Local Coverage Determination (LCD)

Wheelchair Options/Accessories

L33792

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Contractor Information

LCD Information

Document Information

LCD ID
L33792
LCD Title
Wheelchair Options/Accessories
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 01/01/2020
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A
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CMS National Coverage Policy

Pub. 100-03 (Medicare National Coverage Determinations Manual), Chapter 1, Sections 280.1, 280.3

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

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.

The purpose of a Local Coverage Determination (LCD) is to provide information regarding “reasonable and necessary” criteria based on Social Security Act § 1862(a)(1)(A) provisions.

In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement:

  • The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.

  • The LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.

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

  • Refer to the DME MAC web sites for additional bulletin articles and other publications related to this LCD.

For the items addressed in this LCD, the “reasonable and necessary” criteria, based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.

Options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. Coverage criteria for specific items are described below.

If these criteria are not met, the item will be denied as not reasonable and necessary.

ARM OF CHAIR:

Adjustable arm height option (E0973, K0017, K0018, K0020) is covered if the beneficiary requires an arm height that is different from that available using nonadjustable arms and the beneficiary spends at least 2 hours per day in the wheelchair.

An arm trough (E2209) is covered if the beneficiary has quadriplegia, hemiplegia, or uncontrolled arm movements.

FOOTREST/ LEGREST:

Elevating legrests (E0990, K0046, K0047, K0053, K0195) are covered if:

  1. The beneficiary has a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee; or

  2. The beneficiary has significant edema of the lower extremities that requires an elevating legrest; or

  3. The beneficiary meets the criteria for and has a reclining back on the wheelchair.

NONSTANDARD SEAT FRAME DIMENSIONS:

A nonstandard seat width and/or depth for a manual wheelchair (E2201, E2202, E2203, E2204) is covered only if the beneficiary's physical dimensions justify the need.

WHEELS/TIRES FOR MANUAL WHEELCHAIRS:

A gear reduction drive wheel (E2227) is covered if all of the following criteria are met:

  1. The beneficiary has been self-propelling in a manual wheelchair for at least one year; and

  2. The beneficiary has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, or practitioner who has specific training and experience in rehabilitation wheelchair evaluations and that documents the need for the device in the beneficiary’s home. The PT, OT, or practitioner may have no financial relationship with the supplier; and

  3. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the beneficiary.

BATTERIES/ CHARGERS:

Up to two batteries (E2359, E2361, E2363, E2365, E2371, K0733) at any one time are allowed if required for a power wheelchair.

A non-sealed battery (E2358, E2360, E2362, E2364, E2372) will be denied as not reasonable and necessary.

A single mode battery charger (E2366) is appropriate for charging a sealed lead acid battery. If a dual mode battery charger (E2367) is provided as a replacement, it will be denied as not reasonable and necessary.

The usual maximum frequency of replacement for a lithium-based battery (E2397) is one every 3 years. Only one battery is allowed at any one time.

POWER TILT AND/OR RECLINE SEATING SYSTEMS (E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1012):

A power seating system – tilt only, recline only, or combination tilt and recline – with or without power elevating legrests will be covered if criteria 1, 2, and 3 are met and if criterion 4, 5, or 6 is met:

  1. The beneficiary meets all the coverage criteria for a power wheelchair described in the Power Mobility Devices LCD; and

  2. A specialty evaluation that was performed by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT) or practitioner who has specific training and experience in rehabilitation wheelchair evaluations of the beneficiary’s seating and positioning needs. The PT, OT, or practitioner may have no financial relationship with the supplier; and

  3. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the beneficiary.

  4. The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or

  5. The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed; or

  6. The power seating system is needed to manage increased tone or spasticity.

If these criteria are not met, the power seating component(s) will be denied as not reasonable and necessary.

POWER WHEELCHAIR DRIVE CONTROL SYSTEMS:

An attendant control is covered in place of a beneficiary-operated drive control system if the beneficiary meets coverage criteria for a wheelchair, is unable to operate a manual or power wheelchair and has a caregiver who is unable to operate a manual wheelchair but is able to operate a power wheelchair.

OTHER POWER WHEELCHAIR ACCESSORIES:

An electronic interface (E2351) to allow a speech generating device to be operated by the power wheelchair control interface is covered if the beneficiary has a covered speech generating device. (Refer to the Speech Generating Devices LCD for details.)

MISCELLANEOUS ACCESSORIES:

Anti-rollback device (E0974) is covered if the beneficiary self-propels and needs the device because of ramps.

