Local Coverage Article

Wheelchair Seating - Policy Article

A52505

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Article ID
A52505
Article Title
Wheelchair Seating - Policy Article
Article Type
Article
Original Effective Date
10/01/2015
Revision Effective Date
10/01/2021
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”).

There is no separate payment for a solid insert (E0992) (see definition in Coding Guidelines) that is used with a seat or back cushion because a solid base is included in the allowance for a wheelchair seat or back cushion.

There is no separate payment for mounting hardware for a seat or back cushion.

There is no separate payment for a wheelchair seat or back cushion when it is used with a rollabout chair (E1031).

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 MODIFIER:

For a skin protection seat cushion (E2603, E2604, E2622, E2623), a KX modifier must be added to the code only if one of the following criteria (a), (b), or (c) is met:

  1. There is a past history of, or current, pressure ulcer in the area of contact with the seating surface (refer to the Group 1 codes in the ICD-10 code list section); or

  2. There is absent or impaired sensation in the area of contact with the seating surface due to one of the diagnoses listed as a covered diagnosis in the Group 2 ICD-10 code list section; or

  3. There is an inability to carry out a functional weight shift due to one of the diagnoses listed as a covered diagnosis in the Group 2 ICD-10 code list section.

For a positioning seat cushion (E2605, E2606), positioning back cushion (E2613, E2614, E2615, E2616, E2620, E2621), or positioning accessory (E0953, E0956, E0957, E0960), a KX modifier must be added to the code only if the beneficiary has significant postural asymmetries due to one of the diagnoses listed as a covered diagnosis in Group 2 or Group 3 of the ICD-10 code list section.

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

For a combination skin protection and positioning seat cushion (E2607, E2608, E2624, E2625), a KX modifier must be added to the code only if criterion (a) or (b) or (c) is met and criterion (d) is met:

  1. There is a past history of, or current, pressure ulcer in the area of contact with the seating surface (refer to the Group 1 codes in the ICD-10 code list section); or

  2. There is absent or impaired sensation in the area of contact with the seating surface due to one of the diagnoses listed as a covered diagnosis for skin protection cushions (refer to the Group 2 codes in the ICD-10 code list section); or

  3. There is an inability to carry out a functional weight shift due one of the diagnoses listed as a covered diagnosis for skin protection cushions (refer to the Group 2 codes in the ICD-10 code list section); and

  4. The beneficiary has significant postural asymmetries due to one of the diagnoses listed as a covered diagnosis for positioning cushions (refer to the Group 2 and Group 3 codes in the ICD-10 code list section).

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

  1. For E2609 or E2617, there is a comprehensive written evaluation by a licensed/certified medical professional, such as a PT or OT (who has no financial relationship with the supplier) which explains why a prefabricated seating system is not sufficient to meet the beneficiary’s seating and positioning needs; and

  2. For E2609, there is a past history of, or current, pressure ulcer in the area of contact with the seating surface; or

  3. For E2609, there is absent or impaired sensation in the area of contact with the seating surface or an inability to carry out a functional weight shift due to one of the diagnoses listed as a covered diagnosis for skin protection cushions (refer to the ICD-10 code list section); or

  4. For E2609 or E2617, the beneficiary has significant postural asymmetries due to one of the diagnoses listed as a covered diagnosis for positioning cushions (refer to the ICD-10 code list section).

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

GA, GY, AND GZ MODIFIERS:

For a cushion or positioning accessory that is used with a power mobility device (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 items.

For items provided with a manual wheelchair or power mobility device, if it is only needed for mobility outside the home, the GY modifier must be added to the codes for all items.

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

When there is an expectation of a medical necessity denial, suppliers must enter the GA modifier on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or the GZ modifier if they have not obtained a valid ABN.

If the GY modifier is used, the KX, GA, and GZ modifiers should not be used.

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

Miscellaneous

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

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

CODING GUIDELINES:

The following definitions of seat cushions include results of simulation testing or human subject testing. See the Testing Methodologies section for technical information about the required testing.

A general use seat cushion (E2601, E2602) is a prefabricated cushion, which has the following characteristics:

  1. It has the following minimum performance characteristics:
    1. Simulation tests demonstrate a loaded contour depth of at least 25mm with an overload deflection of at least 5 mm, or

    2. Human subject tests demonstrate an average peak pressure index that is less than 125% of that of a standard reference cushion within the area of the ischial tuberosities and sacrum/coccyx; and

  2. Following testing simulating 12 months of use:
    1. Simulation tests demonstrate an overload deflection of at least 5 mm, or

    2. Human subject tests demonstrate an average peak pressure index that is less than 125% of those of a standard reference cushion within the area of the ischial tuberosities and sacrum/coccyx; and

  3. It has a removable vapor permeable or waterproof cover or it has a waterproof surface; and

  4. The cushion and cover meet the minimum standards of the California Bulletin 117, California Bulletin 133, or equivalent (such as standards established by the American Society for Testing and Materials (ASTM), the Environmental Protection Agency (EPA), or other national or international standards agencies), for flame resistance; and

  5. It has a permanent label indicating the model and the manufacturer; and

  6. It has a warranty that provides for repair or full replacement if manufacturing defects are identified or the surface does not remain intact due to normal wear within 12 months.

 

A nonadjustable skin protection seat cushion (E2603, E2604) is a prefabricated cushion, which has the following characteristics:

  1. It has the following minimum performance characteristics:
    1. Simulation tests demonstrate a loaded contour depth of at least 40 mm with an overload deflection of at least 5 mm, or

    2. Human subject tests demonstrate an average peak pressure index that is less than 85% of that of a standard reference cushion within the area of the ischial tuberosities and sacrum/coccyx; and

  2. Following testing simulating 18 months of use:
    1. Simulation tests demonstrate an overload deflection of at least 5 mm, or

    2. Human subject tests demonstrate an average peak pressure index that is less than 85% of those of a standard reference cushion within the area of the ischial tuberosities and sacrum/coccyx; and

  3. It has a removable vapor permeable or waterproof cover or it has a waterproof surface; and

  4. The cushion and cover meet the minimum standards of the California Bulletin 117, California Bulletin 133, or equivalent (such as standards established by the ASTM, the EPA, or other national or international standards agencies), for flame resistance; and

  5. It has a permanent label indicating the model and the manufacturer; and

  6. It has a warranty that provides for repair or full replacement if manufacturing defects are identified or the surface does not remain intact due to normal wear within 18 months.


An adjustable skin protection seat cushion (E2622, E2623) has all the characteristics of a E2603 or E2604 cushion and is determined to be adjustable by the PDAC.

A positioning seat cushion (E2605, E2606) is a prefabricated cushion that has the following characteristics:

  1. It has the minimum structural features described in (a) or (b):

    1. The feature must be at least 25 mm in height in the pre-loaded state. It has two or more of the following:
      1. A pre-ischial bar or ridge which is placed anterior to the ischial tuberosities and prevents forward migration of the pelvis,

      2. Two lateral pelvic supports which are placed posterior to the trochanters and are intended to maintain the pelvis in a centered position in the seat and/or provide lateral stability to the pelvis,

      3. A medial thigh support which is placed in contact with the adductor region of the thigh and provides the prescribed amount of abduction and prevents adduction of the thighs,

      4. Two lateral thigh supports which are placed anterior to the trochanters and provide lateral stability to the lower extremities and prevent unwanted abduction of the thighs.

    2. It has two or more air compartments located in areas which address postural asymmetries, each of which must have a cell height of at least 50 mm, must allow the user to add or remove air, and must have a valve which retains the desired air volume; and

  2. It has the following minimum performance characteristics:

    1. Simulation tests demonstrate a loaded contour depth of at least 25mm with an overload deflection of at least 5 mm, or

    2. Human subject tests demonstrate an average peak pressure index that is less than 125% of that of a standard reference cushion within the area of the ischial tuberosities and sacrum/coccyx; and

  3. Following testing simulating 18 months of use:

    1. Simulation tests demonstrate an overload deflection of at least 5 mm, or

    2. Human subject tests demonstrate an average peak pressure index that is less than 125% of those of a standard reference cushion within the area of the ischial tuberosities and sacrum/coccyx; and

  4. It has a removable vapor permeable or waterproof cover or it has a waterproof surface; and

  5. The cushion and cover meet the minimum standards of the California Bulletin 117, California Bulletin 133, or equivalent (such as standards established by the ASTM, the EPA, or other national or international standards agencies), for flame resistance; and

  6. It has a permanent label indicating the model and the manufacturer; and

  7. It has a warranty that provides for repair or full replacement if manufacturing defects are identified or the surface does not remain intact due to normal wear within 18 months.

A positioning cushion may have materials or components that can be added or removed to help address orthopedic deformities or postural asymmetries. This definition includes cushions which have a planar surface but have positioning features within the cushion which are made of a firmer material than the surface material.

A nonadjustable skin protection and positioning seat cushion (E2607, E2608) is a prefabricated cushion which has the following characteristics:

  1. It has the minimum structural features described in (a) or (b):

    1. The feature must be at least 25 mm in height in the pre-loaded state. It has two or more of the following:
      1. A pre-ischial bar or ridge which is placed anterior to the ischial tuberosities and prevents forward migration of the pelvis,

      2. Two lateral pelvic supports which are placed posterior to the trochanters and are intended to maintain the pelvis in a centered position in the seat and/or provide lateral stability to the pelvis,

      3. A medial thigh support which is placed in contact with the adductor region of the thigh and provides the prescribed amount of abduction and prevents adduction of the thighs,

      4. Two lateral thigh supports which are placed anterior to the trochanters and provide lateral stability to the lower extremities and prevent unwanted abduction of the thighs.

