Local Coverage Article

Power Mobility Devices - Policy Article

A52498

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General Information

Article ID
A52498
Original ICD-9 Article ID
A47122
A41136
A36239
A41127
Article Title
Power Mobility Devices - 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
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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”).

Power mobility devices 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 Medicare Prescription Drug, Improvement, and Modernization Act of 2003, added section 1834(a)(1)(E)(iv) which provides that payment may not be made for a motorized or power wheelchair unless the treating practitioner conducts the face-to-face encounter and writes the Standard Written Order (SWO). If the treating practitioner does not conduct the face-to-face encounter or write the SWO for the PMD base item, the claim will be denied as statutorily noncovered. 

A power mobility device may not be ordered by a podiatrist. If it is, it will be denied as statutorily noncovered.

FACE-TO-FACE ENCOUNTER:

If the POV or PWC is a replacement during the 5-year useful lifetime of an item in the same performance group that was previously covered by Medicare, a face-to-face encounter is not required. Note: Replacement during an item’s useful lifetime is limited to situations involving loss or irreparable damage from a specific accident or natural disaster (e.g., fire, flood, etc.).

The treating practitioner may conduct the entire mobility face-to-face encounter or may refer the beneficiary to a licensed/certified medical professional (LCMP), such as a physical therapist (PT) or occupational therapist (OT), who has experience and training in mobility evaluations to perform part of the face-to-face encounter. This person may have no financial relationship with the supplier. (Exception: If the supplier is owned by a hospital, the PT or OT working in the inpatient or outpatient hospital setting may perform part of the face-to-face encounter.)

To accommodate the requirements at 42 CFR 410.38, when the treating practitioner sees the beneficiary, regardless of whether a referral to an LCMP is made, that visit date starts the six (6) month timeline for completion of the SWO for the wheelchair base. If the treating practitioner chooses to refer the beneficiary to an LCMP for a mobility evaluation, the treating practitioner's co-signature, dating and indicating agreement or disagreement with the LCMP evaluation must occur within this six (6) month timeframe. In cases where the LCMP evaluation is being adopted into the practitioner's documentation to substantiate the need for the base item, the SWO may not be written until the LCMP report is signed, dated and agreement/disagreement indicated.

MISCELLANEOUS:

A custom motorized/power wheelchair base (K0013) 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 must not be able to be accommodated by any other existing PMD and accessories, including customized seating arrangements. See 42 CFR Section 414.224(a).

A seat elevator is a statutorily noncovered option on a power wheelchair. If a PWC with a seat elevator (K0830, K0831) is provided, it will be denied as noncovered.

If any POV or PWC is only for use outside the home, it will be denied as noncovered.

Reimbursement for the wheelchair codes includes all labor charges involved in the assembly of the wheelchair. Reimbursement also includes support services, such as delivery, set-up, and education about the use of the PMD.

Upgrades that are beneficial primarily in allowing the beneficiary to perform leisure or recreational activities are noncovered.

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 provides 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

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.

If documentation of the medical necessity for a K0013 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 custom motorized/power 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 power wheelchair base that incorporates seating modifications or other options or accessories (prefabricated and/or custom). The documentation must demonstrate that the K0013 is so different from another power wheelchair base that the two items cannot be grouped together for pricing purposes.

MODIFIERS

KX, GA, GY, AND GZ MODIFIERS:

If the requirements related to a face-to-face encounter have not been met, the GY modifier must be added to the codes for the power mobility device and all accessories.

If the power mobility device or push-rim activated power assist device that is provided is only needed for mobility outside the home, the GY modifier must be added to the codes for the item and all accessories.

A KX modifier may be added to the code for a power mobility device and all accessories only if one of the following conditions is met:

  1. If all of the coverage criteria specified in the related LCD have been met for the product that is provided; or

  2. If there is an affirmative Advance Determination of Medicare Coverage (ADMC) for the product that is provided.

If the requirements for use of the KX modifier or GY modifier are not 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 GA on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or GZ if they have not obtained a valid ABN.