A safety belt/pelvic strap (E0978) is covered if the beneficiary has weak upper body muscles, upper body instability or muscle spasticity which requires use of this item for proper positioning.

One example (not all-inclusive) of a covered indication for swingaway, retractable, or removable hardware (E1028) would be to move the component out of the way so that a beneficiary can perform a slide transfer to a chair or bed.

A manual fully reclining back option (E1226) is covered if the beneficiary has one or more of the following conditions:

  1. The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or

  2. The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to the bed.

If these criteria are not met, the manual reclining back will be denied as not reasonable and necessary.

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

GENERAL

A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving a completed SWO, the claim shall be denied as not reasonable and necessary.

For Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) base items that require a Written Order Prior to Delivery (WOPD), the supplier must have received a signed SWO before the DMEPOS item is delivered to a beneficiary. If a supplier delivers a DMEPOS item without first receiving a WOPD, the claim shall be denied as not reasonable and necessary. Refer to the LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.

For DMEPOS base items that require a WOPD, and also require separately billed associated options, accessories, and/or supplies, the supplier must have received a WOPD which lists the base item and which may list all the associated options, accessories, and/or supplies that are separately billed prior to the delivery of the items. In this scenario, if the supplier separately bills for associated options, accessories, and/or supplies without first receiving a completed and signed WOPD of the base item prior to delivery, the claim(s) shall be denied as not reasonable and necessary.

An item/service is correctly coded when it meets all the coding guidelines listed in CMS HCPCS guidelines, LCDs, LCD-related Policy Articles, or DME MAC articles. Claims that do not meet coding guidelines shall be denied as not reasonable and necessary/incorrectly coded.

Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD documentation in their files. Proof of delivery documentation must be made available to the Medicare contractor upon request. All services that do not have appropriate proof of delivery from the supplier shall be denied as not reasonable and necessary.

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Coding Information

CPT/HCPCS Codes

Group 1

Group 1 Paragraph

The appearance of a code in this section does not necessarily indicate coverage.

 

HCPCS MODIFIERS:

EY – No physician or other licensed health care provider order for this item or service

GA - Waiver of liability statement issued, as required by payer policy, individual case

GY – Item or service statutorily excluded or does not meet the definition of any Medicare benefit

GZ - Item or service expected to be denied as not reasonable and necessary

KC - Replacement of special power wheelchair interface

KX - Requirements specified in the medical policy have been met

RB – Replacement of a part of DME furnished as part of a repair

 

HCPCS CODES:

 

ARM OF CHAIR:

Group 1 Codes
CodeDescription
E0973 WHEELCHAIR ACCESSORY, ADJUSTABLE HEIGHT, DETACHABLE ARMREST, COMPLETE ASSEMBLY, EACH
E2209 ACCESSORY, ARM TROUGH, WITH OR WITHOUT HAND SUPPORT, EACH
K0015 DETACHABLE, NON-ADJUSTABLE HEIGHT ARMREST, REPLACEMENT ONLY, EACH
K0017 DETACHABLE, ADJUSTABLE HEIGHT ARMREST, BASE, REPLACEMENT ONLY, EACH
K0018 DETACHABLE, ADJUSTABLE HEIGHT ARMREST, UPPER PORTION, REPLACEMENT ONLY, EACH
K0019 ARM PAD, REPLACEMENT ONLY, EACH
K0020 FIXED, ADJUSTABLE HEIGHT ARMREST, PAIR

