the back raises, the legrest lowers.

A power leg elevation feature (E1010, E1012) involves dedicated motor(s) and related electronics with or without variable speed programmability which allows the legrest to be raised and lowered independently of the recline and/or tilt of the seating system. It includes a switch control which may or may not be integrated with the power tilt and/or recline control(s). It includes either articulating or non-articulating legrests. The unit of service of code E1010 is a pair. The unit of service for code E1012 is each.

HCPCS code E1012 includes all components of the leg rest, including fixed angle footplates and foot platforms. Adjustable angle footplates coded K0040 (ADJUSTABLE ANGLE FOOTPLATE, EACH) are separately payable when provided with leg rests coded as E1012.

A power seat elevation system (E2300) includes: a motor and related electronics with or without variable speed programmability; a switch control which is independent of the power wheelchair drive control interface; any hardware that is needed to attach the seating system to the wheelchair base. It must provide a seat elevation of at least 6 inches.

A power standing system (E2301) includes: a solid seat platform and a solid back; detachable or flip-up fixed height armrests; hinged legrests; anterior knee supports; fixed or flip-up footplates; a motor and related electronics with or without variable speed programmability; a basic switch control which is independent of the power wheelchair drive control interface; any hardware that is needed to attach the seating system to the wheelchair base. It does not include a headrest. It must have the following features: ability to move the beneficiary to a standing position; ability to support beneficiary weight of at least 250 pounds.

Codes E2310 and E2311 describe the electronic components that allow the beneficiary to control two or more of the following motors from a single interface (e.g., proportional joystick, touchpad, or non-proportional interface): power wheelchair drive, power tilt, power recline, power shear reduction, power leg elevation, power seat elevation, power standing. It includes a function selection switch which allows the beneficiary to select the motor that is being controlled and an indicator feature to visually show which function has been selected. When the wheelchair drive function has been selected, the indicator feature may also show the direction that has been selected (forward, reverse, left, right). This indicator feature may be in a separate display box or may be integrated into the wheelchair interface. Payment for the code includes an allowance for fixed mounting hardware for the control box and for the display box (if present).

POWER WHEELCHAIR DRIVE CONTROL SYSTEMS:

The term interface in the code narrative and definitions describes the mechanism for controlling the movement of a power wheelchair. Examples of interfaces include, but are not limited to, joystick, sip and puff, chin control, head control, etc. (Note: In the Power Mobility Devices policy, the term "control input device" is used instead of "interface".)

A proportional interface is one in which the direction and amount of movement by the beneficiary controls the direction and speed of the wheelchair. One example of a proportional interface is a standard joystick.

A non-proportional interface is one which involves a number of switches. Selecting a particular switch determines the direction of the wheelchair, but the speed is pre-programmed. One example of a non-proportional interface is a sip-and-puff mechanism.

The term controller describes the microprocessor and other related electronics that receive and interpret input from the joystick (or other drive control interface) and convert that input into power output which controls speed and direction. A high power wire harness connects the controller to the motor and gears.

A non-expandable controller has the following features:

  • May have the ability to control up to 2 power seating actuators through the drive control (for example, seat elevator and single actuator power elevating legrests). (Note: Control of the power seating actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.)

  • Can accommodate only an integral joystick or a standard proportional remote joystick

  • May allow for the incorporation of an attendant control


An expandable controller is capable of accommodating one or more of the following additional functions:

  • Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.)

  • Non-proportional input devices (e.g., sip and puff, head array, etc.)

  • Operate 3 or more powered seating actuators through the drive control. (Note: Control of the power seating actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.)

An expandable controller may also be able to operate one or more of the following:

  • A separate display (i.e., for alternate control devices)

  • Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control)

  • An attendant control

For power wheelchairs which are capable of being upgraded to an expandable controller (K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856 K0857, K0858, K0859, K0860, K0861 K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886, K0890, K0891), E2377 is used if an expandable controller is provided at the time of initial issue. Code E2376 is used with complete replacement of an expandable controller.

A harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc. that are required for the operation of an expandable controller. It also includes all the necessary fasteners, connectors, and mounting hardware. Code E2313 is separately billable in addition to an expandable controller both at initial issue and with complete replacement of the expandable controller. Code K0108 must not be used for any component or feature of an expandable controller at the time of initial issue. The reimbursement for any type of complete expandable controller is included in the allowance for codes E2377/E2376 plus E2313. However, if individual components of the harness are replaced, code K0108 should be used.