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

CODING GUIDELINES

DEFINITIONS:

Power Mobility Device (PMD) - Base codes include both integral frame and modular construction type power wheelchairs (PWCs) and power operated vehicles (POVs).

Power Wheelchair - Chair-like battery powered mobility device for people with difficulty walking due to illness or disability, with integrated or modular seating system, electronic steering, and four or more wheel non-highway construction.

Power Operated Vehicle - Chair-like battery powered mobility device for people with difficulty walking due to illness or disability, with integrated seating system, tiller steering, and three or four-wheel non-highway construction.

Beneficiary Weight Capacity – The terms Standard Duty, Heavy Duty, etc., refer to weight capacity, not performance. For example, the term Group 3 heavy duty power wheelchair denotes that the PWC has Group 3 performance characteristics and beneficiary weight handling capacity between 301 and 450 pounds. A device is not required to carry all the weight listed in the class of devices, but must have a beneficiary weight capacity within the range to be included. For example, a PMD that has a weight capacity of 400 pounds is coded as a Heavy Duty device.

Portable - A category of devices with lightweight construction or ability to disassemble into lightweight components that allows easy placement into a vehicle for use in a distant location.

Performance Testing - Term used to denote the RESNA based test parameters used to test PMDs. The PMD is expected to meet or exceed the listed performance and durability figures for the category in which it is to be used when tested. There is no requirement to test the PMD with all possible accessories.

Test Standards - Performance and durability acceptance criteria defined by ANSI/RESNA standard testing protocols.

Crash Testing - Successful completion of WC-19 testing.

Top End Speed - Minimum speed acceptable for a given category of devices. It is to be determined by the RESNA test for maximum speed on a flat hard surface.

Range - Minimum distance acceptable for a given category of devices on a single charge of the batteries. It is to be determined by the appropriate RESNA test for range.

Obstacle Climb - Vertical height of a solid obstruction that can be climbed using the standing and/or 0.5 meter run-up RESNA test.

Dynamic Stability Incline - The minimum degree of slope at which the PMD in the most common seating and positioning configuration(s) remains stable at the required beneficiary weight capacity. If the PMD is stable at only one configuration, the PMD may have protective mechanisms that prevent climbing inclines in configurations that may be unstable.

Radius Pivot Turn – The distance required for the smallest turning radius of the PMD base. This measurement is equivalent to the “minimum turning radius” specified in the ANSI/RESNA bulletins.

PWC 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. Adjustable height armrests 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, seat 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., nonproportional or mini, compact or short throw proportional), or other alternative control device may be billed separately.

Refer to the bundling table in the Wheelchair Options and Accessories Policy Article for a list of codes that are not separately billable at the time of initial issue of a PWC.

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

  • 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

Cross Brace Chair - A type of construction for a power wheelchair in which opposing rigid braces hinge on pivot points to allow the device to fold.

Power Options - Tilt, recline, elevating legrests, seat elevators, or standing systems that may be added to a PWC to accommodate a beneficiary’s specific need for seating assistance.

No Power Options – A category of PWCs that is incapable of accommodating a power tilt, recline, seat elevation, or standing system. If a PWC can only accept power elevating legrests, it is considered to be a No Power Option chair.

Single Power Option - A category of PWCs with the capability to accept and operate a power tilt or power recline or power standing or, for Groups 3, 4, and 5, a power seat elevation system, but not a combination power tilt and recline seating system. It may be able to accommodate power elevating legrests, seat elevator, and/or standing system in combination with a power tilt or power recline. A PMD does not have to be able to accommodate all features to qualify for this code. For example, a power wheelchair that can only accommodate a power tilt could qualify for this code.