Group 2

Group 2 Paragraph FOOTREST/LEGREST: Group 2 Codes
CodeDescription
E0951 HEEL LOOP/HOLDER, ANY TYPE, WITH OR WITHOUT ANKLE STRAP, EACH
E0952 TOE LOOP/HOLDER, ANY TYPE, EACH
E0954 WHEELCHAIR ACCESSORY, FOOT BOX, ANY TYPE, INCLUDES ATTACHMENT AND MOUNTING HARDWARE, EACH FOOT
E0990 WHEELCHAIR ACCESSORY, ELEVATING LEG REST, COMPLETE ASSEMBLY, EACH
E0995 WHEELCHAIR ACCESSORY, CALF REST/PAD, REPLACEMENT ONLY, EACH
E1020 RESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCHAIR, ANY TYPE
K0037 HIGH MOUNT FLIP-UP FOOTREST, EACH
K0038 LEG STRAP, EACH
K0039 LEG STRAP, H STYLE, EACH
K0040 ADJUSTABLE ANGLE FOOTPLATE, EACH
K0041 LARGE SIZE FOOTPLATE, EACH
K0042 STANDARD SIZE FOOTPLATE, REPLACEMENT ONLY, EACH
K0043 FOOTREST, LOWER EXTENSION TUBE, REPLACEMENT ONLY, EACH
K0044 FOOTREST, UPPER HANGER BRACKET, REPLACEMENT ONLY, EACH
K0045 FOOTREST, COMPLETE ASSEMBLY, REPLACEMENT ONLY, EACH
K0046 ELEVATING LEGREST, LOWER EXTENSION TUBE, REPLACEMENT ONLY, EACH
K0047 ELEVATING LEGREST, UPPER HANGER BRACKET, REPLACEMENT ONLY, EACH
K0050 RATCHET ASSEMBLY, REPLACEMENT ONLY
K0051 CAM RELEASE ASSEMBLY, FOOTREST OR LEGREST, REPLACEMENT ONLY, EACH
K0052 SWINGAWAY, DETACHABLE FOOTRESTS, REPLACEMENT ONLY, EACH
K0053 ELEVATING FOOTRESTS, ARTICULATING (TELESCOPING), EACH
K0195 ELEVATING LEG RESTS, PAIR (FOR USE WITH CAPPED RENTAL WHEELCHAIR BASE)

Group 3

Group 3 Paragraph NONSTANDARD SEAT FRAME DIMENSIONS:
Group 3 Codes
CodeDescription
E1011 MODIFICATION TO PEDIATRIC SIZE WHEELCHAIR, WIDTH ADJUSTMENT PACKAGE (NOT TO BE DISPENSED WITH INITIAL CHAIR)
E2201 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME, WIDTH GREATER THAN OR EQUAL TO 20 INCHES AND LESS THAN 24 INCHES
E2202 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME WIDTH, 24-27 INCHES
E2203 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 20 TO LESS THAN 22 INCHES
E2204 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 22 TO 25 INCHES
K0056 SEAT HEIGHT LESS THAN 17" OR EQUAL TO OR GREATER THAN 21" FOR A HIGH STRENGTH, LIGHTWEIGHT, OR ULTRALIGHTWEIGHT WHEELCHAIR

Group 4

Group 4 Paragraph REAR WHEELS FOR MANUAL WHEELCHAIRS:
Group 4 Codes
CodeDescription
E0961 MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK BRAKE EXTENSION (HANDLE), EACH
E0967 MANUAL WHEELCHAIR ACCESSORY, HAND RIM WITH PROJECTIONS, ANY TYPE, REPLACEMENT ONLY, EACH
E0988 MANUAL WHEELCHAIR ACCESSORY, LEVER-ACTIVATED, WHEEL DRIVE, PAIR
E2205 MANUAL WHEELCHAIR ACCESSORY, HANDRIM WITHOUT PROJECTIONS (INCLUDES ERGONOMIC OR CONTOURED), ANY TYPE, REPLACEMENT ONLY, EACH
E2206 MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK ASSEMBLY, COMPLETE, REPLACEMENT ONLY, EACH
E2211 MANUAL WHEELCHAIR ACCESSORY, PNEUMATIC PROPULSION TIRE, ANY SIZE, EACH
E2212 MANUAL WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC PROPULSION TIRE, ANY SIZE, EACH
E2213 MANUAL WHEELCHAIR ACCESSORY, INSERT FOR PNEUMATIC PROPULSION TIRE (REMOVABLE), ANY TYPE, ANY SIZE, EACH
E2214 MANUAL WHEELCHAIR ACCESSORY, PNEUMATIC CASTER TIRE, ANY SIZE, EACH
E2215 MANUAL WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC CASTER TIRE, ANY SIZE, EACH
E2216 MANUAL WHEELCHAIR ACCESSORY, FOAM FILLED PROPULSION TIRE, ANY SIZE, EACH
E2217 MANUAL WHEELCHAIR ACCESSORY, FOAM FILLED CASTER TIRE, ANY SIZE, EACH
E2218 MANUAL WHEELCHAIR ACCESSORY, FOAM PROPULSION TIRE, ANY SIZE, EACH
E2219 MANUAL WHEELCHAIR ACCESSORY, FOAM CASTER TIRE, ANY SIZE, EACH
E2220 MANUAL WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) PROPULSION TIRE, ANY SIZE, REPLACEMENT ONLY, EACH
E2221 MANUAL WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE (REMOVABLE), ANY SIZE, REPLACEMENT ONLY, EACH
E2222 MANUAL WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE WITH INTEGRATED WHEEL, ANY SIZE, REPLACEMENT ONLY, EACH
E2224 MANUAL WHEELCHAIR ACCESSORY, PROPULSION WHEEL EXCLUDES TIRE, ANY SIZE, REPLACEMENT ONLY, EACH
E2225 MANUAL WHEELCHAIR ACCESSORY, CASTER WHEEL EXCLUDES TIRE, ANY SIZE, REPLACEMENT ONLY, EACH
E2226 MANUAL WHEELCHAIR ACCESSORY, CASTER FORK, ANY SIZE, REPLACEMENT ONLY, EACH
E2227 MANUAL WHEELCHAIR ACCESSORY, GEAR REDUCTION DRIVE WHEEL, EACH
E2228 MANUAL WHEELCHAIR ACCESSORY, WHEEL BRAKING SYSTEM AND LOCK, COMPLETE, EACH
K0065 SPOKE PROTECTORS, EACH
K0069 REAR WHEEL ASSEMBLY, COMPLETE, WITH SOLID TIRE, SPOKES OR MOLDED, REPLACEMENT ONLY, EACH
K0070 REAR WHEEL ASSEMBLY, COMPLETE, WITH PNEUMATIC TIRE, SPOKES OR MOLDED, REPLACEMENT ONLY, EACH
K0071 FRONT CASTER ASSEMBLY, COMPLETE, WITH PNEUMATIC TIRE, REPLACEMENT ONLY, EACH
K0072 FRONT CASTER ASSEMBLY, COMPLETE, WITH SEMI-PNEUMATIC TIRE, REPLACEMENT ONLY, EACH
K0073 CASTER PIN LOCK, EACH
K0077 FRONT CASTER ASSEMBLY, COMPLETE, WITH SOLID TIRE, REPLACEMENT ONLY, EACH