A switch is an electronic device which turns power to a particular function either "on" or "off". The external component of a switch may be either mechanical or non-mechanical. Mechanical switches involve physical contact in order to be activated. Examples of the external components of mechanical switches include, but are not limited to, toggle, button, ribbon, etc. Examples of the external components of non-mechanical switches include, but are not limited to, proximity, infrared, etc. Some of the codes include multiple switches. In those situations, each functional switch may have its own external component or multiple functional switches may be integrated into a single external switch component or multiple functional switches may be integrated into the wheelchair control interface without having a distinct external switch component.

A stop switch allows for an emergency stop when a wheelchair with a non-proportional interface is operating in the latched mode. (Latched mode is when the wheelchair continues to move without the beneficiary having to continually activate the interface.) This switch is sometimes referred to as a kill switch.

A direction change switch allows the beneficiary to change the direction that is controlled by another separate switch or by a mechanical proportional head control interface. For example, it allows a switch to initiate forward movement one time and backward movement another time.

A function selection switch allows the beneficiary to determine what operation is being controlled by the interface at any particular time. Operations may include, but are not limited to, drive forward, drive backward, tilt forward, recline backward, etc.

An integrated proportional joystick and controller is an electronics package in which a joystick and controller electronics are in a single box, which is mounted on the arm of the wheelchair.

The interfaces described by codes E2312, E2321, E2322, E2325, E2327, E2328, E2329, E2330, E2373, E2374, E2375, E2376, E2377 must have programmable control parameters for speed adjustment, tremor dampening, acceleration control, and braking.

A remote joystick is one in which the joystick is in one box that is typically mounted on the arm of the wheelchair and the controller electronics are located in a different box that is typically located under the seat of the wheelchair. The joystick is connected to the controller through a low power wire harness. A remote joystick may be used for either hand control, chin control, or attendant control.

A standard proportional remote joystick is one which requires approximately 340 grams of force to activate and which has an excursion (length of throw) of approximately 25 mm from neutral position. It can be used with a non-expandable or an expandable controller. There is no separate billing for a standard proportional remote joystick when it is provided at the time of initial issue of a power wheelchair whether it is used for hand or chin control by the beneficiary or whether it is used as an attendant control in place of a beneficiary-operated drive control interface.

A mini-proportional (short throw) remote joystick (E2312) is one which can be activated by a very low force (approximately 25 grams) and which has a very short displacement (a maximum excursion of approximately 5 mm from neutral). It can only be used with an expandable controller. It can be used for hand or chin control or control by other body part (e.g., tongue, lip, fingertip, etc.). There is no separate billing for control buttons, displays, switches, etc. There is no separate billing for fixed mounting hardware, regardless of the body part used to activate the joystick.

A compact proportional remote joystick (E2373) is one which has a maximum excursion of about 15 mm from neutral position but requires approximately 340 grams of force to activate. It can only be used with an expandable controller. It can be used for hand or chin control or control by other body part (e.g., foot, amputee stump, etc.). There is no separate billing for control buttons, displays, switches, etc. There is no separate billing for fixed mounting hardware, regardless of the body part used to activate the joystick.

A touchpad is an interface similar to the pad-type mouse found on portable computers. It is billed with code K0108.

Code E2321 is used for a non-proportional remote joystick, regardless of whether it is used for hand or chin control.

When code E2312, E2321, E2373, or E2374 is used for a chin control interface, the chin cup is billed separately with code E2324.

Code E2322 describes a system of 3-5 mechanical switches which are activated by the beneficiary touching the switch. The switch that is selected determines the direction of the wheelchair. A mechanical stop switch and a mechanical direction change switch, if provided, are included in the allowance for the code.

Code E2323 includes prefabricated joystick handles that have shapes other than a straight stick - e.g., U shape or T shape - or that have some other nonstandard feature - e.g., flexible shaft.

A sip and puff interface (E2325) is a non-proportional interface in which the beneficiary holds a tube in their mouth and controls the wheelchair by either sucking in (sip) or blowing out (puff). A mechanical stop switch is included in the allowance for the code. E2325 does not include the breath tube kit which is described by code E2326.

A proportional, mechanical head control interface (E2327) is one in which a headrest is attached to a joystick-like device. The direction and amount of movement of the beneficiary's head pressing on the headrest control the direction and speed of the wheelchair. A mechanical direction control switch is included in the code.