Multiple Power Options - A category of PWCs with the capability to accept and operate a combination power tilt and recline seating system. It may also be able to accommodate power elevating legrests, a power seat elevator, and/or a power standing system. A PWC does not have to accommodate all features to qualify for this code.

Actuator – A motor that operates a specific function of a power seating system – i.e., tilt, back recline, power sliding back, elevating legrest(s), seat elevation, or standing.

Proportional Control Input Device - A device that transforms a user's drive command (a physical action initiated by the wheelchair user) into a corresponding and comparative movement, both in direction and in speed, of the wheelchair. The input device shall be considered proportional if it allows for both a non-discrete directional command and a non-discrete speed command from a single drive command movement. (Note: In the Wheelchair Options and Accessories policy, the term “interface” is used instead of “control input device”.)

Non-Proportional Control Input Device - A device that transforms a user's discrete drive command (a physical action initiated by the wheelchair user, such as activation of a switch) into perceptually discrete changes in the wheelchair's speed, direction, or both.

Alternative Control Device - A device that transforms a user’s drive commands by physical actions initiated by the user to input control directions to a power wheelchair that replaces a standard proportional joystick. Includes mini-proportional, compact, or short throw joysticks, head arrays, sip and puff and other types of different input control devices.

Non-Expandable Controller - An electronic system that controls the speed and direction of the power wheelchair drive mechanism. Only a standard proportional joystick (used for hand or chin control) can be used as the input device. This system may be in the form of an integral controller or a remotely placed controller. The non-expandable controller:

  1. 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.)

  2. May allow for the incorporation of an attendant control.

Expandable Controller - An electronic system that is capable of accommodating one or more of the following additional functions:

  1. Proportional input devices (e.g., mini, compact, or short throw joysticks, touchpads, chin control, head control, etc.) other than a standard proportional joystick.

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

  3. 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:

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

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

  3. An attendant control

Integral Control System - Non-expandable wheelchair control system where the joystick is housed in the same box as the controller. The entire unit is located and mounted near the hand of the user. A direct electrical connection is made from the Integral Control box to the motors and batteries through a high power wire harness.

Remotely Placed Controller - Non-expandable or expandable wheelchair control system where the joystick (or alternative control device) and the controller box are housed in separate locations. The joystick (or alternative control device) is connected to the controller through a low power wire harness. The separate controller connects directly to the motors and batteries through a high power wire harness.

Codes E2310 and E2311 describe electronic components that allow the patient to control two or more of the following motors from a single interface, e.g., proportional joystick, touchpad, or nonproportional interface:

  • Power tilt
  • Power recline, with or without shear reduction
  • Combination power tilt and recline, with or without shear reduction
  • Power leg elevation with or without articulation, power center mount elevating foot platform with or without articulating properties.

The interface includes a function selection switch that allows the patient 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 interface code includes an allowance for fixed mounting hardware for the control box and the display box, if present.

A harness (E2313) describes all the wires, fuse boxes, fuses, circuits, switches, etc. that are required for the operation of an expandable controller (E2377). It also includes all the necessary fasteners, connectors, and mounting hardware.

Sling Seat/Back - Flexible cloth, vinyl, leather or equal material designed to serve as the support for buttocks or back of the user respectively. They may or may not have thin padding but are not intended to provide cushioning or positioning for the user.

Solid Seat/Back - Rigid metal or plastic material usually covered with cloth, vinyl, leather or equal material, with or without some padding material designed to serve as the support for the buttocks or back of the user respectively. They may or may not have thin padding but are not intended to provide cushioning or positioning for the user. PWCs with an automotive-style back and a solid seat pan are considered as a solid seat/back system, not a captains chair.

Captains chair - A one or two-piece automotive-style seat with rigid frame, cushioning material in both seat and back sections, covered in cloth, vinyl, leather or equal as upholstery, and designed to serve as a complete seating, support, and cushioning system for the user. It may have armrests that can be fixed, swingaway, or detachable. It may or may not have a headrest, either integrated or separate.