    2. It has two or more air compartments located in areas which address postural asymmetries, each of which must have a cell height of at least 50 mm, must allow the user to add or remove air, and must have a valve which retains the desired air volume; and

  2. It has the following minimum performance characteristics:

    1. Simulation tests demonstrate a loaded contour depth of at least 40mm with an overload deflection of at least 5 mm, or

    2. Human subject tests demonstrate an average peak pressure index that is less than 85% of that of a standard reference cushion within the area of the ischial tuberosities and sacrum/coccyx; and

  3. Following testing simulating 18 months of use:

    1. Simulation tests demonstrate an overload deflection of at least 5 mm, or

    2. Human subject tests demonstrate an average peak pressure index that is less than 85% of those of a standard reference cushion within the area of the ischial tuberosities and sacrum/coccyx; and

  4. It has a removable vapor permeable or waterproof cover or it has a waterproof surface; and

  5. The cushion and cover meet the minimum standards of the California Bulletin 117, California Bulletin 133, or equivalent (such as standards established by the ASTM, the EPA, or other national or international standards agencies), for flame resistance; and

  6. It has a permanent label indicating the model and the manufacturer; and

  7. It has a warranty that provides for repair or full replacement if manufacturing defects are identified or the surface does not remain intact due to normal wear within 18 months.

This definition includes cushions which have a planar surface but have positioning features within the cushion which are made of a firmer material than the surface material.

An adjustable skin protection and positioning seat cushion (E2624, E2625) has all the characteristics of a E2607 or E2608 cushion and is determined to be adjustable by the PDAC. The adjustability feature only relates to the skin protection properties of the cushion.

Wheelchair cushions containing a fluid medium (air, gas, liquid, or gel) that have the capability for the immersion characteristics of the cushion to be altered by addition or removal of fluid will be considered adjustable. The adjustment may be in the manner of direct addition or removal of the fluid (e.g. add or remove air) or indirectly by addition or removal of packets of fluid.

Adjustment applies to the skin protection portion of the cushion's function only.

All cushions are considered to be adjustable up to the point of delivery to the beneficiary. Fitting of the cushion to the individual beneficiary may involve various forms of adjustment. Adjustable as applied here, requires that the procedure is capable of being performed by the beneficiary or caregiver using items supplied at the time of initial issue of the device in response to the beneficiary's need for more or less skin protection because of weight loss or gain or muscle tone changes.

A general use back cushion (E2611, E2612) is a prefabricated cushion, which has the following characteristics:

  1. It is planar or contoured; and

  2. It has a removable vapor permeable or waterproof cover or it has a waterproof surface; and

  3. The cushion and cover meet the minimum standards of the California Bulletin 117, California Bulletin 133, or equivalent (such as standards established by the ASTM, the EPA, or other national or international standards agencies), for flame resistance; and

  4. It has a permanent label indicating the model and the manufacturer; and

  5. It has a warranty that provides for repair or full replacement if manufacturing defects are identified or the surface does not remain intact due to normal wear within 12 months.

 

A positioning back cushion (E2613, E2614, E2615, E2616, E2620, E2621) is a prefabricated cushion which has the following characteristics:

  1. For codes E2613, E2614, E2615, E2616, there is at least 25 mm of posterior contour in the pre-loaded state. A posterior contour is a backward curve measured from a horizontal line in the midline of the cushion; and

  2. For posterior-lateral cushions (E2615, E2616) and for planar cushions with lateral supports (E2620, E2621), there is at least 75 mm of lateral contour in the pre-loaded state. A lateral contour is a backward curve measured from a horizontal line connecting the lateral extensions of the cushion; and

  3. For posterior pelvic cushions (E2613, E2614), there is mounting hardware that is adjustable for horizontal position, depth, and angle; and

  4. It has a removable vapor permeable or waterproof cover or it has a waterproof surface; and

  5. The cushion and cover meet the minimum standards of the California Bulletin 117, California Bulletin 133, or equivalent (such as standards established by the ASTM, the EPA, or other national or international standards agencies), for flame resistance; and

  6. It has a permanent label indicating the model and the manufacturer; and

  7. It has a warranty that provides for repair or full replacement if manufacturing defects are identified or the surface does not remain intact due to normal wear within 18 months.


Included in this definition are cushions which have a planar surface but have positioning features within the cushion which are made of a firmer material than the surface material.

A positioning back cushion may have materials or components that may be added or removed to help address orthopedic deformities or postural asymmetries.

A custom fabricated seat cushion (E2609) and a custom fabricated back cushion (E2617) are cushions that are individually made for a specific beneficiary starting with basic materials including:

  1. liquid foam or a block of foam and

  2. sheets of fabric or liquid coating material.

The cushion must be fabricated using molded-to-beneficiary-model technique, direct molded-to-beneficiary technique, CAD-CAM technology, or detailed measurements of the beneficiary used to create a configured cushion. The cushion must have structural features that significantly exceed the minimum requirements for a seat or back positioning cushion. The cushion must have a removable vapor permeable or waterproof cover or it must have a waterproof surface. A custom fabricated cushion may include certain prefabricated components (e.g., gel or multi-cellular air inserts); these components must not be billed separately. If a custom fabricated seat and back are integrated into a one-piece cushion, code as E2609 plus E2617.

If foam-in-place or other material is used to fit a substantially prefabricated cushion to an individual beneficiary, the cushion must be billed as a prefabricated cushion, not custom fabricated.

A powered wheelchair seat cushion (E2610) is a battery-powered, prefabricated cushion in which an air pump provides either sequential inflation or deflation of the air cells or a low interface pressure throughout the cushion. One type of powered seat cushion is an alternating pressure cushion.

Pediatric seating system codes E2291, E2292, E2293, E2294 may only be billed with pediatric wheelchair base codes.

A headrest extension (E0966) is a sling support for the head. Code E0955 describes any type of cushioned headrest.

A headrest (E0955) describes any type of cushioned headrest which may contain one or more cushions to position the head and fixed mounting hardware.

Lateral positioning items are used to provide lateral thigh or knee support (E0953) or lateral trunk or hip support (E0956). These are provided in a variety of shapes and sizes to suit the needs of the user.

The code for a seat or back cushion includes any rigid or semi-rigid base or posterior panel, respectively, that is an integral part of the cushion.

A solid insert is a separate rigid piece of wood or plastic which is inserted in the cover of a cushion to provide additional support. If a supplier chooses to bill separately for a solid insert used with a seat cushion use code E0992 whether it is a manual or a power wheelchair. Code A9900 must be used for a solid insert used with a back cushion.

A solid support base for a seat cushion is a rigid piece of plastic or other material which is attached with hardware to the seat frame of a wheelchair in place of a sling seat. A cushion is placed on top of the support base. Use code E2231 for a solid support base that is used with a manual wheelchair. A solid support base is included in the allowance for the power wheelchair codes. There should be no separate billing with power wheelchairs.

If a supplier chooses to bill separately for mounting hardware, either nonadjustable or adjustable, for a seat or back cushion or solid support base, code A9900 must be used.

The only products which may be billed using codes E2601, E2602, E2603, E2604, E2605, E2606, E2607, E2608, E2610, E2611, E2612, E2613, E2614, E2615, E2616, E2620, E2621, and E2622, E2623, E2624, E2625 and the only brand name products that may be billed using codes E2609 or E2617 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.

If the prefabricated seat cushion, prefabricated back cushion, or a brand name custom fabricated seat or back cushion has not received a written CVR from the PDAC or if the PDAC has reviewed and determined that the product does not meet the criteria for the code, then it must be billed with code K0669.

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.

Pediatric size positioning accessories are billed with the codes described in this policy. Codes E1025, E1026, E1027 (lateral thoracic and lateral/anterior supports) are invalid for claim submission.

Code E1028 (swingaway or removable mounting hardware upgrade) may be billed in addition to codes E0953, E0955, E0956, E0957. It must not be billed in addition to code E0960. It must not be used for mounting hardware related to a wheelchair seat cushion or back cushion code.

Wheelchair seat and back cushion codes are all-inclusive. Use of HCPCS code K0108 or any other HCPCS code to separately bill for added components such as the foam blocks, gel packs, air cells, or equivalent material is incorrect coding.

The right (RT) and left (LT) modifiers must be used when applicable. Effective for claims with dates of service (DOS) on or after 3/1/2019, when the same HCPCS code for bilateral items (left and right) is billed on the same DOS, 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 billed without modifiers RT and/or LT, or with RTLT on the same claim line and 2 UOS, will be rejected as incorrect coding.

TESTING METHODOLOGY

There are two testing methods that may be used to document wheelchair seat cushion criteria: the simulation method and the human subject method. Simulation tests are used to measure loaded contour depth and bottoming out. Human subject tests are used to measure peak interface pressure.

Simulation Test

Simulation tests measure loaded contour depth and bottoming out. They use standardized models of the human buttocks known as cushion-loading indenters (CLIs). There are two CLIs that are used for simulation testing, a 25 mm CLI and a 40 mm CLI. Specific design features of acceptable CLIs can be found on the PDAC web site.

Test method for determining 25 mm and 40 mm of contour depth:

  1. Place the test cushion on a flat, horizontal surface. Cushions with curved bases must be stable during contour measurement testing.

  2. Align the CLI so that it is centered from the sides of the cushion and so that the ischial tuberosities of the models are 11-15 cm from the rear edge of the cushion. The ischial tuberosity portion of the CLI should be aligned with the analogous portion of the test cushion.

  3. Load the CLI to 140 Newtons (31 pounds) & wait 5 minutes.

  4. Contact of the lateral buttons with the cushion indicates that the cushion has contoured to 25 or 40 mm depending on the CLI used - i.e., that it has passed the test for that trial.