A proportional, electronic head control interface (E2328) is one in which a beneficiary's head movements are sensed by a box placed behind the beneficiary's head. The direction and amount of movement of the beneficiary's head (which does not come in contact with the box) control the direction and speed of the wheelchair. A proportional, electronic extremity control interface (E2328) is one in which the direction and amount of movement of the beneficiary's arm or leg control the direction and speed of the wheelchair.

A non-proportional, contact switch head control interface (E2329) is one in which a beneficiary activates one of three mechanical switches placed around the back and sides of their head. These switches are activated by pressure of the head against the switch. The switch that is selected determines the direction of the wheelchair. A mechanical stop switch and a mechanical direction change switch are included in the allowance for the code.

A non-proportional, proximity switch head control interface (E2330) is one in which a beneficiary activates one of three switches placed around the back and sides of their head. These switches are activated by movement of the head toward the switch, though the head does not touch the switch. The switch that is selected determines the direction of the wheelchair. A mechanical stop switch and a mechanical direction change switch is included in the allowance for the code.

An attendant control is one which allows a caregiver to drive the wheelchair instead of the beneficiary. The attendant control is usually mounted on one of the rear canes of the wheelchair. This code is limited to proportional control devices, usually a joystick. Code E2331 is used when an attendant control is provided in addition to a beneficiary-operated drive control interface.

Codes E2374, E2375, E2376 describe components of drive control systems. They may only be used for replacements other than at the time of initial issue.

Code K0108 is appropriately used at the time of initial issue only when the drive control interface that is provided is not included in the base code and there is no specific E code which describes it. K0108 must not be used for additional features of a joystick.

Code K0108 is appropriately used at the time of replacement in the following situations:

    1. An integrated proportional joystick and controller box are being replaced due to damage; or

    2. An interface other than a remote joystick (e.g. sip and puff, head control) is being replaced but the controller is not being replaced; or

    3. There is no specific E code which describes the type of drive control interface system which is provided.

The KC modifier (replacement of special power wheelchair interface) is used in the following situations:

    1. Due to a change in the beneficiary's condition an integrated joystick and controller is being replaced by another drive control interface - e.g., remote joystick, head control, sip and puff, etc.; or

    2. The beneficiary had a drive control interface described by codes E2321, E2322, E2325, E2327, E2328, E2329, E2330, or E2373 and both the interface (e.g., joystick, head control, sip and puff) and the controller electronics are being replaced due to irreparable damage.

The KC modifier would never be used at the time of initial issue of a wheelchair. The KC modifier specifically states replacement, therefore, the RB modifier is not required.

OTHER POWER WHEELCHAIR ACCESSORIES:

A drive wheel is one which is directly controlled by the motor of the power wheelchair. It may be either a rear wheel, mid wheel, or front wheel, depending on the model of the power wheelchair.

A caster is a smaller wheel that is in contact with the ground during normal operation of the wheelchair and which not directly controlled by the motor. It may be in the front and/or rear, depending on the location of the drive wheel.

A pneumatic tire (E2381, E2384) is a rubber tire which is used in conjunction with a separate tube (E2382, E2385) which is filled with air.

A flat free insert (E2383) is a removable ring of firm material that is placed inside of a pneumatic tire to allow the wheelchair to continue to move if the pneumatic tire is punctured. This code may not be used for a foam filled tire.

A foam filled tire (E2386, E2387) is one in which a rubber tire shell has been filled with foam which is non-removable.

A foam tire (E2388, E2389) is one which is made entirely of self-skinning urethane.

A solid tire (E2390, E2391, E2392) is one which is made of hard plastic or rubber.

All types of tires and wheels are included in the code for a power mobility base. Codes E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2393, E2394, E2395, E2396 may only be used for replacements other than at the time of initial issue.

Code E2351 describes an electronic interface used with a speech generating device. An electronic interface that is used to allow lights or other electrical devices to be operated using the power wheelchair control interface must be billed with code A9270 (non-covered item).

Codes E2368, E2369, E2370 are for a replacement motor and/or gearbox. These codes are not used at the time of initial issue. If the item is a rebuilt component, the UE (used DME) modifier must be added to the code.

MISCELLANEOUS:

Code E1028 is used for

    1. Swingaway hardware used with remote joysticks or touchpads,

    2. Swingaway or flip-down hardware for head control interfaces E2327, E2328, E2329, E2330, and

    3. Swingaway hardware for an indicator display box that is related to the multi-motor electronic connection codes E2310 or E2311.