Group 5

Group 5 Paragraph BATTERIES/CHARGERS:
Group 5 Codes
CodeDescription
E2358 POWER WHEELCHAIR ACCESSORY, GROUP 34 NON-SEALED LEAD ACID BATTERY, EACH
E2359 POWER WHEELCHAIR ACCESSORY, GROUP 34 SEALED LEAD ACID BATTERY, EACH (E.G., GEL CELL, ABSORBED GLASSMAT)
E2360 POWER WHEELCHAIR ACCESSORY, 22NF NON-SEALED LEAD ACID BATTERY, EACH
E2361 POWER WHEELCHAIR ACCESSORY, 22NF SEALED LEAD ACID BATTERY, EACH, (E.G., GEL CELL, ABSORBED GLASSMAT)
E2362 POWER WHEELCHAIR ACCESSORY, GROUP 24 NON-SEALED LEAD ACID BATTERY, EACH
E2363 POWER WHEELCHAIR ACCESSORY, GROUP 24 SEALED LEAD ACID BATTERY, EACH (E.G., GEL CELL, ABSORBED GLASSMAT)
E2364 POWER WHEELCHAIR ACCESSORY, U-1 NON-SEALED LEAD ACID BATTERY, EACH
E2365 POWER WHEELCHAIR ACCESSORY, U-1 SEALED LEAD ACID BATTERY, EACH (E.G., GEL CELL, ABSORBED GLASSMAT)
E2366 POWER WHEELCHAIR ACCESSORY, BATTERY CHARGER, SINGLE MODE, FOR USE WITH ONLY ONE BATTERY TYPE, SEALED OR NON-SEALED, EACH
E2367 POWER WHEELCHAIR ACCESSORY, BATTERY CHARGER, DUAL MODE, FOR USE WITH EITHER BATTERY TYPE, SEALED OR NON-SEALED, EACH
E2371 POWER WHEELCHAIR ACCESSORY, GROUP 27 SEALED LEAD ACID BATTERY, (E.G., GEL CELL, ABSORBED GLASSMAT), EACH
E2372 POWER WHEELCHAIR ACCESSORY, GROUP 27 NON-SEALED LEAD ACID BATTERY, EACH
E2397 POWER WHEELCHAIR ACCESSORY, LITHIUM-BASED BATTERY, EACH
K0733 POWER WHEELCHAIR ACCESSORY, 12 TO 24 AMP HOUR SEALED LEAD ACID BATTERY, EACH (E.G., GEL CELL, ABSORBED GLASSMAT)

