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”).
Manual wheelchairs 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.
If the manual wheelchair is only for use outside the home, it will be denied as noncovered, no benefit, as the DME benefit requires use within the home for coverage eligibility.
Reimbursement for wheelchair codes includes all labor charges involved in the assembly of the wheelchair. Reimbursement also includes support services such as emergency services, delivery, set-up, education, and on-going assistance with use of the wheelchair.
A custom manual wheelchair base (K0008) must be uniquely constructed or substantially modified for a specific beneficiary according to the description and orders of the beneficiary’s treating practitioner. The beneficiary’s needs cannot be accommodated by any other existing manual wheelchair and accessories, including customized seating arrangements. See 42 CFR Section 414.224, and Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 20, Section 30.3 for more information on customized DME.
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.
Information showing that the coverage criteria in the Coverage Indications, Limitations, and/or Medical Necessity section of the related LCD have been met must be present in the beneficiary’s medical record. Information about whether the beneficiary’s home can accommodate the wheelchair (Criterion C), also called the home assessment, must be fully documented in the medical record or elsewhere by the supplier. For manual wheelchairs, the home assessment may be done directly by visiting the beneficiary’s home or indirectly based upon information provided by the beneficiary or their designee. When the home assessment is based upon indirectly obtained information, the supplier must, at the time of delivery, verify that the item delivered meets the requirements specified in criterion C. Issues such as the physical layout of the home, surfaces to be traversed, and obstacles must be addressed by and documented in the home assessment. Information from the beneficiary’s medical record and the supplier’s records must be available upon request.
Manual wheelchairs described by codes E1161, E1231, E1232, E1233, E1234, K0005, K0008 and K0009 are eligible for Advance Determination of Medicare Coverage (ADMC). Refer to the ADMC chapter in the Supplier Manual for details concerning the ADMC process.
If documentation of the medical necessity for a K0005 wheelchair is requested, it must include a description of the beneficiary’s routine activities. This may include the types of activities the beneficiary frequently encounters and whether the beneficiary is fully independent in the use of the wheelchair. Describe the features of the K0005 base which are needed compared to the K0004 base.
If documentation of the medical necessity for a K0008 wheelchair is requested, contractors must be able to determine that the item delivered is a customized item. Documentation must include a description of the beneficiary’s unique physical and functional characteristics that require a customized manual wheelchair base. This must include a detailed description of the manufacturing of the wheelchair base, including types of materials used in custom fabricating or substantially modifying it, and the construction process and labor skills required to modify it. The record must document that the needs of the beneficiary cannot be met using another manual wheelchair base that incorporates seating modifications or other options or accessories (prefabricated and/or custom). The documentation must demonstrate that the K0008 is so different from another wheelchair base that the two items cannot be grouped together for pricing purposes.
If documentation of the medical necessity for a transport chair (E1037, E1038 and E1039) is requested, it must include a description of why the beneficiary is unable to make use of a standard manual wheelchair (K0001, K0002, K0003, K0004, and K0005) on their own, and provide specific information that the beneficiary has a caregiver who is available, willing, and able to provide assistance with the wheelchair.
KX, GA, GY, AND GZ MODIFIERS:
Suppliers must add a KX modifier to the code for the manual wheelchair base only if all of the coverage criteria in the Coverage Indications, Limitations, and/or Medical Necessity section of the related LCD have been met and evidence of such is retained in the supplier’s files and available to the DME MAC upon request. If the coverage criteria are not met, the KX modifier must not be used.
If all of the coverage criteria in the Coverage Indications, Limitations, and/or Medical Necessity section of the related LCD have not been met, the GA or GZ modifier must be added to the code. When there is an expectation of a medical necessity denial, suppliers must enter the GA modifier on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or the GZ modifier if they have not obtained a valid ABN.
If the wheelchair is only to be used for mobility outside the home, the GY modifier must be added to the code.
Claim lines billed without a KX, GA, GY, or GZ modifier will be rejected as missing information.