  5. Repeat the test two times waiting 5 minutes between trials.


A cushion must pass the respective contour test during all trials to meet the minimum criteria specified in the cushion definition section.

Overload test method for measuring bottoming out:

  1. Record the height of the CLI from the horizontal surface at the end of the loaded contour depth test described above.

  2. Add 47 Newtons (10 pounds) to the CLI and record the height from the horizontal surface after 1 minute.

  3. Subtract the height at overload (#2) from the height at standard load (#1).

  4. Round the value in #3 to the nearest 5mm.

  5. Remove the overload weight and repeat the test twice, waiting 5 minutes between tests and measuring the height in #1 and #2 each time.

  6. Determine the median of the three values recorded in #4. This is the "overload deflection".

If the overload deflection is greater than or equal to 5mm, then the cushion is determined not to have bottomed out during the test.

Simulated use testing:

There must be simulation of 12 or 18 months of use of the cushion (depending on the cushion type - see Definitions section). Following simulated use, the measurements for loaded contour depth and overload as described above must be repeated.

Test report:

There must be a report of the tests which includes:

  1. The name and address of the facility performing the tests and the date(s) of the tests; and

  2. The manufacturer and brand name/number of the test cushion; and

  3. The weight of the cushion to the nearest 250 gm; and

  4. The width and length of the cushion; and

  5. The temperature and relative humidity of the room where the tests are conducted; and

  6. Identification of which CLI was used (25 mm or 40mm); and

  7. The results of the three loaded contour depth tests and the overload deflection test prior to simulated used testing; and

  8. A description of the method used to simulate cushion use; and

  9. A statement specifying the number of months of use that were simulated; and

  10. Measurements as described in #7 obtained after simulated use testing; and

  11. A statement attesting that the testing methodology described in this policy was followed; and

  12. The printed name and signature of the person performing or supervising the tests and the signature date.


Human Subject Tests

The ability to demonstrate that there is an important reduction in interface pressure in comparison with a standard reference cushion when tested with human subjects is the basis for this approach. Human subject tests must be performed by an entity that has received human subject testing approval from an Institutional Review Board approved by the US Department of Health and Human Services. Ten (10) wheelchair users must be studied, at least five of which must be clinically insensate on the body surface contacting the cushion.

Interface pressure measurements are taken with each subject seated on the cushion being tested as well as on a standardized reference cushion (see below). The measurements are obtained with a transducer placed on top of the cushion. Subjects must be seated on the cushion and interface pressure transducer for at least 60 seconds before data is collected. The subject should be positioned in their typical posture as determined by query and independent facility judgment. Three measurements are taken on each subject on each cushion separated by a complete unloading of the cushion for at least 60 seconds.

The standard reference cushion must be an uncovered 75 mm (± 5mm) thick high resiliency foam with a rated 25% indentation force deflection (IFD) equal to 45 pounds (density range of 2.6-2.9 pounds/cubic ft and IFD range of 40-49 pounds).

There must be a report of the tests which includes:

  1. The name and address of the facility performing the tests and the date(s) of the tests; and

  2. The manufacturer and brand name/number of the test cushion; and

  3. Information about the interface pressure measurement device utilized:

    1. Manufacturer and brand name

    2. Date of most recent calibration

    3. Percent error of measurement at 50 and 100 mm Hg pressure; and

  4. Actual 25% IFD and density of the reference cushion (obtained from the foam manufacturer or supplier) and actual thickness of the reference cushion; and

  5. Information on each subject (coding subjects to preserve confidentiality) including:

    1. Age

    2. Height

    3. Weight

    4. Disability

    5. Buttocks sensation status; and

  6. Interface pressure measurements for each subject on the test cushion and on the reference cushion:

    1. If the transducer covers the entire seating area, the entire map showing the pressure in each cell must be submitted. The anatomical locations (as determined by palpation) of the right and left ischial tuberosities and the sacrum/coccyx must be identified on each map. (Data can be submitted as a hard copy map or utilizing the device software.) or,

    2. If the transducer only covers a portion of the seat surface, measurements must be taken at the following three locations (as determined by palpation): right and left ischial tuberosities and sacrum/coccyx. The report must identify the anatomical location of each set of measurements. The report must list the pressure in each cell at each specified location. The values for the three locations are considered a single test; and

  7. The Peak Pressure Index (PPI) for each subject on the test cushion and on the reference cushion. The PPI is determined as follows:

    1. For each test, identify the cell in the sacro-ischial zone with the highest pressure;

    2. Determine the greatest sum of pressures in the identified cell and the adjacent cells in a 9-10 square centimeter area. If there are multiple cells with the same "highest pressure", consider all of them in the determination of the "greatest sum". [Note: A 3 cm by 3 cm square or a 3.5 cm diameter circular area are examples of a 9-10 sq cm area. For example, if using an interface pressure sensing array with a cell size of 1 sq cm, 9 cells (a 3 by 3 array) are used and if using a sensing array with a cell size of 2.5 sq cm, 4 cells (a 2 by 2 array) are used.];

    3. For each test, calculate the average of the cells with the greatest sum of pressures;

    4. Calculate the average of the results obtained in step (c) for the 3 tests on the test cushion and the 3 tests on the reference cushion. These values are the PPIs for the subject on each cushion; and

  8. A statement attesting that the testing methodology described in this policy was followed; and

  9. The printed name and signature of the person performing or supervising the tests and the signature date.


To determine if the minimum performance characteristics specified in the Definitions section for a particular type of cushion have been met, calculate the average PPI for the 10 subjects on the test cushion and the average PPI for the 10 subjects on the reference cushion. Divide the average PPI on the test cushion by the average PPI on the reference cushion and multiply the value by 100 to give the percentage comparison of Peak Pressure Indexes. If the comparative pressures are less than the specified values (125% or 85% depending on the cushion), then the minimum performance characteristics with respect to pressure have been met.

Coding Information

CPT/HCPCS Codes

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph

The presence of an ICD-10 code listed in this section is not sufficient by itself to assure coverage. Refer to the LCD section on "Coverage Indications, Limitations, and/or Medical Necessity" for other coverage criteria and payment information.

The instructions below summarize the coverage criteria for the wheelchair seating options. For further description, please refer to the LCD section on "Coverage Indications, Limitations, and/or Medical Necessity." They apply to the diagnoses in Groups 1, 2, 3, and 4.

For skin protection items (HCPCS codes E2603, E2604, E2622, E2623) one diagnosis code from either Group 1 or Group 2.

For combination skin protection and positioning items (HCPCS codes E2607, E2608, E2624, E2625), use one of the following (either 1 or 2):
(1) one diagnosis code from Group 1 and one diagnosis code from Group 3 (total of 2 diagnosis codes); or,
(2) one diagnosis code from Group 2.

The presence of an ICD-10 code listed in this section is not sufficient by itself to assure coverage. Refer to the LCD section on "Coverage Indications, Limitations, and/or Medical Necessity" for other coverage criteria and payment information.

Skin protection criterion 2a diagnosis codes (pressure ulcer codes)

Group 1 Codes
CodeDescription
L89.130 Pressure ulcer of right lower back, unstageable
L89.131 Pressure ulcer of right lower back, stage 1
L89.132 Pressure ulcer of right lower back, stage 2
L89.133 Pressure ulcer of right lower back, stage 3
L89.134 Pressure ulcer of right lower back, stage 4
L89.140 Pressure ulcer of left lower back, unstageable
L89.141 Pressure ulcer of left lower back, stage 1
L89.142 Pressure ulcer of left lower back, stage 2
L89.143 Pressure ulcer of left lower back, stage 3
L89.144 Pressure ulcer of left lower back, stage 4
L89.150 Pressure ulcer of sacral region, unstageable
L89.151 Pressure ulcer of sacral region, stage 1
L89.152 Pressure ulcer of sacral region, stage 2
L89.153 Pressure ulcer of sacral region, stage 3
L89.154 Pressure ulcer of sacral region, stage 4
L89.200 Pressure ulcer of unspecified hip, unstageable
L89.201 Pressure ulcer of unspecified hip, stage 1
L89.202 Pressure ulcer of unspecified hip, stage 2
L89.203 Pressure ulcer of unspecified hip, stage 3
L89.204 Pressure ulcer of unspecified hip, stage 4
L89.210 Pressure ulcer of right hip, unstageable
L89.211 Pressure ulcer of right hip, stage 1
L89.212 Pressure ulcer of right hip, stage 2
L89.213 Pressure ulcer of right hip, stage 3
L89.214 Pressure ulcer of right hip, stage 4
L89.220 Pressure ulcer of left hip, unstageable
L89.221 Pressure ulcer of left hip, stage 1
L89.222 Pressure ulcer of left hip, stage 2
L89.223 Pressure ulcer of left hip, stage 3
L89.224 Pressure ulcer of left hip, stage 4
L89.300 Pressure ulcer of unspecified buttock, unstageable
L89.301 Pressure ulcer of unspecified buttock, stage 1
L89.302 Pressure ulcer of unspecified buttock, stage 2
L89.303 Pressure ulcer of unspecified buttock, stage 3
L89.304 Pressure ulcer of unspecified buttock, stage 4
L89.310 Pressure ulcer of right buttock, unstageable
L89.311 Pressure ulcer of right buttock, stage 1
L89.312 Pressure ulcer of right buttock, stage 2
L89.313 Pressure ulcer of right buttock, stage 3
L89.314 Pressure ulcer of right buttock, stage 4
L89.320 Pressure ulcer of left buttock, unstageable
L89.321 Pressure ulcer of left buttock, stage 1
L89.322 Pressure ulcer of left buttock, stage 2
L89.323 Pressure ulcer of left buttock, stage 3
L89.324 Pressure ulcer of left buttock, stage 4
L89.41 Pressure ulcer of contiguous site of back, buttock and hip, stage 1
L89.42 Pressure ulcer of contiguous site of back, buttock and hip, stage 2
L89.43 Pressure ulcer of contiguous site of back, buttock and hip, stage 3
L89.44 Pressure ulcer of contiguous site of back, buttock and hip, stage 4
L89.45 Pressure ulcer of contiguous site of back, buttock and hip, unstageable

Group 2

Group 2 Paragraph

The instructions below summarize the coverage criteria for the wheelchair seating options. For further description, please refer to the LCD section on "Coverage Indications, Limitations, and/or Medical Necessity."