Group 6

Group 6 Paragraph POWER SEATING SYSTEMS:
Group 6 Codes
CodeDescription
E1002 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, TILT ONLY
E1003 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITHOUT SHEAR REDUCTION
E1004 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITH MECHANICAL SHEAR REDUCTION
E1005 WHEELCHAIR ACCESSORY, POWER SEATNG SYSTEM, RECLINE ONLY, WITH POWER SHEAR REDUCTION
E1006 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITHOUT SHEAR REDUCTION
E1007 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITH MECHANICAL SHEAR REDUCTION
E1008 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITH POWER SHEAR REDUCTION
E1009 WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, MECHANICALLY LINKED LEG ELEVATION SYSTEM, INCLUDING PUSHROD AND LEG REST, EACH
E1010 WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, POWER LEG ELEVATION SYSTEM, INCLUDING LEG REST, PAIR
E1012 WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, CENTER MOUNT POWER ELEVATING LEG REST/PLATFORM, COMPLETE SYSTEM, ANY TYPE, EACH
E2300 WHEELCHAIR ACCESSORY, POWER SEAT ELEVATION SYSTEM, ANY TYPE
E2301 WHEELCHAIR ACCESSORY, POWER STANDING SYSTEM, ANY TYPE
E2310 POWER WHEELCHAIR ACCESSORY, ELECTRONIC CONNECTION BETWEEN WHEELCHAIR CONTROLLER AND ONE POWER SEATING SYSTEM MOTOR, INCLUDING ALL RELATED ELECTRONICS, INDICATOR FEATURE, MECHANICAL FUNCTION SELECTION SWITCH, AND FIXED MOUNTING HARDWARE
E2311 POWER WHEELCHAIR ACCESSORY, ELECTRONIC CONNECTION BETWEEN WHEELCHAIR CONTROLLER AND TWO OR MORE POWER SEATING SYSTEM MOTORS, INCLUDING ALL RELATED ELECTRONICS, INDICATOR FEATURE, MECHANICAL FUNCTION SELECTION SWITCH, AND FIXED MOUNTING HARDWARE

Group 7

Group 7 Paragraph POWER WHEELCHAIR DRIVE CONTROL SYSTEMS:
Group 7 Codes
CodeDescription
E2312 POWER WHEELCHAIR ACCESSORY, HAND OR CHIN CONTROL INTERFACE, MINI-PROPORTIONAL REMOTE JOYSTICK, PROPORTIONAL, INCLUDING FIXED MOUNTING HARDWARE
E2313 POWER WHEELCHAIR ACCESSORY, HARNESS FOR UPGRADE TO EXPANDABLE CONTROLLER, INCLUDING ALL FASTENERS, CONNECTORS AND MOUNTING HARDWARE, EACH
E2321 POWER WHEELCHAIR ACCESSORY, HAND CONTROL INTERFACE, REMOTE JOYSTICK, NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, AND FIXED MOUNTING HARDWARE
E2322 POWER WHEELCHAIR ACCESSORY, HAND CONTROL INTERFACE, MULTIPLE MECHANICAL SWITCHES, NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, AND FIXED MOUNTING HARDWARE
E2323 POWER WHEELCHAIR ACCESSORY, SPECIALTY JOYSTICK HANDLE FOR HAND CONTROL INTERFACE, PREFABRICATED
E2324 POWER WHEELCHAIR ACCESSORY, CHIN CUP FOR CHIN CONTROL INTERFACE
E2325 POWER WHEELCHAIR ACCESSORY, SIP AND PUFF INTERFACE, NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, AND MANUAL SWINGAWAY MOUNTING HARDWARE
E2326 POWER WHEELCHAIR ACCESSORY, BREATH TUBE KIT FOR SIP AND PUFF INTERFACE
E2327 POWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, MECHANICAL, PROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL DIRECTION CHANGE SWITCH, AND FIXED MOUNTING HARDWARE
E2328 POWER WHEELCHAIR ACCESSORY, HEAD CONTROL OR EXTREMITY CONTROL INTERFACE, ELECTRONIC, PROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS AND FIXED MOUNTING HARDWARE
E2329 POWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, CONTACT SWITCH MECHANISM, NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, MECHANICAL DIRECTION CHANGE SWITCH, HEAD ARRAY, AND FIXED MOUNTING HARDWARE
E2330 POWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, PROXIMITY SWITCH MECHANISM, NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, MECHANICAL DIRECTION CHANGE SWITCH, HEAD ARRAY, AND FIXED MOUNTING HARDWARE
E2331 POWER WHEELCHAIR ACCESSORY, ATTENDANT CONTROL, PROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS AND FIXED MOUNTING HARDWARE
E2373 POWER WHEELCHAIR ACCESSORY, HAND OR CHIN CONTROL INTERFACE, COMPACT REMOTE JOYSTICK, PROPORTIONAL, INCLUDING FIXED MOUNTING HARDWARE
E2374 POWER WHEELCHAIR ACCESSORY, HAND OR CHIN CONTROL INTERFACE, STANDARD REMOTE JOYSTICK (NOT INCLUDING CONTROLLER), PROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS AND FIXED MOUNTING HARDWARE, REPLACEMENT ONLY
E2375 POWER WHEELCHAIR ACCESSORY, NON-EXPANDABLE CONTROLLER, INCLUDING ALL RELATED ELECTRONICS AND MOUNTING HARDWARE, REPLACEMENT ONLY
E2376 POWER WHEELCHAIR ACCESSORY, EXPANDABLE CONTROLLER, INCLUDING ALL RELATED ELECTRONICS AND MOUNTING HARDWARE, REPLACEMENT ONLY
E2377 POWER WHEELCHAIR ACCESSORY, EXPANDABLE CONTROLLER, INCLUDING ALL RELATED ELECTRONICS AND MOUNTING HARDWARE, UPGRADE PROVIDED AT INITIAL ISSUE