For Medicare coding purposes, all manual wheelchair base codes describe a complete product. This includes items described by HCPCS codes:
Rollabout Chair (E1031)
Transport Chairs (E1037, E1038, E1039)
Manual Wheelchair Bases (E1161, E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0009)
A complete manual wheelchair base includes:
A complete frame
A sling seat, seat pan which can accommodate a wheelchair seat cushion, or a seat frame structured in such a way as to be capable of accepting a seating system
A sling back, other seat back support which can accommodate a wheelchair back cushion, or a back frame structured in such a way as to be capable of accepting a back system
Standard leg and footrests
Safety accessories (other than those separately billable in the Wheelchair Accessories Local Coverage Determination)
Adult manual wheelchairs (K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0008, K0009, E1161) are those which have a seat width and a seat depth of 15” or greater. For codes K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0008, K0009, the wheels must be large enough and positioned such that the wheelchair could be propelled by the user. In addition, specific codes are defined by the following characteristics:
Standard wheelchair (K0001)
Weight: Greater than 36 lbs.
Seat Height: 19 inches or greater
Weight capacity: 250 pounds or less
Standard hemi (low seat) wheelchair (K0002)
Weight: Greater than 36 lbs
Seat Height: Less than 19 inches
Weight capacity: 250 pounds or less
Lightweight wheelchair (K0003)
Weight: 34-36 lbs
Weight capacity: 250 pounds or less
High strength, lightweight wheelchair (K0004)
Weight: Less than 34 lbs
Lifetime Warranty on side frames and crossbraces
Ultralightweight wheelchair (K0005)
Weight: Less than 30 lbs
Adjustable rear axle position
Lifetime Warranty on side frames and crossbraces
Heavy duty wheelchair (K0006)
Weight capacity: Greater than 250 pounds
Extra heavy duty wheelchair (K0007)
Weight capacity: Greater than 300 pounds
Custom manual wheelchair/base (K0008)
In addition to meeting the statutory criteria above in the “Non-Medical Necessity Coverage and Payment Rules”, custom manual wheelchairs must also have a lifetime warranty on side frames and crossbraces.
Adult tilt-in-space wheelchair (E1161)
Ability to tilt the frame of the wheelchair greater than or equal to 20 degrees from horizontal while maintaining the same back to seat angle. Lifetime Warranty: On side frames and crossbraces
Wheelchairs with less than 20 degrees of tilt must not to be coded based upon the tilt feature. The appropriate base product must be coded as K0001, K0002, K0003, K0004, K0005, K0006, or K0007. The product must not be coded as E1161 or K0108.
“Weight” represents the weight of the wheelchair itself in pounds without the front rigging as in the case of the K0001, K0002, K0003, K0004, and K0005. ”Weight capacity” represents the carrying capacity or the amount of weight (beneficiary plus all accessories) that the wheelchair can carry for safe operation as in the case of the K0001, K0002, K0003, K0006 and K0007.
The following features are included in the allowance for all adult manual wheelchairs:
Seat Width: 15" - 19"
Seat Depth: 15" – 19”
Arm Style: Fixed, swingaway, or detachable; fixed height
Footrests: Fixed, swingaway, or detachable
Codes K0003, K0004, K0005, K0006, K0007, K0008 and E1161 include any seat height.
Manual wheelchair bases (K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0008, and K0009) include construction of any type material, including but not limited to, titanium, carbon, or any other lightweight high strength material. Suppliers must not bill HCPCS code K0108 in addition to the base wheelchair for construction materials or for a “heavy duty package” reflecting the type of material used to construct the manual wheelchair base. Billing for construction material is considered incorrect coding – unbundling.
Refer to the medical policy on Wheelchair Options and Accessories for information on other features included in the allowance for the wheelchair base.
A manual wheelchair with a seat width and/or depth of 14” or less is considered a pediatric size wheelchair and is billed with codes E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238 or E1229.
Codes E1050, E1060, E1070, E1083, E1084, E1085, E1086, E1087, E1088, E1089, E1090, E1091, E1092, E1093, E1100, E1110, E1130, E1140, E1150, E1160, E1170, E1171, E1172, E1180, E1190, E1195, E1200, E1220, E1221, E1222, E1223, E1224, E1240, E1250, E1260, E1270, E1280, E1285, E1290, E1295 should only be used to bill for maintenance and service for an item for which the initial claim was paid by the local carrier prior to transition to the DME MAC.
Manual wheelchairs with additional options and accessories, other than tilt, are billed by selecting the correct code for the wheelchair base and then using appropriate codes for wheelchair options and accessories. (Refer to the Wheelchair Options and Accessories policy.)
Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items.