For skin protection items (HCPCS codes E2603, E2604, E2622, E2623) one diagnosis code from either Group 1 or Group 2.

For positioning items (HCPCS codes E0953, E0956, E0957, E0960, E2605, E2606, E2613, E2614, E2615, E2616, E2617, E2620, and E2621) one diagnosis code from either Group 2 or Group 3.

For combination skin protection and positioning items (HCPCS codes E2607, E2608, E2624, E2625), use one of the following (either 1 or 2):
(1) one diagnosis code from Group 1 and one diagnosis code from Group 3 (total of 2 diagnosis codes); or,
(2) one diagnosis code from Group 2.

The presence of an ICD-10 code listed in this section is not sufficient by itself to assure coverage. Refer to the LCD section on "Coverage Indications, Limitations, and/or Medical Necessity" for other coverage criteria and payment information.

Skin Protection criterion 2b diagnosis codes and Positioning criterion 2a diagnosis codes

Group 2 Codes
CodeDescription
B91 Sequelae of poliomyelitis
E75.00 GM2 gangliosidosis, unspecified
E75.01 Sandhoff disease
E75.02 Tay-Sachs disease
E75.09 Other GM2 gangliosidosis
E75.10 Unspecified gangliosidosis
E75.11 Mucolipidosis IV
E75.19 Other gangliosidosis
E75.23 Krabbe disease
E75.25 Metachromatic leukodystrophy
E75.29 Other sphingolipidosis
E75.4 Neuronal ceroid lipofuscinosis
F84.2 Rett's syndrome
G04.1 Tropical spastic paraplegia
G04.82 Acute flaccid myelitis
G04.89 Other myelitis
G10 Huntington's disease
G11.0 Congenital nonprogressive ataxia
G11.10 Early-onset cerebellar ataxia, unspecified
G11.11 Friedreich ataxia
G11.19 Other early-onset cerebellar ataxia
G11.2 Late-onset cerebellar ataxia
G11.3 Cerebellar ataxia with defective DNA repair
G11.4 Hereditary spastic paraplegia
G11.8 Other hereditary ataxias
G11.9 Hereditary ataxia, unspecified
G12.0 Infantile spinal muscular atrophy, type I [Werdnig-Hoffman]
G12.1 Other inherited spinal muscular atrophy
G12.20 Motor neuron disease, unspecified
G12.21 Amyotrophic lateral sclerosis
G12.23 Primary lateral sclerosis
G12.24 Familial motor neuron disease
G12.25 Progressive spinal muscle atrophy
G12.29 Other motor neuron disease
G12.8 Other spinal muscular atrophies and related syndromes
G12.9 Spinal muscular atrophy, unspecified
G14 Postpolio syndrome
G20 Parkinson's disease
G21.4 Vascular parkinsonism
G24.1 Genetic torsion dystonia
G30.0 Alzheimer's disease with early onset
G30.1 Alzheimer's disease with late onset
G30.8 Other Alzheimer's disease
G30.9 Alzheimer's disease, unspecified
G31.81 Alpers disease
G31.82 Leigh's disease
G32.0 Subacute combined degeneration of spinal cord in diseases classified elsewhere
G32.81 Cerebellar ataxia in diseases classified elsewhere
G32.89 Other specified degenerative disorders of nervous system in diseases classified elsewhere
G35 Multiple sclerosis
G36.0 Neuromyelitis optica [Devic]
G36.1 Acute and subacute hemorrhagic leukoencephalitis [Hurst]
G36.8 Other specified acute disseminated demyelination
G36.9 Acute disseminated demyelination, unspecified
G37.0 Diffuse sclerosis of central nervous system
G37.1 Central demyelination of corpus callosum
G37.2 Central pontine myelinolysis
G37.3 Acute transverse myelitis in demyelinating disease of central nervous system
G37.4 Subacute necrotizing myelitis of central nervous system
G37.5 Concentric sclerosis [Balo] of central nervous system
G37.8 Other specified demyelinating diseases of central nervous system
G37.9 Demyelinating disease of central nervous system, unspecified
G61.0 Guillain-Barre syndrome
G71.00 Muscular dystrophy, unspecified
G71.01 Duchenne or Becker muscular dystrophy
G71.02 Facioscapulohumeral muscular dystrophy
G71.09 Other specified muscular dystrophies
G71.11 Myotonic muscular dystrophy
G71.20 Congenital myopathy, unspecified
G71.21 Nemaline myopathy
G71.220 X-linked myotubular myopathy
G71.228 Other centronuclear myopathy
G71.29 Other congenital myopathy
G80.0 Spastic quadriplegic cerebral palsy
G80.1 Spastic diplegic cerebral palsy
G80.2 Spastic hemiplegic cerebral palsy
G80.3 Athetoid cerebral palsy
G80.4 Ataxic cerebral palsy
G80.8 Other cerebral palsy
G80.9 Cerebral palsy, unspecified
G81.00 Flaccid hemiplegia affecting unspecified side
G81.01 Flaccid hemiplegia affecting right dominant side
G81.02 Flaccid hemiplegia affecting left dominant side
G81.03 Flaccid hemiplegia affecting right nondominant side
G81.04 Flaccid hemiplegia affecting left nondominant side
G81.10 Spastic hemiplegia affecting unspecified side
G81.11 Spastic hemiplegia affecting right dominant side
G81.12 Spastic hemiplegia affecting left dominant side
G81.13 Spastic hemiplegia affecting right nondominant side
G81.14 Spastic hemiplegia affecting left nondominant side
G81.90 Hemiplegia, unspecified affecting unspecified side
G81.91 Hemiplegia, unspecified affecting right dominant side
G81.92 Hemiplegia, unspecified affecting left dominant side
G81.93 Hemiplegia, unspecified affecting right nondominant side
G81.94 Hemiplegia, unspecified affecting left nondominant side
G82.20 Paraplegia, unspecified
G82.21 Paraplegia, complete
G82.22 Paraplegia, incomplete
G82.50 Quadriplegia, unspecified
G82.51 Quadriplegia, C1-C4 complete
G82.52 Quadriplegia, C1-C4 incomplete
G82.53 Quadriplegia, C5-C7 complete
G82.54 Quadriplegia, C5-C7 incomplete
G93.89 Other specified disorders of brain
G93.9 Disorder of brain, unspecified
G94 Other disorders of brain in diseases classified elsewhere
G95.0 Syringomyelia and syringobulbia
G95.11 Acute infarction of spinal cord (embolic) (nonembolic)
G95.19 Other vascular myelopathies
G99.2 Myelopathy in diseases classified elsewhere
I69.051 Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right dominant side
I69.052 Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left dominant side
I69.053 Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right non-dominant side
I69.054 Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non-dominant side
I69.059 Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting unspecified side
I69.151 Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side
I69.152 Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left dominant side
I69.153 Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right non-dominant side
I69.154 Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side
I69.159 Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting unspecified side
I69.251 Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side
I69.252 Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting left dominant side
I69.253 Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right non-dominant side
I69.254 Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting left non-dominant side
I69.259 Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting unspecified side
I69.351 Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side
I69.352 Hemiplegia and hemiparesis following cerebral infarction affecting left dominant side
I69.353 Hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side
I69.354 Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side
I69.359 Hemiplegia and hemiparesis following cerebral infarction affecting unspecified side
I69.851 Hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side
I69.852 Hemiplegia and hemiparesis following other cerebrovascular disease affecting left dominant side
I69.853 Hemiplegia and hemiparesis following other cerebrovascular disease affecting right non-dominant side
I69.854 Hemiplegia and hemiparesis following other cerebrovascular disease affecting left non-dominant side
I69.859 Hemiplegia and hemiparesis following other cerebrovascular disease affecting unspecified side
I69.951 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side
I69.952 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side
I69.953 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right non-dominant side
I69.954 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side
I69.959 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side
M62.3 Immobility syndrome (paraplegic)
M62.89 Other specified disorders of muscle
Q05.0 Cervical spina bifida with hydrocephalus
Q05.1 Thoracic spina bifida with hydrocephalus
Q05.2 Lumbar spina bifida with hydrocephalus
Q05.3 Sacral spina bifida with hydrocephalus
Q05.4 Unspecified spina bifida with hydrocephalus
Q05.5 Cervical spina bifida without hydrocephalus
Q05.6 Thoracic spina bifida without hydrocephalus
Q05.7 Lumbar spina bifida without hydrocephalus
Q05.8 Sacral spina bifida without hydrocephalus
Q05.9 Spina bifida, unspecified
Q07.00 Arnold-Chiari syndrome without spina bifida or hydrocephalus
Q07.01 Arnold-Chiari syndrome with spina bifida
Q07.02 Arnold-Chiari syndrome with hydrocephalus
Q07.03 Arnold-Chiari syndrome with spina bifida and hydrocephalus
Q67.8 Other congenital deformities of chest
Q68.1 Congenital deformity of finger(s) and hand
Q74.3 Arthrogryposis multiplex congenita
Q78.0 Osteogenesis imperfecta

Group 3

Group 3 Paragraph

The instructions below summarize the coverage criteria for the wheelchair seating options. For further description, please refer to the LCD section on "Coverage Indications, Limitations, and/or Medical Necessity."