Group 8

Group 8 Paragraph OTHER POWER WHEELCHAIR ACCESSORIES:
Group 8 Codes
CodeDescription
E1016 SHOCK ABSORBER FOR POWER WHEELCHAIR, EACH
E1018 HEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY DUTY POWER WHEELCHAIR, EACH
E2351 POWER WHEELCHAIR ACCESSORY, ELECTRONIC INTERFACE TO OPERATE SPEECH GENERATING DEVICE USING POWER WHEELCHAIR CONTROL INTERFACE
E2368 POWER WHEELCHAIR COMPONENT, DRIVE WHEEL MOTOR, REPLACEMENT ONLY
E2369 POWER WHEELCHAIR COMPONENT, DRIVE WHEEL GEAR BOX, REPLACEMENT ONLY
E2370 POWER WHEELCHAIR COMPONENT, INTEGRATED DRIVE WHEEL MOTOR AND GEAR BOX COMBINATION, REPLACEMENT ONLY
E2378 POWER WHEELCHAIR COMPONENT, ACTUATOR, REPLACEMENT ONLY
E2381 POWER WHEELCHAIR ACCESSORY, PNEUMATIC DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT ONLY, EACH
E2382 POWER WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT ONLY, EACH
E2383 POWER WHEELCHAIR ACCESSORY, INSERT FOR PNEUMATIC DRIVE WHEEL TIRE (REMOVABLE), ANY TYPE, ANY SIZE, REPLACEMENT ONLY, EACH
E2384 POWER WHEELCHAIR ACCESSORY, PNEUMATIC CASTER TIRE, ANY SIZE, REPLACEMENT ONLY, EACH
E2385 POWER WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC CASTER TIRE, ANY SIZE, REPLACEMENT ONLY, EACH
E2386 POWER WHEELCHAIR ACCESSORY, FOAM FILLED DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT ONLY, EACH
E2387 POWER WHEELCHAIR ACCESSORY, FOAM FILLED CASTER TIRE, ANY SIZE, REPLACEMENT ONLY, EACH
E2388 POWER WHEELCHAIR ACCESSORY, FOAM DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT ONLY, EACH
E2389 POWER WHEELCHAIR ACCESSORY, FOAM CASTER TIRE, ANY SIZE, REPLACEMENT ONLY, EACH
E2390 POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT ONLY, EACH
E2391 POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE (REMOVABLE), ANY SIZE, REPLACEMENT ONLY, EACH
E2392 POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE WITH INTEGRATED WHEEL, ANY SIZE, REPLACEMENT ONLY, EACH
E2394 POWER WHEELCHAIR ACCESSORY, DRIVE WHEEL EXCLUDES TIRE, ANY SIZE, REPLACEMENT ONLY, EACH
E2395 POWER WHEELCHAIR ACCESSORY, CASTER WHEEL EXCLUDES TIRE, ANY SIZE, REPLACEMENT ONLY, EACH
E2396 POWER WHEELCHAIR ACCESSORY, CASTER FORK, ANY SIZE, REPLACEMENT ONLY, EACH
K0098 DRIVE BELT FOR POWER WHEELCHAIR, REPLACEMENT ONLY