Stadium Style Seat - A one or two piece stadium-style seat with rigid frame and cushioning material in both seat and back sections, covered in cloth, vinyl, leather or equal as upholstery, and designed to serve as a complete seating, support, and cushioning system for the user. It may have armrests that can be fixed, swingaway, or detachable. It will not have a headrest. Chairs with stadium style seats are billed using the captains chair codes.

Highway Use - Mobility devices that are powered and configured to operate legally on public streets.

Push-rim activated power assist (E0986) – An option for a manual wheelchair in which sensors in specially designed wheels determines the force that is exerted by the beneficiary upon the wheel. Additional propulsive and/or braking force is then provided by motors in each wheel. E0986 is all-inclusive. All components, e.g., drive wheels, batteries, chargers, controls, mounting hardware, etc, for a manual wheel chair conversion are considered as included in 1 UOS of the code.

CODE-SPECIFIC REQUIREMENTS:

There are five PWC Groups and two POV Groups. Groups are divided based on performance. Each group of PMDs has subdivisions based on beneficiary weight capacity, seat type, portability, and/or power seating system capability.

All POVs (K0800, K0801, K0802, K0806, K0807, K0808, K0812) must have the specified components and meet the following requirements:

  • Have all components in the POV Basic Equipment Package

  • Seat Width: Any width appropriate to weight group

  • Seat Depth: Any depth appropriate to weight group

  • Seat Height: Any height (adjustment requirements-none)

  • Back Height: Any height (minimum back height requirement-none)

  • Seat to Back Angle: Fixed or adjustable (adjustment requirements – none)

  • Meet the following testing requirements:

    • Fatigue test – 200, 000 cycles

    • Drop test – 6,666 cycles

Group 1 POVs (K0800, K0801, K0802) must meet the following requirements:

  • Length - less than or equal to 48 inches

  • Width - less than or equal to 28 inches

  • Minimum Top End Speed - 3 MPH

  • Minimum Range - 5 miles

  • Minimum Obstacle Climb - 20 mm

  • Radius Pivot Turn - less than or equal to 54 inches

  • Dynamic Stability Incline - 6 degrees

Group 2 POVs (K0806, K0807, K0808) must meet the following requirements:

  • Length - less than or equal to 48 inches

  • Width - less than or equal to 28 inches

  • Minimum Top End Speed - 4 MPH

  • Minimum Range - 10 miles

  • Minimum Obstacle Climb - 50 mm

  • Radius Pivot Turn - less than or equal to 54 inches

  • Dynamic Stability Incline - 7.5 degrees

The following requirements describe the configurations of power wheelchairs as they are coded by the Pricing, Data Analysis, and Coding (PDAC) contractor. Items provided to the beneficiary may include upgraded components which are substituted for the basic component and are billed separately. One example is a power seating system. When this is provided, the base code used should be that with a sling/solid seat/back. Another example is the provision of an expandable controller when the base code includes a non-expandable controller but is capable of an upgrade.

All PWCs (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, 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, K0898) must have the specified components and meet the following requirements:

  • Have all components in the PWC Basic Equipment Package

  • Have the seat option listed in the code descriptor

  • Seat Width: Any width appropriate to weight group

  • Seat Depth: Any depth appropriate to weight group

  • Seat Height: Any height (adjustment requirements-none)

  • Back Height: Any height (minimum back height requirement-none)

  • Seat to Back Angle: Fixed or adjustable (adjustment requirements – none)

  • May include semi-reclining back

  • Meet the following testing requirements:

    • Fatigue test – 200, 000 cycles

    • Drop test – 6,666 cycles

All Group 1 PWCs (K0813, K0814, K0815, K0816) must have the specified components and meet the following requirements:

  • Standard integrated or remote proportional joystick

  • Non-expandable controller

  • Incapable of upgrade to expandable controller

  • Incapable of upgrade to alternative control devices

  • May have crossbrace construction

  • Accommodates non-powered options and seating systems (e.g., recline-only backs, manually elevating legrests) (except captains chairs)

  • Length - less than or equal to 40 inches

  • Width - less than or equal to 24 inches

  • Minimum Top End Speed - 3 MPH

  • Minimum Range - 5 miles

  • Minimum Obstacle Climb - 20 mm

  • Dynamic Stability Incline - 6 degrees

For Group 1 portable wheelchairs (K0813, K0814), the largest single component may not exceed 55 pounds.

