Manual Wheelchairs

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What’s Changed?

We updated the improper payment rate and denial reasons for the 2024 reporting period.

Affected Providers

Treating practitioners and DME suppliers who bill for manual wheelchairs.

HCPCS & CPT Codes

Local Coverage Determination (LCD): Manual Wheelchair Bases (L33788) has the current HCPCS and CPT codes.

Background

According to the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data, the improper payment rate for manual wheelchairs is 30.5%, with a projected improper payment amount of $28.1 million.

We cover manual wheelchairs under the DME benefit. We outline other policy requirements in:

Denial Reasons

Insufficient documentation accounted for 79.7% of improper payments for manual wheelchairs during the 2024 reporting period, while other errors (20.3%) also caused improper payments. “Other” errors include duplicate payment, non-covered or unallowable service, or ineligible Medicare patient errors.

Preventing Denials

Decide if:

The patient has mobility limitations significantly impairing their participation in 1 or more mobility-related activities of daily living (MRADLs) (for example, toileting, feeding, dressing, grooming, and bathing in customary locations within the home) that meet 1 of these criteria:
- Prevents them from doing an MRADL entirely
- Places them at reasonably found heightened risk of morbidity or mortality secondary to attempting an MRADL
- Prevents them from completing an MRADL within a reasonable time frame
Using a properly fitted cane or walker doesn’t resolve the patient’s mobility limitation
The patient’s home allows adequate access between rooms, maneuvering space, and surfaces for using the specific manual wheelchair
Using a manual wheelchair will significantly improve the patient’s ability to take part in MRADLs and they’ll use it regularly in the home
The patient hasn’t expressed an unwillingness to use a manual wheelchair in their home
The patient has enough upper extremity function and other physical and mental abilities to safely self-propel the manual wheelchair in their home during a typical day (strength limitations, endurance, range of motion, coordination, presence of pain, or deformity or absence of 1 or both upper extremities are relevant to assessing upper extremity function)
The patient’s caregiver is available, willing, and able to help with the wheelchair

Providers may reference LCD L33788 for specific manual wheelchair criteria.

NOTE:
For use inside the home, a manual wheelchair must meet criteria 1–5 and 6 or 7.

Documentation Requirements

To justify payment, you must meet specific requirements when ordering DMEPOS.

Example of Improper Payments Due to Insufficient Documentation for Manual Wheelchairs

A supplier bills the claim for HCPCS code E1161 (Manual adult size wheelchair, includes tilt in space) and submits the following documentation per the review contractor’s request:

Standard written order with correct HCPCS coding
Treating practitioner’s medical record documentation that meets general coverage criteria for a manual wheelchair
Occupational therapy evaluation details
Proof of delivery

What Documentation Was Missing?

The patient’s medical record doesn’t meet specific criteria for a tilt in space manual wheelchair.

What Happens Next?

The review contractor completes the claim as an insufficient documentation error, and the Medicare Administrative Contractor recoups payment.

Recommendation

To justify payment for E1161, the patient must meet general coverage criteria for a manual wheelchair, as well as meet both these criteria:

A physical therapist (PT), occupational therapist (OT), or practitioner who has specific training and experience in rehabilitation wheelchair evaluations performs a specialty evaluation of the patient and documents the medical necessity for the wheelchair and its special features (see the Policy Specific Documentation Requirements section in Article A52497 for more information). The PT, OT, or practitioner may have no financial relationship with the supplier.
The wheelchair is provided by a Rehabilitative Technology Supplier that employs a Rehabilitation Engineering and Assistive Technology Society of North America (RESNA)-certified assistive technology professional who specializes in wheelchairs and has direct, in-person involvement in the wheelchair selection for the patient.

Disclaimers

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