For positioning items (HCPCS codes E0953, E0956, E0957, E0960, E2605, E2606, E2613, E2614, E2615, E2616, E2617, E2620, and E2621) one diagnosis code from either Group 2 or Group 3.

For combination skin protection and positioning items (HCPCS codes E2607, E2608, E2624, E2625), use one of the following (either 1 or 2):
(1) one diagnosis code from Group 1 and one diagnosis code from Group 3 (total of 2 diagnosis codes); or,
(2) one diagnosis code from Group 2.

The presence of an ICD-10 code listed in this section is not sufficient by itself to assure coverage. Refer to the LCD section on "Coverage Indications, Limitations, and/or Medical Necessity" for other coverage criteria and payment information.

Positioning Criterion 2b diagnosis codes

Group 3 Codes
CodeDescription
G83.10 Monoplegia of lower limb affecting unspecified side
G83.11 Monoplegia of lower limb affecting right dominant side
G83.12 Monoplegia of lower limb affecting left dominant side
G83.13 Monoplegia of lower limb affecting right nondominant side
G83.14 Monoplegia of lower limb affecting left nondominant side
I69.041 Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting right dominant side
I69.042 Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting left dominant side
I69.043 Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting right non-dominant side
I69.044 Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting left non-dominant side
I69.049 Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting unspecified side
I69.141 Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting right dominant side
I69.142 Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting left dominant side
I69.143 Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting right non-dominant side
I69.144 Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting left non-dominant side
I69.149 Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting unspecified side
I69.241 Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting right dominant side
I69.242 Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting left dominant side
I69.243 Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting right non-dominant side
I69.244 Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting left non-dominant side
I69.249 Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting unspecified side
I69.341 Monoplegia of lower limb following cerebral infarction affecting right dominant side
I69.342 Monoplegia of lower limb following cerebral infarction affecting left dominant side
I69.343 Monoplegia of lower limb following cerebral infarction affecting right non-dominant side
I69.344 Monoplegia of lower limb following cerebral infarction affecting left non-dominant side
I69.349 Monoplegia of lower limb following cerebral infarction affecting unspecified side
I69.841 Monoplegia of lower limb following other cerebrovascular disease affecting right dominant side
I69.842 Monoplegia of lower limb following other cerebrovascular disease affecting left dominant side
I69.843 Monoplegia of lower limb following other cerebrovascular disease affecting right non-dominant side
I69.844 Monoplegia of lower limb following other cerebrovascular disease affecting left non-dominant side
I69.849 Monoplegia of lower limb following other cerebrovascular disease affecting unspecified side
I69.941 Monoplegia of lower limb following unspecified cerebrovascular disease affecting right dominant side
I69.942 Monoplegia of lower limb following unspecified cerebrovascular disease affecting left dominant side
I69.943 Monoplegia of lower limb following unspecified cerebrovascular disease affecting right non-dominant side
I69.944 Monoplegia of lower limb following unspecified cerebrovascular disease affecting left non-dominant side
I69.949 Monoplegia of lower limb following unspecified cerebrovascular disease affecting unspecified side
Q78.0 Osteogenesis imperfecta
S78.011A Complete traumatic amputation at right hip joint, initial encounter
S78.011D Complete traumatic amputation at right hip joint, subsequent encounter
S78.011S Complete traumatic amputation at right hip joint, sequela
S78.012A Complete traumatic amputation at left hip joint, initial encounter
S78.012D Complete traumatic amputation at left hip joint, subsequent encounter
S78.012S Complete traumatic amputation at left hip joint, sequela
S78.019A Complete traumatic amputation at unspecified hip joint, initial encounter
S78.019D Complete traumatic amputation at unspecified hip joint, subsequent encounter
S78.019S Complete traumatic amputation at unspecified hip joint, sequela
S78.021A Partial traumatic amputation at right hip joint, initial encounter
S78.021D Partial traumatic amputation at right hip joint, subsequent encounter
S78.021S Partial traumatic amputation at right hip joint, sequela
S78.022A Partial traumatic amputation at left hip joint, initial encounter
S78.022D Partial traumatic amputation at left hip joint, subsequent encounter
S78.022S Partial traumatic amputation at left hip joint, sequela
S78.029A Partial traumatic amputation at unspecified hip joint, initial encounter
S78.029D Partial traumatic amputation at unspecified hip joint, subsequent encounter
S78.029S Partial traumatic amputation at unspecified hip joint, sequela
S78.111A Complete traumatic amputation at level between right hip and knee, initial encounter
S78.111D Complete traumatic amputation at level between right hip and knee, subsequent encounter
S78.111S Complete traumatic amputation at level between right hip and knee, sequela
S78.112A Complete traumatic amputation at level between left hip and knee, initial encounter
S78.112D Complete traumatic amputation at level between left hip and knee, subsequent encounter
S78.112S Complete traumatic amputation at level between left hip and knee, sequela
S78.119A Complete traumatic amputation at level between unspecified hip and knee, initial encounter
S78.119D Complete traumatic amputation at level between unspecified hip and knee, subsequent encounter
S78.119S Complete traumatic amputation at level between unspecified hip and knee, sequela
S78.121A Partial traumatic amputation at level between right hip and knee, initial encounter
S78.121D Partial traumatic amputation at level between right hip and knee, subsequent encounter
S78.121S Partial traumatic amputation at level between right hip and knee, sequela
S78.122A Partial traumatic amputation at level between left hip and knee, initial encounter
S78.122D Partial traumatic amputation at level between left hip and knee, subsequent encounter
S78.122S Partial traumatic amputation at level between left hip and knee, sequela
S78.129A Partial traumatic amputation at level between unspecified hip and knee, initial encounter
S78.129D Partial traumatic amputation at level between unspecified hip and knee, subsequent encounter
S78.129S Partial traumatic amputation at level between unspecified hip and knee, sequela
S78.911A Complete traumatic amputation of right hip and thigh, level unspecified, initial encounter
S78.911D Complete traumatic amputation of right hip and thigh, level unspecified, subsequent encounter
S78.911S Complete traumatic amputation of right hip and thigh, level unspecified, sequela
S78.912A Complete traumatic amputation of left hip and thigh, level unspecified, initial encounter
S78.912D Complete traumatic amputation of left hip and thigh, level unspecified, subsequent encounter
S78.912S Complete traumatic amputation of left hip and thigh, level unspecified, sequela
S78.919A Complete traumatic amputation of unspecified hip and thigh, level unspecified, initial encounter
S78.919D Complete traumatic amputation of unspecified hip and thigh, level unspecified, subsequent encounter
S78.919S Complete traumatic amputation of unspecified hip and thigh, level unspecified, sequela
S78.921A Partial traumatic amputation of right hip and thigh, level unspecified, initial encounter
S78.921D Partial traumatic amputation of right hip and thigh, level unspecified, subsequent encounter
S78.921S Partial traumatic amputation of right hip and thigh, level unspecified, sequela
S78.922A Partial traumatic amputation of left hip and thigh, level unspecified, initial encounter
S78.922D Partial traumatic amputation of left hip and thigh, level unspecified, subsequent encounter
S78.922S Partial traumatic amputation of left hip and thigh, level unspecified, sequela
S78.929A Partial traumatic amputation of unspecified hip and thigh, level unspecified, initial encounter
S78.929D Partial traumatic amputation of unspecified hip and thigh, level unspecified, subsequent encounter
S78.929S Partial traumatic amputation of unspecified hip and thigh, level unspecified, sequela
S88.011A Complete traumatic amputation at knee level, right lower leg, initial encounter
S88.011D Complete traumatic amputation at knee level, right lower leg, subsequent encounter
S88.011S Complete traumatic amputation at knee level, right lower leg, sequela
S88.012A Complete traumatic amputation at knee level, left lower leg, initial encounter
S88.012D Complete traumatic amputation at knee level, left lower leg, subsequent encounter
S88.012S Complete traumatic amputation at knee level, left lower leg, sequela
S88.019A Complete traumatic amputation at knee level, unspecified lower leg, initial encounter
S88.019D Complete traumatic amputation at knee level, unspecified lower leg, subsequent encounter
S88.019S Complete traumatic amputation at knee level, unspecified lower leg, sequela
S88.021A Partial traumatic amputation at knee level, right lower leg, initial encounter
S88.021D Partial traumatic amputation at knee level, right lower leg, subsequent encounter
S88.021S Partial traumatic amputation at knee level, right lower leg, sequela
S88.022A Partial traumatic amputation at knee level, left lower leg, initial encounter
S88.022D Partial traumatic amputation at knee level, left lower leg, subsequent encounter
S88.022S Partial traumatic amputation at knee level, left lower leg, sequela
S88.029A Partial traumatic amputation at knee level, unspecified lower leg, initial encounter
S88.029D Partial traumatic amputation at knee level, unspecified lower leg, subsequent encounter
S88.029S Partial traumatic amputation at knee level, unspecified lower leg, sequela
S88.911A Complete traumatic amputation of right lower leg, level unspecified, initial encounter
S88.911D Complete traumatic amputation of right lower leg, level unspecified, subsequent encounter
S88.911S Complete traumatic amputation of right lower leg, level unspecified, sequela
S88.912A Complete traumatic amputation of left lower leg, level unspecified, initial encounter
S88.912D Complete traumatic amputation of left lower leg, level unspecified, subsequent encounter
S88.912S Complete traumatic amputation of left lower leg, level unspecified, sequela
S88.919A Complete traumatic amputation of unspecified lower leg, level unspecified, initial encounter
S88.919D Complete traumatic amputation of unspecified lower leg, level unspecified, subsequent encounter
S88.919S Complete traumatic amputation of unspecified lower leg, level unspecified, sequela
S88.921A Partial traumatic amputation of right lower leg, level unspecified, initial encounter
S88.921D Partial traumatic amputation of right lower leg, level unspecified, subsequent encounter
S88.921S Partial traumatic amputation of right lower leg, level unspecified, sequela
S88.922A Partial traumatic amputation of left lower leg, level unspecified, initial encounter
S88.922D Partial traumatic amputation of left lower leg, level unspecified, subsequent encounter
S88.922S Partial traumatic amputation of left lower leg, level unspecified, sequela
S88.929A Partial traumatic amputation of unspecified lower leg, level unspecified, initial encounter
S88.929D Partial traumatic amputation of unspecified lower leg, level unspecified, subsequent encounter
S88.929S Partial traumatic amputation of unspecified lower leg, level unspecified, sequela
Z89.511 Acquired absence of right leg below knee
Z89.512 Acquired absence of left leg below knee
Z89.519 Acquired absence of unspecified leg below knee
Z89.611 Acquired absence of right leg above knee
Z89.612 Acquired absence of left leg above knee
Z89.619 Acquired absence of unspecified leg above knee
Z89.621 Acquired absence of right hip joint
Z89.622 Acquired absence of left hip joint
Z89.629 Acquired absence of unspecified hip joint