Code E1028 is not to be used for swingaway hardware used with a sip and puff interface (E2325) because swingaway hardware is included in the allowance for that code. Code E1028 is not to be used for hardware on a wheelchair tray (E0950). Do not use E1028 in addition to E1020 (Residual limb support system) as it includes swingaway hardware.

Code E1029 describes a ventilator tray which is attached in a fixed position to the wheelchair base or back. Code E1030 describes a ventilator tray which is attached to the seat back and is articulated so that the tray will remain horizontal when the seat back is raised or lowered.

Code E1225 describes a manually operated reclining back that can recline greater than 15 degrees but less than 80 degrees. Code E1226 describes a manually operated reclining back that reclines 80 degrees or greater.

Code E2398 describes a wheelchair component attached to a wheelchair frame that allows for dynamic movement of the seat back or pelvis component in response to increased musculoskeletal tone or spasticity.

A Column II code is included in the allowance for the corresponding Column I code when provided at the same time. When multiple codes are listed in column I, all the codes in column II relate to each code in column I

Column I Column II
Power Operated Vehicle (K0800, K0801, K0802, K0806, K0807, K0808, K0812) All options and accessories
Rollabout Chair (E1031) All options and accessories
Transport Chair (E1037, E1038, E1039) All options and accessories except E0990, K0195
Manual Wheelchair Base (E1161, E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0009) E0967, E0981, E0982, E0995, E2205, E2206, E2210, E2220, E2221, E2222, E2224, E2225, E2226, K0015, K0017, K0018, K0019, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0052, K0069, K0070, K0071, K0072, K0077
Power Wheelchair Base Groups 1 and 2 (K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843) E0971, E0978, E0981, E0982, E0995, E1225, E2366, E2367, E2368, E2369, E2370, E2374, E2375, E2376, E2378, E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2394, E2395, E2396, K0015, K0017, K0018, K0019, K0037, K0040, K0041, K0042, K0043, K0044, K0045, K0046, K0047, K0051, K0052, K0077, K0098
Power Wheelchair Base Groups 3, 4, and 5 (K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856 K0857, K0858, K0859, K0860, K0861 K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886, K0890, K0891) E0971, E0978, E0981, E0982, E0995, E1225, E2366, E2367, E2368, E2369, E2370, E2374, E2375, E2376, E2378, E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2394, E2395, E2396, K0015, K0017, K0018, K0019, K0037, K0041, K0042, K0043, K0044, K0045, K0046, K0047, K0051, K0052, K0077, K0098
E0973 K0017, K0018, K0019
E0950 E1028
E0954 E1028
E0990 E0995, K0042, K0043, K0044, K0045, K0046, K0047
Power tilt and/or recline seating systems (E1002, E1003, E1004, E1005, E1006, E1007, E1008) E0973, K0015, K0017, K0018, K0019, K0020, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052
E1009, E1010, E1012 E0990, E0995, K0042, K0043, K0044, K0045, K0046, K0047, K0052, K0053, K0195
E2325 E1028
E1020 E1028
K0039 K0038
K0045 K0043, K0044
K0046 K0043
K0047 K0044
K0053 E0990, E0995, K0042, K0043, K0044, K0045, K0046, K0047
K0069 E2220, E2224
K0070 E2211, E2212, E2224
K0071 E2214, E2215, E2225, E2226
K0072 E2219, E2225, E2226
K0077 E2221, E2222, E2225, E2226
K0195 E0995, K0042, K0043, K0044, K0045, K0046, K0047

 

Suppliers should contact the Pricing, Data Analysis, and Coding (PDAC) contractor for guidance on correct coding of these items.

Coding Information

CPT/HCPCS Codes

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

N/A

Additional ICD-10 Information

N/A

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

N/A

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 article, 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 article should be assumed to apply equally to all Revenue Codes.