All Group 2 PWCs (K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843) must have the specified components and meet the following requirements:

  • Standard integrated or remote proportional joystick

  • May have crossbrace construction

  • Accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports) (except captains chairs)

  • Length - less than or equal to 48 inches

  • Width - less than or equal to 34 inches

  • Minimum Top End Speed - 3 MPH

  • Minimum Range - 7 miles

  • Minimum Obstacle Climb - 40 mm

  • Dynamic Stability Incline - 6 degrees

For Group 2 portable PWCs (K0820, K0821), the largest single component may not exceed 55 pounds.

Group 2 no power option PWCs (K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829) must have the specified components and meet the following requirements:

  • Non-expandable controller

  • Incapable upgrade to expandable controller

  • Incapable of upgrade to alternative control devices

  • Incapable of accommodating a power tilt, recline, seat elevation, standing system

  • Accommodates non-powered options and seating systems (e.g., recline-only backs, manually elevating legrests) (except captains chairs)

Group 2 seat elevator PWCs (K0830, K0831) must have the specified components and meet the following requirements:

  • Non-expandable controller

  • Incapable of upgrade to expandable controller

  • Incapable of upgrade to alternative control devices

  • Accommodates only a power seat elevating system

Group 2 single power option PWCs (K0835, K0836, K0837, K0838, K0839, K0840) must have the specified components and meet the following requirements:

  • Non-expandable controller

  • Capable of upgrade to expandable controller

  • Capable of upgrade to alternative control devices

  • See Single Power Option definition for seating system capability

Group 2 multiple power option PWCs (K0841, K0842, K0843) must have the specified components and meet the following requirements:

  • Non-expandable controller

  • Capable of upgrade to expandable controller

  • Capable of upgrade to alternative control devices

  • See Multiple Power Options definition for seating system capability

  • Accommodates a ventilator

All Group 3 PWCs (K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864) must have the specified components and meet the following requirements:

  • Standard integrated or remote proportional joystick

  • Non-expandable controller

  • Capable of upgrade to expandable controller

  • Capable of upgrade to alternative control devices

  • May not have crossbrace construction

  • Accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports) (except captains chairs)

  • Drive wheel suspension to reduce vibration

  • Length - less than or equal to 48 inches

  • Width - less than or equal to 34 inches

  • Minimum Top End Speed - 4.5 MPH

  • Minimum Range - 12 miles

  • Minimum Obstacle Climb - 60 mm

  • Dynamic Stability Incline - 7.5 degrees

All Group 4 PWCs (K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886) must have the specified components and meet the following requirements:

  • Standard integrated or remote proportional joystick

  • Non-expandable controller

  • Capable of upgrade to expandable controller

  • Capable of upgrade to alternative control devices

  • May not have crossbrace construction

  • Accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports) (except captains chairs)

  • Drive wheel suspension to reduce vibration

  • Length - less than or equal to 48 inches

  • Width - less than or equal to 34 inches

  • Minimum Top End Speed - 6 MPH

  • Minimum Range - 16 miles

  • Minimum Obstacle Climb - 75 mm

  • Dynamic Stability Incline - 9 degrees

Group 3 and 4 no power option PWCs (K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0868, K0869, K0870, K0871) must have the specified components and meet the following requirements:

  • Incapable of accommodating a power tilt, recline, seat elevation, standing system