Group 4

Group 4 Paragraph

The instructions below summarize the coverage criteria for the wheelchair seating options. For further description, please refer to the LCD section on "Coverage Indications, Limitations, and/or Medical Necessity."

The presence of an ICD-10 code listed in this section is not sufficient by itself to assure coverage. Refer to the LCD section on "Coverage Indications, Limitations, and/or Medical Necessity" for other coverage criteria and payment information.

For HCPCS code E2609 custom fabricated seat cushions:

Group 4 Codes
CodeDescription
B91 Sequelae of poliomyelitis
E75.00 GM2 gangliosidosis, unspecified
E75.01 Sandhoff disease
E75.02 Tay-Sachs disease
E75.09 Other GM2 gangliosidosis
E75.10 Unspecified gangliosidosis
E75.11 Mucolipidosis IV
E75.19 Other gangliosidosis
E75.23 Krabbe disease
E75.25 Metachromatic leukodystrophy
E75.29 Other sphingolipidosis
E75.4 Neuronal ceroid lipofuscinosis
F84.2 Rett's syndrome
G04.1 Tropical spastic paraplegia
G04.82 Acute flaccid myelitis
G04.89 Other myelitis
G10 Huntington's disease
G11.0 Congenital nonprogressive ataxia
G11.10 Early-onset cerebellar ataxia, unspecified
G11.11 Friedreich ataxia
G11.19 Other early-onset cerebellar ataxia
G11.2 Late-onset cerebellar ataxia
G11.3 Cerebellar ataxia with defective DNA repair
G11.4 Hereditary spastic paraplegia
G11.8 Other hereditary ataxias
G11.9 Hereditary ataxia, unspecified
G12.0 Infantile spinal muscular atrophy, type I [Werdnig-Hoffman]
G12.1 Other inherited spinal muscular atrophy
G12.20 Motor neuron disease, unspecified
G12.21 Amyotrophic lateral sclerosis
G12.23 Primary lateral sclerosis
G12.24 Familial motor neuron disease
G12.25 Progressive spinal muscle atrophy
G12.29 Other motor neuron disease
G12.8 Other spinal muscular atrophies and related syndromes
G12.9 Spinal muscular atrophy, unspecified
G14 Postpolio syndrome
G20 Parkinson's disease
G21.4 Vascular parkinsonism
G24.1 Genetic torsion dystonia
G30.0 Alzheimer's disease with early onset
G30.1 Alzheimer's disease with late onset
G30.8 Other Alzheimer's disease
G30.9 Alzheimer's disease, unspecified
G31.81 Alpers disease
G31.82 Leigh's disease
G32.0 Subacute combined degeneration of spinal cord in diseases classified elsewhere
G32.81 Cerebellar ataxia in diseases classified elsewhere
G32.89 Other specified degenerative disorders of nervous system in diseases classified elsewhere
G35 Multiple sclerosis
G36.0 Neuromyelitis optica [Devic]
G36.1 Acute and subacute hemorrhagic leukoencephalitis [Hurst]
G36.8 Other specified acute disseminated demyelination
G36.9 Acute disseminated demyelination, unspecified
G37.0 Diffuse sclerosis of central nervous system
G37.1 Central demyelination of corpus callosum
G37.2 Central pontine myelinolysis
G37.3 Acute transverse myelitis in demyelinating disease of central nervous system
G37.4 Subacute necrotizing myelitis of central nervous system
G37.5 Concentric sclerosis [Balo] of central nervous system
G37.8 Other specified demyelinating diseases of central nervous system
G37.9 Demyelinating disease of central nervous system, unspecified
G61.0 Guillain-Barre syndrome
G71.00 Muscular dystrophy, unspecified
G71.01 Duchenne or Becker muscular dystrophy
G71.02 Facioscapulohumeral muscular dystrophy
G71.09 Other specified muscular dystrophies
G71.11 Myotonic muscular dystrophy
G71.20 Congenital myopathy, unspecified
G71.21 Nemaline myopathy
G71.220 X-linked myotubular myopathy
G71.228 Other centronuclear myopathy
G71.29 Other congenital myopathy
G80.0 Spastic quadriplegic cerebral palsy
G80.1 Spastic diplegic cerebral palsy
G80.2 Spastic hemiplegic cerebral palsy
G80.3 Athetoid cerebral palsy
G80.4 Ataxic cerebral palsy
G80.8 Other cerebral palsy
G80.9 Cerebral palsy, unspecified
G81.00 Flaccid hemiplegia affecting unspecified side
G81.01 Flaccid hemiplegia affecting right dominant side
G81.02 Flaccid hemiplegia affecting left dominant side
G81.03 Flaccid hemiplegia affecting right nondominant side
G81.04 Flaccid hemiplegia affecting left nondominant side
G81.10 Spastic hemiplegia affecting unspecified side
G81.11 Spastic hemiplegia affecting right dominant side
G81.12 Spastic hemiplegia affecting left dominant side
G81.13 Spastic hemiplegia affecting right nondominant side
G81.14 Spastic hemiplegia affecting left nondominant side
G81.90 Hemiplegia, unspecified affecting unspecified side
G81.91 Hemiplegia, unspecified affecting right dominant side
G81.92 Hemiplegia, unspecified affecting left dominant side
G81.93 Hemiplegia, unspecified affecting right nondominant side
G81.94 Hemiplegia, unspecified affecting left nondominant side
G82.20 Paraplegia, unspecified
G82.21 Paraplegia, complete
G82.22 Paraplegia, incomplete
G82.50 Quadriplegia, unspecified
G82.51 Quadriplegia, C1-C4 complete
G82.52 Quadriplegia, C1-C4 incomplete
G82.53 Quadriplegia, C5-C7 complete
G82.54 Quadriplegia, C5-C7 incomplete
G83.10 Monoplegia of lower limb affecting unspecified side
G83.11 Monoplegia of lower limb affecting right dominant side
G83.12 Monoplegia of lower limb affecting left dominant side
G83.13 Monoplegia of lower limb affecting right nondominant side
G83.14 Monoplegia of lower limb affecting left nondominant side
G93.89 Other specified disorders of brain
G93.9 Disorder of brain, unspecified
G94 Other disorders of brain in diseases classified elsewhere
G95.0 Syringomyelia and syringobulbia
G95.11 Acute infarction of spinal cord (embolic) (nonembolic)
G95.19 Other vascular myelopathies
G99.2 Myelopathy in diseases classified elsewhere
I69.041 Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting right dominant side
I69.042 Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting left dominant side
I69.043 Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting right non-dominant side
I69.044 Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting left non-dominant side
I69.049 Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting unspecified side
I69.051 Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right dominant side
I69.052 Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left dominant side
I69.053 Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right non-dominant side
I69.054 Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non-dominant side
I69.059 Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting unspecified side
I69.141 Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting right dominant side
I69.142 Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting left dominant side
I69.143 Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting right non-dominant side
I69.144 Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting left non-dominant side
I69.149 Monoplegia of lower limb following nontraumatic intracerebral hemorrhage affecting unspecified side
I69.151 Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side
I69.152 Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left dominant side
I69.153 Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right non-dominant side
I69.154 Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side
I69.159 Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting unspecified side
I69.241 Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting right dominant side
I69.242 Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting left dominant side
I69.243 Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting right non-dominant side
I69.244 Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting left non-dominant side
I69.249 Monoplegia of lower limb following other nontraumatic intracranial hemorrhage affecting unspecified side
I69.251 Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side
I69.252 Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting left dominant side
I69.253 Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right non-dominant side
I69.254 Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting left non-dominant side
I69.259 Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting unspecified side
I69.341 Monoplegia of lower limb following cerebral infarction affecting right dominant side
I69.342 Monoplegia of lower limb following cerebral infarction affecting left dominant side
I69.343 Monoplegia of lower limb following cerebral infarction affecting right non-dominant side
I69.344 Monoplegia of lower limb following cerebral infarction affecting left non-dominant side
I69.349 Monoplegia of lower limb following cerebral infarction affecting unspecified side
I69.351 Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side
I69.352 Hemiplegia and hemiparesis following cerebral infarction affecting left dominant side
I69.353 Hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side
I69.354 Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side
I69.359 Hemiplegia and hemiparesis following cerebral infarction affecting unspecified side
I69.841 Monoplegia of lower limb following other cerebrovascular disease affecting right dominant side
I69.842 Monoplegia of lower limb following other cerebrovascular disease affecting left dominant side
I69.843 Monoplegia of lower limb following other cerebrovascular disease affecting right non-dominant side
I69.844 Monoplegia of lower limb following other cerebrovascular disease affecting left non-dominant side
I69.849 Monoplegia of lower limb following other cerebrovascular disease affecting unspecified side
I69.851 Hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side
I69.852 Hemiplegia and hemiparesis following other cerebrovascular disease affecting left dominant side
I69.853 Hemiplegia and hemiparesis following other cerebrovascular disease affecting right non-dominant side
I69.854 Hemiplegia and hemiparesis following other cerebrovascular disease affecting left non-dominant side
I69.859 Hemiplegia and hemiparesis following other cerebrovascular disease affecting unspecified side
I69.941 Monoplegia of lower limb following unspecified cerebrovascular disease affecting right dominant side
I69.942 Monoplegia of lower limb following unspecified cerebrovascular disease affecting left dominant side
I69.943 Monoplegia of lower limb following unspecified cerebrovascular disease affecting right non-dominant side
I69.944 Monoplegia of lower limb following unspecified cerebrovascular disease affecting left non-dominant side
I69.949 Monoplegia of lower limb following unspecified cerebrovascular disease affecting unspecified side
I69.951 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side
I69.952 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side
I69.953 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right non-dominant side
I69.954 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side
I69.959 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side
L89.130 Pressure ulcer of right lower back, unstageable
L89.131 Pressure ulcer of right lower back, stage 1
L89.132 Pressure ulcer of right lower back, stage 2
L89.133 Pressure ulcer of right lower back, stage 3
L89.134 Pressure ulcer of right lower back, stage 4
L89.140 Pressure ulcer of left lower back, unstageable
L89.141 Pressure ulcer of left lower back, stage 1
L89.142 Pressure ulcer of left lower back, stage 2
L89.143 Pressure ulcer of left lower back, stage 3
L89.144 Pressure ulcer of left lower back, stage 4
L89.150 Pressure ulcer of sacral region, unstageable
L89.151 Pressure ulcer of sacral region, stage 1