Group 9

Group 9 Paragraph MISCELLANEOUS ACCESSORIES: Group 9 Codes
CodeDescription
A9270 NON-COVERED ITEM OR SERVICE
A9900 MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS CODE
E0705 TRANSFER DEVICE, ANY TYPE, EACH
E0950 WHEELCHAIR ACCESSORY, TRAY, EACH
E0958 MANUAL WHEELCHAIR ACCESSORY, ONE-ARM DRIVE ATTACHMENT, EACH
E0959 MANUAL WHEELCHAIR ACCESSORY, ADAPTER FOR AMPUTEE, EACH
E0971 MANUAL WHEELCHAIR ACCESSORY, ANTI-TIPPING DEVICE, EACH
E0974 MANUAL WHEELCHAIR ACCESSORY, ANTI-ROLLBACK DEVICE, EACH
E0978 WHEELCHAIR ACCESSORY, POSITIONING BELT/SAFETY BELT/PELVIC STRAP, EACH
E0981 WHEELCHAIR ACCESSORY, SEAT UPHOLSTERY, REPLACEMENT ONLY, EACH
E0982 WHEELCHAIR ACCESSORY, BACK UPHOLSTERY, REPLACEMENT ONLY, EACH
E0985 WHEELCHAIR ACCESSORY, SEAT LIFT MECHANISM
E1014 RECLINING BACK, ADDITION TO PEDIATRIC SIZE WHEELCHAIR
E1015 SHOCK ABSORBER FOR MANUAL WHEELCHAIR, EACH
E1017 HEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY DUTY MANUAL WHEELCHAIR, EACH
E1028 WHEELCHAIR ACCESSORY, MANUAL SWINGAWAY, RETRACTABLE OR REMOVABLE MOUNTING HARDWARE FOR JOYSTICK, OTHER CONTROL INTERFACE OR POSITIONING ACCESSORY
E1029 WHEELCHAIR ACCESSORY, VENTILATOR TRAY, FIXED
E1030 WHEELCHAIR ACCESSORY, VENTILATOR TRAY, GIMBALED
E1225 WHEELCHAIR ACCESSORY, MANUAL SEMI-RECLINING BACK, (RECLINE GREATER THAN 15 DEGREES, BUT LESS THAN 80 DEGREES), EACH
E1226 WHEELCHAIR ACCESSORY, MANUAL FULLY RECLINING BACK, (RECLINE GREATER THAN 80 DEGREES), EACH
E2207 WHEELCHAIR ACCESSORY, CRUTCH AND CANE HOLDER, EACH
E2208 WHEELCHAIR ACCESSORY, CYLINDER TANK CARRIER, EACH
E2210 WHEELCHAIR ACCESSORY, BEARINGS, ANY TYPE, REPLACEMENT ONLY, EACH
E2230 MANUAL WHEELCHAIR ACCESSORY, MANUAL STANDING SYSTEM
E2295 MANUAL WHEELCHAIR ACCESSORY, FOR PEDIATRIC SIZE WHEELCHAIR, DYNAMIC SEATING FRAME, ALLOWS COORDINATED MOVEMENT OF MULTIPLE POSITIONING FEATURES
E2398 WHEELCHAIR ACCESSORY, DYNAMIC POSITIONING HARDWARE FOR BACK
K0105 IV HANGER, EACH
K0108 WHEELCHAIR COMPONENT OR ACCESSORY, NOT OTHERWISE SPECIFIED

General Information

Associated Information


DOCUMENTATION REQUIREMENTS

Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider.” It is expected that the beneficiary's medical records will reflect the need for the care provided. The beneficiary's medical records include the treating practitioner's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.

GENERAL DOCUMENTATION REQUIREMENTS

In order to justify payment for DMEPOS items, suppliers must meet the following requirements:

  • SWO

  • Medical Record Information (including continued need/use if applicable)

  • Correct Coding

  • Proof of Delivery

Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this policy under the Related Local Coverage Documents section for additional information regarding these requirements.

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

Refer to the DME MAC web sites for additional bulletin articles and other publications related to this LCD.

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS

Items covered in this LCD have additional policy-specific requirements that must be met prior to Medicare reimbursement.