  • Accommodates non-powered options and seating systems (e.g., recline-only backs, manually elevating legrests)

Group 3 and 4 single power option PWCs (K0856, K0857, K0858, K0859, K0860, K0877, K0878, K0879, K0880) must have the specified components and meet the following requirements:

  • See Single Power Option definition for seating system capability

Group 3 and 4 multiple power option PWCs (K0861, K0862, K0863, K0864, K0884, K0885, K0886) must have the specified components and meet the following requirements:

  • See Multiple Power Options definition for seating system capability

  • Accommodates a ventilator

All Group 5 PWCs (K0890, K0891) must have the specified components and meet the following requirements:

  • Standard integrated or remote proportional joystick

  • Non-expandable controller

  • Capable of upgrade to expandable controller

  • Capable of upgrade to alternative control devices

  • Seat Width: minimum of 5 one-inch options

  • Seat Depth: minimum of 3 one-inch options

  • Seat Height: adjustment requirements-≥ 3 inches

  • Back Height: adjustment requirements minimum of 3 options

  • Seat to Back Angle: range of adjustment-minimum of 12 degrees

  • Accommodates non-powered options and seating systems

  • Accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports)

  • Adjustability for growth (minimum of 3 inches for width, depth and back height adjustment)

  • Special developmental capability (i.e., seat to floor, standing, etc.)

  • Drive wheel suspension to reduce vibration

  • Length - less than or equal to 48 inches

  • Width - less than or equal to 34 inches

  • Minimum Top End Speed - 4 MPH

  • Minimum Range - 12 miles

  • Minimum Obstacle Climb - 60 mm

  • Dynamic Stability Incline - 9 degrees

  • Crash testing - Passed

Group 5 single power option PWC (K0890) must have the specified components and meet the following requirements:

  • See Single Power Option definition for seating system capability

Group 5 multiple power option PWC (K0891) must have the specified components and meet the following requirements:

  • See Multiple Power Options definition for seating system capability

  • Accommodates a ventilator


MISCELLANEOUS:

The only products that may be billed using codes K0800, K0801, K0802, K0806, K0807, K0808, K0812, 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, 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, K0898 are those products for which a written coding verification review (CVR) has been made by the Pricing, Data Analysis, and Coding (PDAC) contractor. Information concerning the documentation that must be submitted to the PDAC for a written CVR can be found on the PDAC web site or by contacting the PDAC. A Product Classification List (PCL) with products which have received a written CVR can be found on the PDAC web site. Note that code K0013 is not included in the list of products requiring CVR.

Manufacturers and suppliers should refer to the PDAC web site or contact the PDAC for information concerning testing requirements.

If a power mobility device has not received a written CVR from the PDAC or if the PDAC has reviewed and determined that the product does not meet the requirements of any code, then it must be billed with code K0899.

If a product is billed to Medicare using one of the HCPCS codes that requires written CVR, but the product is not on the PCL for that particular HCPCS code, then the claim line will be denied as incorrect coding.

Suppliers should contact the PDAC contractor for guidance on the correct coding of these items.

Coding Information

CPT/HCPCS Codes

N/A

ICD-10-CM Codes that Support Medical Necessity

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.

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Revision History Information

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

Revision Effective Date: 01/01/2020
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: “physician’s” to “practitioner’s”
MISCELLANEOUS:
Revised: “coding verification determination” to “coding verification review”
Added: "CVR" after reference to "coding verification review"
Added: “PCL” after reference to “Product Classification List”
Revised: Coding verification review reference of “devices” to “products"
Added: Incorrect coding denial language for products billed using HCPCS that require written coding verification review