L89.152 Pressure ulcer of sacral region, stage 2
L89.153 Pressure ulcer of sacral region, stage 3
L89.154 Pressure ulcer of sacral region, stage 4
L89.200 Pressure ulcer of unspecified hip, unstageable
L89.201 Pressure ulcer of unspecified hip, stage 1
L89.202 Pressure ulcer of unspecified hip, stage 2
L89.203 Pressure ulcer of unspecified hip, stage 3
L89.204 Pressure ulcer of unspecified hip, stage 4
L89.210 Pressure ulcer of right hip, unstageable
L89.211 Pressure ulcer of right hip, stage 1
L89.212 Pressure ulcer of right hip, stage 2
L89.213 Pressure ulcer of right hip, stage 3
L89.214 Pressure ulcer of right hip, stage 4
L89.220 Pressure ulcer of left hip, unstageable
L89.221 Pressure ulcer of left hip, stage 1
L89.222 Pressure ulcer of left hip, stage 2
L89.223 Pressure ulcer of left hip, stage 3
L89.224 Pressure ulcer of left hip, stage 4
L89.300 Pressure ulcer of unspecified buttock, unstageable
L89.301 Pressure ulcer of unspecified buttock, stage 1
L89.302 Pressure ulcer of unspecified buttock, stage 2
L89.303 Pressure ulcer of unspecified buttock, stage 3
L89.304 Pressure ulcer of unspecified buttock, stage 4
L89.310 Pressure ulcer of right buttock, unstageable
L89.311 Pressure ulcer of right buttock, stage 1
L89.312 Pressure ulcer of right buttock, stage 2
L89.313 Pressure ulcer of right buttock, stage 3
L89.314 Pressure ulcer of right buttock, stage 4
L89.320 Pressure ulcer of left buttock, unstageable
L89.321 Pressure ulcer of left buttock, stage 1
L89.322 Pressure ulcer of left buttock, stage 2
L89.323 Pressure ulcer of left buttock, stage 3
L89.324 Pressure ulcer of left buttock, stage 4
L89.41 Pressure ulcer of contiguous site of back, buttock and hip, stage 1
L89.42 Pressure ulcer of contiguous site of back, buttock and hip, stage 2
L89.43 Pressure ulcer of contiguous site of back, buttock and hip, stage 3
L89.44 Pressure ulcer of contiguous site of back, buttock and hip, stage 4
L89.45 Pressure ulcer of contiguous site of back, buttock and hip, unstageable
M62.3 Immobility syndrome (paraplegic)
M62.89 Other specified disorders of muscle
Q05.0 Cervical spina bifida with hydrocephalus
Q05.1 Thoracic spina bifida with hydrocephalus
Q05.2 Lumbar spina bifida with hydrocephalus
Q05.3 Sacral spina bifida with hydrocephalus
Q05.4 Unspecified spina bifida with hydrocephalus
Q05.5 Cervical spina bifida without hydrocephalus
Q05.6 Thoracic spina bifida without hydrocephalus
Q05.7 Lumbar spina bifida without hydrocephalus
Q05.8 Sacral spina bifida without hydrocephalus
Q05.9 Spina bifida, unspecified
Q07.00 Arnold-Chiari syndrome without spina bifida or hydrocephalus
Q07.01 Arnold-Chiari syndrome with spina bifida
Q07.02 Arnold-Chiari syndrome with hydrocephalus
Q07.03 Arnold-Chiari syndrome with spina bifida and hydrocephalus
Q67.8 Other congenital deformities of chest
Q68.1 Congenital deformity of finger(s) and hand
Q74.3 Arthrogryposis multiplex congenita
Q78.0 Osteogenesis imperfecta
S78.011A Complete traumatic amputation at right hip joint, initial encounter
S78.011D Complete traumatic amputation at right hip joint, subsequent encounter
S78.011S Complete traumatic amputation at right hip joint, sequela
S78.012A Complete traumatic amputation at left hip joint, initial encounter
S78.012D Complete traumatic amputation at left hip joint, subsequent encounter
S78.012S Complete traumatic amputation at left hip joint, sequela
S78.019A Complete traumatic amputation at unspecified hip joint, initial encounter
S78.019D Complete traumatic amputation at unspecified hip joint, subsequent encounter
S78.019S Complete traumatic amputation at unspecified hip joint, sequela
S78.021A Partial traumatic amputation at right hip joint, initial encounter
S78.021D Partial traumatic amputation at right hip joint, subsequent encounter
S78.021S Partial traumatic amputation at right hip joint, sequela
S78.022A Partial traumatic amputation at left hip joint, initial encounter
S78.022D Partial traumatic amputation at left hip joint, subsequent encounter
S78.022S Partial traumatic amputation at left hip joint, sequela
S78.029A Partial traumatic amputation at unspecified hip joint, initial encounter
S78.029D Partial traumatic amputation at unspecified hip joint, subsequent encounter
S78.029S Partial traumatic amputation at unspecified hip joint, sequela
S78.111A Complete traumatic amputation at level between right hip and knee, initial encounter
S78.111D Complete traumatic amputation at level between right hip and knee, subsequent encounter
S78.111S Complete traumatic amputation at level between right hip and knee, sequela
S78.112A Complete traumatic amputation at level between left hip and knee, initial encounter
S78.112D Complete traumatic amputation at level between left hip and knee, subsequent encounter
S78.112S Complete traumatic amputation at level between left hip and knee, sequela
S78.119A Complete traumatic amputation at level between unspecified hip and knee, initial encounter
S78.119D Complete traumatic amputation at level between unspecified hip and knee, subsequent encounter
S78.119S Complete traumatic amputation at level between unspecified hip and knee, sequela
S78.121A Partial traumatic amputation at level between right hip and knee, initial encounter
S78.121D Partial traumatic amputation at level between right hip and knee, subsequent encounter
S78.121S Partial traumatic amputation at level between right hip and knee, sequela
S78.122A Partial traumatic amputation at level between left hip and knee, initial encounter
S78.122D Partial traumatic amputation at level between left hip and knee, subsequent encounter
S78.122S Partial traumatic amputation at level between left hip and knee, sequela
S78.129A Partial traumatic amputation at level between unspecified hip and knee, initial encounter
S78.129D Partial traumatic amputation at level between unspecified hip and knee, subsequent encounter
S78.129S Partial traumatic amputation at level between unspecified hip and knee, sequela
S78.911A Complete traumatic amputation of right hip and thigh, level unspecified, initial encounter
S78.911D Complete traumatic amputation of right hip and thigh, level unspecified, subsequent encounter
S78.911S Complete traumatic amputation of right hip and thigh, level unspecified, sequela
S78.912A Complete traumatic amputation of left hip and thigh, level unspecified, initial encounter
S78.912D Complete traumatic amputation of left hip and thigh, level unspecified, subsequent encounter
S78.912S Complete traumatic amputation of left hip and thigh, level unspecified, sequela
S78.919A Complete traumatic amputation of unspecified hip and thigh, level unspecified, initial encounter
S78.919D Complete traumatic amputation of unspecified hip and thigh, level unspecified, subsequent encounter
S78.919S Complete traumatic amputation of unspecified hip and thigh, level unspecified, sequela
S78.921A Partial traumatic amputation of right hip and thigh, level unspecified, initial encounter
S78.921D Partial traumatic amputation of right hip and thigh, level unspecified, subsequent encounter
S78.921S Partial traumatic amputation of right hip and thigh, level unspecified, sequela
S78.922A Partial traumatic amputation of left hip and thigh, level unspecified, initial encounter
S78.922D Partial traumatic amputation of left hip and thigh, level unspecified, subsequent encounter
S78.922S Partial traumatic amputation of left hip and thigh, level unspecified, sequela
S78.929A Partial traumatic amputation of unspecified hip and thigh, level unspecified, initial encounter
S78.929D Partial traumatic amputation of unspecified hip and thigh, level unspecified, subsequent encounter
S78.929S Partial traumatic amputation of unspecified hip and thigh, level unspecified, sequela
S88.011A Complete traumatic amputation at knee level, right lower leg, initial encounter
S88.011D Complete traumatic amputation at knee level, right lower leg, subsequent encounter
S88.011S Complete traumatic amputation at knee level, right lower leg, sequela
S88.012A Complete traumatic amputation at knee level, left lower leg, initial encounter
S88.012D Complete traumatic amputation at knee level, left lower leg, subsequent encounter
S88.012S Complete traumatic amputation at knee level, left lower leg, sequela
S88.019A Complete traumatic amputation at knee level, unspecified lower leg, initial encounter
S88.019D Complete traumatic amputation at knee level, unspecified lower leg, subsequent encounter
S88.019S Complete traumatic amputation at knee level, unspecified lower leg, sequela
S88.021A Partial traumatic amputation at knee level, right lower leg, initial encounter
S88.021D Partial traumatic amputation at knee level, right lower leg, subsequent encounter
S88.021S Partial traumatic amputation at knee level, right lower leg, sequela
S88.022A Partial traumatic amputation at knee level, left lower leg, initial encounter
S88.022D Partial traumatic amputation at knee level, left lower leg, subsequent encounter
S88.022S Partial traumatic amputation at knee level, left lower leg, sequela
S88.029A Partial traumatic amputation at knee level, unspecified lower leg, initial encounter
S88.029D Partial traumatic amputation at knee level, unspecified lower leg, subsequent encounter
S88.029S Partial traumatic amputation at knee level, unspecified lower leg, sequela
S88.911A Complete traumatic amputation of right lower leg, level unspecified, initial encounter
S88.911D Complete traumatic amputation of right lower leg, level unspecified, subsequent encounter
S88.911S Complete traumatic amputation of right lower leg, level unspecified, sequela
S88.912A Complete traumatic amputation of left lower leg, level unspecified, initial encounter
S88.912D Complete traumatic amputation of left lower leg, level unspecified, subsequent encounter
S88.912S Complete traumatic amputation of left lower leg, level unspecified, sequela
S88.919A Complete traumatic amputation of unspecified lower leg, level unspecified, initial encounter
S88.919D Complete traumatic amputation of unspecified lower leg, level unspecified, subsequent encounter
S88.919S Complete traumatic amputation of unspecified lower leg, level unspecified, sequela
S88.921A Partial traumatic amputation of right lower leg, level unspecified, initial encounter
S88.921D Partial traumatic amputation of right lower leg, level unspecified, subsequent encounter
S88.921S Partial traumatic amputation of right lower leg, level unspecified, sequela
S88.922A Partial traumatic amputation of left lower leg, level unspecified, initial encounter
S88.922D Partial traumatic amputation of left lower leg, level unspecified, subsequent encounter
S88.922S Partial traumatic amputation of left lower leg, level unspecified, sequela
S88.929A Partial traumatic amputation of unspecified lower leg, level unspecified, initial encounter
S88.929D Partial traumatic amputation of unspecified lower leg, level unspecified, subsequent encounter
S88.929S Partial traumatic amputation of unspecified lower leg, level unspecified, sequela
Z89.511 Acquired absence of right leg below knee
Z89.512 Acquired absence of left leg below knee
Z89.519 Acquired absence of unspecified leg below knee
Z89.611 Acquired absence of right leg above knee
Z89.612 Acquired absence of left leg above knee
Z89.619 Acquired absence of unspecified leg above knee
Z89.621 Acquired absence of right hip joint
Z89.622 Acquired absence of left hip joint
Z89.629 Acquired absence of unspecified hip joint