Refer to the LCD-related Policy article, located at the bottom of this policy under the Related Local Coverage Documents section for additional information.

Miscellaneous

Appendices

Utilization Guidelines
Refer to Coverage Indications, Limitations and/or Medical Necessity.

Sources of Information
Reserved for future use
Bibliography

N/A

Revision History Information

Revision History DateRevision History NumberRevision History ExplanationReasons for Change
01/01/2020 R9

Revision Effective Date: 01/01/2020
COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:
Revised: Format of HCPCS code references, from code ‘spans’ to individually-listed HCPCS
Revised: "physician" to "practitioner"
Revised: Order information as a result of Final Rule 1713
CODING INFORMATION:
Removed: Field titled “Bill Type”
Removed: Field titled “Revenue Codes”
Removed: Field titled “ICD-10 Codes that Support Medical Necessity”
Removed: Field titled “ICD-10 Codes that DO NOT Support Medical Necessity”
Removed: Field titled “Additional ICD-10 Information”
DOCUMENTATION REQUIREMENTS:
Revised: “physician’s” to “treating practitioner’s”
GENERAL DOCUMENTATION REQUIREMENTS:
Revised: Prescriptions (orders) to SWO
 
03/19/2020: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because they are due to non-discretionary coverage updates reflective of CMS FR-1713, HCPCS code changes, and non-substantive corrections (listing individual HCPCS codes instead of a HCPCS code-span).

  • Provider Education/Guidance
  • Other
01/01/2020 R8

Revision Effective Date:01/01/2020
HCPCS CODES:
Added: HCPCS E2398 to Group 9 codes, per annual HCPCS code release

  • Revisions Due To CPT/HCPCS Code Changes
01/01/2019 R7

Revision Effective Date: 01/01/2019
HCPCS CODES:
Revised: K0037 narrative to remove "replacement only"

  • Revisions Due To CPT/HCPCS Code Changes
01/01/2018 R6

Revision Effective Date: 01/01/2018

HCPCS CODES:

Added: E0954 to Group 2 codes

12/21/2017: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Revisions Due To CPT/HCPCS Code Changes
01/01/2017 R5 Revision Effective Date: 01/01/2017
COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Removed: Standard Documentation Language
Added: New reference language and Directions to Standard Documentation Requirements
Added: General Requirements
HCPCS CODES:
Revised: Descriptor changed in Group 1 - K0015, K0019; Group 2 - E0995, K0037, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052; Group 4 -E0967, E2206, E2220, E2221, E2222, E2224, K0069, K0070, K0071, K0072, K0077; Group 8 - K0098
DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: General Documentation Requirements
Added: New reference language and Directions to Standard Documentation Requirements
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: Direction to Standard Documentation Requirements
Removed: Information under Miscellaneous
Removed: Information under Appendices
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements article
  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
07/01/2016 R4 Effective July 1, 2016 oversight for DME MAC LCDs 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 LCDs.
  • Change in Assigned States or Affiliated Contract Numbers
01/01/2016 R3 Revision Effective Date: 01/01/2016
COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Added: HCPCS code E1012 to Power Tilt and/or Recline Seating Systems range
HCPCS CODES:
Added: HCPCS code E1012
Revised: K0017 and K0018 long narrative description
DOCUMENTATION REQUIREMENTS:
Revised: Standard Documentation Language to remove start date verbiage from Prescription Requirements (Effective 11/5/2015)
  • Provider Education/Guidance
  • Revisions Due To CPT/HCPCS Code Changes
10/01/2015 R2 Revision Effective Date: 10/31/2014
COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Revised: Standard Documentation Language to add covered prior to a beneficiary’s Medicare eligibility
Added: HCPCS Codes E2358 and E2359 to the Batteries/Chargers section
DOCUMENTATION REQUIREMENTS:
Deleted: Reference to refill of supplies from Continued Use
Revised: Standard Documentation Language to add who can enter date of delivery date on the POD
Added: Repair/Replacement section
  • Provider Education/Guidance
10/01/2015 R1 07/01/2013 (June 2014 Publication)
MISCELLANEOUS:
Removed: Requirement for accessories to be billed on the same claim as base
  • Provider Education/Guidance

Associated Documents

Attachments
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Related National Coverage Documents
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Public Versions
Updated On Effective Dates Status
03/13/2020 01/01/2020 - N/A Currently in Effect You are here
12/13/2019 01/01/2020 - N/A Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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