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
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: Order and face-to-face encounter denial-related information
Revised: Section information to include that if the treating practitioner does not conduct the face-to-face encounter and write the SWO for the PMD base, the claim will deny as statutorily non-covered
FACE-TO-FACE ENCOUNTER:
Revised: Section information related to face-to-face encounters, LCMP evaluation, and 6-month timeframe
Removed: Custom motorized/power wheelchair base (K0013) information
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
MISCELLANEOUS:
Added: Custom motorized/power wheelchair base (K0013) information, previously located in FACE-TO-FACE ENCOUNTER section
CODE-SPECIFIC REQUIREMENTS:
Revised: Format of HCPCS code references, from code ‘spans’ to individually-listed HCPCS

03/12/2020: 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
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Removed: 7-element order and Detailed Product Description direction
Added: SWO direction
Revised: References of face-to-face “examination” to face-to-face “encounter”
Revised: Face-to-face encounter language and references of "practitioner" updated to "treating practitioner"
Added: Face-to-Face encounter must be completed within 6 months prior to the order
Removed: References to 45-day timeframe for receipt of order and face-to-face
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO 42 CFR 410.38(c) and 42 CFR 410.38(g):
Removed: Entire section based on Final Rule 1713
FACE-TO-FACE ENCOUNTER:
Revised: Section header “FACE-TO-FACE EXAMINATION” to “FACE-TO-FACE ENCOUNTER,” updated section language based on Final Rule 1713, and reference to 42 CFR Section 414.224(a) for customized DME
Removed: References to 45-day timeframe for receipt of face-to-face
Removed: Reference to the Medicare Claims Processing Manual for customized DME
MISCELLANEOUS:
Removed: MISCELLANEOUS section including ADMC and Condition of Payment Prior Authorization (PA) Program-specific information
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”
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”

01/09/2020: 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.

07/22/2019 R9

Revision Effective Date: 07/22/2019
POLICY SPECIFIC DOCUMENTATION:
Added: HCPCS codes K0857 - K0860 and K0862 - K0864 to the Condition of Payment Prior Authorization (PA) Program information

07/04/2019: 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
POLICY SPECFIC DOCUMENTATION:
Removed: Prior Authorization of Power Mobility Devices (PMD) Demonstration information as program ended August 31, 2018.
CODING GUIDELINES:
Added: Coding guidelines for power wheelchair electronics

04/04/2019: 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.

09/01/2018 R7

Revision Effective Date: 09/01/2018

POLICY SPECFIC DOCUMENTATION:

Revised: ADMC, Prior Authorization of Power Mobility Devices (PMD) Demonstration and Condition of Payment Prior Authorization Program information

09/13/2018: 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.

01/01/2017 R6

Revision Effective Date: 01/01/2018
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Added: 42 CFR(c) and (g) language, previously in Policy Specific Documentation section
POLICY SPECFIC DOCUMENTATION:
Revised: ADMC eligible base codes to conform to the Condition of Payment PA Program
Added: Prior Authorization of Power Mobility Devices (PMD) Demonstration and Condition of Payment PA Program 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.

01/01/2017 R5 Revision Effective Date: 01/01/2017
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
42 CFR 410.38(c) and 42 CFR 410.38(g) language, K0013 billing instructions, Modifier instructions and ADMC eligible codes
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements Language Article
07/01/2016 R4 Revision Effective Date: 07/01/2016
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised Standard Language to add Statutory Prescription (Order) Requirements, revised Face to Face and ACA requirements - Effective 04/28/2016
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.
10/01/2015 R2 Revision Effective Date: 10/01/2015
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: HCPCS Narrative for E0986 and updated standard language documentation
10/01/2015 R1 Revision Effective Date: 10/01/2014
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Clarification: The face to face treating physician and prescribing physician requirements under ACA 6407 (Requirements effective 07/01/2013)
CODING GUIDELINES:
Clarification: E0986 is all inclusive

Associated Documents

Related National Coverage Documents
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
03/18/2021 01/01/2020 - N/A Currently in Effect You are here
03/07/2020 01/01/2020 - N/A Superseded View
01/03/2020 01/01/2020 - N/A Superseded View
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Keywords

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