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

Group 1

Group 1 Paragraph

For the specific HCPCS codes indicated above, all ICD-10 codes that are not specified in the preceding section.

For HCPCS codes E2610 and K0669:
All ICD-10 codes

For HCPCS codes E0955, E2601, E2602, E2611, E2612 and E2619:
There are no specified ICD-10 codes

Group 1 Codes

N/A

ICD-10-PCS Codes

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
10/01/2021 R15

Revision Effective Date: 10/01/2021
ICD-10-CM CODES THAT SUPPORT MEDICAL NECESSITY:
Revised: ICD-10-CM code G71.20 description in Group 2 and Group 4 Codes, due to annual ICD-10-CM code updates
Added: ICD-10-CM code G04.82 to Group 2 and Group 4 Codes, due to annual ICD-10-CM code updates

10/07/2021: 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.

06/01/2021 R14

Revision Effective Date: 06/01/2021
CODING GUIDELINES:
Revised: Flame resistance standards language to include “or equivalent” with reference to ASTM, EPA, or other national or international standards agencies

05/27/2021: 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.

10/01/2020 R13

Revision Effective Date: 10/01/2020
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: References to refer to group codes in the ICD-10 code list section
CODING GUIDELINES:
Revised: References of positioning back cushion HCPCS codes, from “E2314” and “E2315” to “E2614” and “E2615” respectively
Added: HCPCS code E2610 to list of HCPCS codes for which products require written coding verification review
Added: "CVR" after reference to "coding verification review"
Added: “(PCL)” after reference to “Product Classification List”
Revised: Coding verification review language for products that must be billed with HCPCS code K0669
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.

10/01/2020 R12

Revision Effective Date: 10/01/2020
CODING GUIDELINES:
Added: RT and LT modifier billing instructions, for use when applicable
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Removed: ICD-10 codes G11.1 and G71.2 from Group 2 and Group 4 codes, due to annual ICD-10 Code updates
Added: ICD-10 codes G11.10, G11.11, and G11.19 to Group 2 and Group 4 codes, due to annual ICD-10 Code updates
Added: ICD-10 codes G71.20, G71.21, G71.220, G71.228, and G71.29 to Group 2 and Group 4 codes, due to annual ICD-10 Code updates

09/24/2020: 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 R11

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: “ICD-10 Codes that are Covered” to “ICD-10 code list”
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
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”
Revised: Format of HCPCS code references, from code 'spans' to individually-listed HCPCS, in Groups 2 and 3 Paragraphs
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”

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.

08/01/2019 R10

Revision Effective Date: 08/01/2019 
ICD-10 CODES THAT ARE COVERED: 
Added: ICD-10 Codes G61.0 and G71.11 to Groups 2 and 4 diagnosis codes

06/13/2019: 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 R9

Revision Effective Date: 01/01/2019
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Removed: Statement to refer to diagnosis codes that support medical necessity section in the LCD
Added: Statement to refer to ICD-10 Codes that are Covered section in the LCD-related Policy Article
ICD-10 CODES THAT ARE COVERED:
Added: All diagnosis codes formerly listed in the LCD
Added: ICD-10 I69.342 to Group 3 due to clerical oversight
Added: ICD-10 codes M62.3, M62.89, Q67.8, Q68.1, and Q74.3 to Group 4 due to clerical oversight
Removed: References to Group 5
ICD-10 CODES THAT ARE NOT COVERED:
Added: Notation excluding all unlisted diagnosis codes from coverage for specified the HCPCS codes. Notation excluding all ICD-10 codes from coverage for E2610 and K0669.
Added: Notation (formerly referenced in the Group 5 Paragraph of the ICD-10 Codes that Support Medical Necessity section within the LCD) indicating that for HCPCS codes E0955, E2601, E2602, E2611, E2612 and E2619, diagnosis codes are not specified.

05/23/2019: 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 R8

Revision Effective Date: 01/01/2018
CODING GUIDELINES:
Revised: Positioning cushion language placement for clarification
Added: Wheelchair seat and back cushion codes are all-inclusive

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 R7

Revision Effective Date: 01/01/2018

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS

Added: E0953 to modifier instructions

CODING GUIDELINES:

Added: E0953 coding instructions

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 R6

Revision Effective Date: 01/01/2017

NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:

Added: 42 CFR 410.38(g) language, previously in Policy Specific Documentation Requirements section

01/01/2017 R5 Revision Effective Date: 01/01/2017
CODING GUIDELINES:
Revised: Coding guidelines for E0956 due to a narrative description error
01/01/2017 R4 Revision Effective Date: 01/01/2017
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: 42 CFR 410.38(g) and Modifiers requirements
CODING GUIDELINES:
Changed: The third bullet for one characteristic of a positioning back cushion (E2613-E2616, E2620, E2621) from “vertical” to “horizontal”.
Revised: Description of headrest (E0955) and fixed mounting hardware
Added: Coding guideline for E0956 to specify that these items may be used on trunk, hip, thigh, and knee
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements Language 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.
10/01/2015 R2 Revision Effective Date: 10/01/2015
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Removed: Start date verbiage from Prescription Requirements
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

Associated Documents

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Public Versions
Updated On Effective Dates Status
09/30/2021 10/01/2021 - N/A Currently in Effect You are here
05/21/2021 06/01/2021 - 09/30/2021 Superseded View
03/19/2021 10/01/2020 - 05/31/2021 Superseded View
09/18/2020 10/01/2020 - N/A Superseded View
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