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
01/01/2020 R12

Revision Effective Date: 01/01/2020
CODING GUIDELINES:
Removed: Reference to HCPCS codes for replacement-only items

03/25/2021: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

01/01/2020 R11

Revision Effective Date: 01/01/2020
CODING GUIDELINES:
Removed: Reference to ICD-10 codes for replacement of E2398
Revised: Column II of table, removing E2398 for manual wheelchair bases and power wheelchair bases
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Removed: Group 1 paragraph information, HCPCS code E2398 reference, and Group 1 ICD-10 Codes

10/08/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

01/01/2020 R10

Revision Effective Date: 01/01/2020
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO 42 CFR 410.38(g):
Removed: Section due to Final Rule 1713
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 Fed. Reg Vol 217):
Added: Section and related information based on Final Rule 1713
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Revised: Information related to GY modifier use, as a result of Final Rule 1713
CODING GUIDELINES:
Revised: Format of HCPCS code references, from code 'spans' to individually-listed HCPCS
Revised: Column II of table, to include E2398 for manual wheelchair bases and power wheelchair bases 

03/19/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

01/01/2020 R9

Revision Effective Date: 01/01/2020
CODING GUIDELINES:
Added: E2398 Coding Guideline
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Covered” updated to “ICD-10 Codes that Support Medical Necessity”
Added: Group 1 ICD-10 codes G80.0, G80.1, G80.2 , G80.3 , G80.4 , G80.8, G80.9, G93.1, S06.2X0S, S06.2X1S, S06.2X2S, S06.2X3S, S06.2X4S, S06.2X5S, S06.2X6S, S06.2X9S
ICD-10 CODES THAT DO NOT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Not Covered” updated to “ICD-10 Codes that DO NOT Support Medical Necessity”

12/19/2019: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

01/01/2019 R8

Revision Effective Date: 01/01/2019
CODING GUIDELINES:
Removed: K0037 from “replacement only” items
Revised: RT and LT modifier billing instructions (Effective 03/01/2019)

02/14/2019: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

01/01/2018 R7

Revision Effective Date: 01/01/2018
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Added: 42 CFR language previously in Policy Specific Documentation section
CODING GUIDELINES:
Revised: Coding Guidelines for E1012
Added: PDAC contact information

04/12/2018: At this time 21st Century Cures Act applies to new and revised LCDs that restrict coverage, which require comment and notice. This revision is to an article that is not a local coverage determination.

01/01/2018 R6

Revision Effective Date: 01/01/2018

Coding Guidelines:

Added: HCPCS code E0954
Added: HCPCS code E0954 to bundling table

12/21/2017: At this time 21st Century Cures Act applies to new and revised LCDs that restrict coverage, which require comment and notice. This revision is to an article that is not a local coverage determination.

01/01/2017 R5 Revision Effective Date: 01/01/2017
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Removed: Non-coverage language for E0950 due to clerical error
01/01/2017 R4 Revision Effective Date: 01/01/2017
NON MEDICAL NECESSITY PAYMENT RULES:
Added: Coverage rule for E0950
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: 42 CFR 410.38(g) and Modifier requirements
Added: Instructions for replacement codes
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements article
07/01/2016 R3 Effective July 1, 2016 oversight for DME MAC Articles is the responsibility of CGS Administrators, LLC 18003 and 17013 and Noridian Healthcare Solutions, LLC 19003 and 16013. No other changes have been made to the Articles.
01/01/2016 R2 Revision Effective Date: 01/01/2016
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: Standard Documentation Language to remove start date verbiage from Prescription Requirements (Effective 11/5/2015)
CODING GUIDELINES:
Added: HCPCS code E1012
Added: HCPCS code E1012 to bundling table
10/01/2015 R1 Revision Effective Date: 10/31/2014
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Removed: “When required by state law” from ACA new prescription requirements
Revised: Face-to-Face Requirements for treating practitioner
CODING GUIDELINES:
Revised: Removed HCPCS K0017 and K0018 from the initial package verbiage for armrest separate billing due to being parts of the whole assembly E0973 and only separately billed for replacement parts.
Added: E0973 was added to the initial package verbiage for armrest separate billing due to being the whole assembly.
Removed: The word “adjustable” was removed from the initial package verbiage for armrest separate billing due to fixed armrests K0020 being included

Associated Documents

Related National Coverage Documents
N/A
Statutory Requirements URLs
N/A
Rules and Regulations URLs
N/A
CMS Manual Explanations URLs
N/A
Other URLs
N/A
Public Versions
Updated On Effective Dates Status
03/19/2021 01/01/2020 - N/A Currently in Effect You are here
10/01/2020 01/01/2020 - N/A Superseded View
03/13/2020 01/01/2020 - N/A Superseded View
12/13/2019 01/01/2020 - N/A Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

N/A