Wheelchair Seating

Affected Providers

Treating practitioners and DME suppliers who bill for wheelchair seating.

HCPCS & CPT Codes

Local Coverage Determination (LCD): Wheelchair Seating (L33312) has the current HCPCS and CPT codes.

Background

The definitions for seat cushions listed in Article: Wheelchair Seating (A52505) include results from simulation testing or human subject testing.

According to the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data, the improper payment rate for wheelchair seating is 17.6%, with a projected improper payment amount of $10.5 million.

Denial Reasons

No denial reasons were listed in the 2024 Comprehensive Error Rate Testing report for wheelchair seating. Medical necessity accounted for (57.2%) of improper payments for wheelchair seating during the 2023 reporting period, while insufficient documentation (24.4%) and other errors (18.4%) also caused improper payments. “Other” errors include duplicate payment, non-covered or unallowable service, or ineligible Medicare patient errors.

Preventing Denials

General Use Seat Cushion

We cover a general-use seat cushion (HCPCS codes E2601 and E2602) and a general-use wheelchair back cushion (HCPCS codes E2611 and E2612) for a patient who has a manual wheelchair or a power wheelchair with a sling or solid seat or back that meets Medicare coverage criteria.

If the patient doesn’t have a Medicare-covered wheelchair, we deny the cushion as not reasonable and necessary. If the patient has a power-operated vehicle or a power wheelchair with a captain’s chair seat, we deny the cushion as not reasonable and necessary.

For patients who meet coverage criteria for a power wheelchair and don’t have special skin protection or positioning needs, a power wheelchair with a captain’s chair provides appropriate support. If you supply a general-use cushion for a power wheelchair with a sling or solid seat or back instead of a captain’s chair, we cover the wheelchair and the cushions if you meet either criterion 1 or criterion 2:

1. You supply the cushion with a covered power wheelchair base that’s not available in a captain’s chair model (for example, HCPCS codes K0839, K0840, K0843, K0860 – K0864, K0890, and K0891)
2. You supply a skin protection or positioning seat or back cushion that meets coverage criteria

If you don’t meet 1 of these criteria, we deny both the power wheelchair with a sling or solid seat and the general use cushion as not reasonable and necessary.

If the patient has a power-operated vehicle or a power wheelchair with a captain’s chair seat, we deny a separate seat and back cushion as not reasonable and necessary.

Skin Protection Seat Cushion

We cover a skin protection seat cushion (HCPCS codes E2603, E2604, E2622, and E2623) for a patient who meets both these criteria:

1. They have a manual wheelchair or a power wheelchair with a sling or solid seat or back, and they meet Medicare coverage criteria for it
2. They have either (a or b):
   1. Current pressure ulcer or history of a pressure ulcer on the area of contact with the seating surface (find the ICD-10-CM Codes that Support Medical Necessity section in Group 1 in A52505)
   2. Absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift (find the ICD-10-CM Codes that Support Medical Necessity section in Group 2 in A52505)

Positioning Seat Cushion

We cover a positioning seat cushion (HCPCS codes E2605 and E2606), positioning back cushion (HCPCS codes E2613 – E2616, E2620, and E2621), and positioning accessories (HCPCS codes E0953, E0955 – E0957, and E0960) for a patient who meets both these criteria:

1. They have a manual wheelchair or a power wheelchair with a sling or solid seat or back and they meet Medicare coverage criteria for it
2. The patient has any significant postural asymmetries that are due to a diagnosis code listed in the ICD-10-CM Codes that Support Medical Necessity section in Group 2 or 3 in Article A52505

We cover a combination skin protection and positioning seat cushion (HCPCS codes E2607, E2608, E2624, and E2625) for a patient who meets the criteria for both a skin protection seat cushion and a positioning seat cushion (find the ICD-10-CM Codes that Support Medical Necessity section in Group 2 in Article A52505).

We cover a headrest (E0955) when the patient has 1 of these covered:

• Manual tilt-in-space wheelchair
• Manual semi- or fully reclining back on a manual wheelchair
• Manual fully reclining back on a power wheelchair
• Power tilt and recline power seating system

If the patient has a power-operated vehicle or a power wheelchair with a captain’s chair seat, we deny a headrest or other positioning accessory as not reasonable and necessary. If you supply a skin protection seat cushion, positioning seat cushion, or combination skin protection and positioning seat cushion, and if the patient doesn’t meet the stated coverage criteria, we deny it as not reasonable and necessary.

If you supply a positioning back cushion to a patient who doesn’t meet the stated coverage criteria, we deny it as not reasonable and necessary. If you supply a positioning accessory and the criteria aren’t met, we deny the item as not reasonable and necessary.

Custom Fabricated Seat Cushion

We cover a custom fabricated seat cushion (HCPCS code E2609) if the patient meets criteria 1 and 3. We cover a custom fabricated back cushion (HCPCS code E2617) if the patient meets criteria 2 and 3.

1. They meet all the criteria for a prefabricated skin protection seat cushion or positioning seat cushion.
2. They meet all the criteria for a prefabricated positioning back cushion.
3. A licensed or certified medical provider, like a physical therapist (PT) or occupational therapist (OT), completes a comprehensive written evaluation that clearly explains why a prefabricated seating system doesn’t meet the patient’s seating and positioning needs. The PT or OT may have no financial relationship with the supplier.

If you supply a custom fabricated cushion for a patient who doesn’t meet the stated coverage criteria, we deny it as not reasonable and necessary.

We deny a seat or back cushion that’s provided for use with a transport chair (HCPCS codes E1037 and E1038) as not reasonable and necessary.

We deny claims for a powered seat cushion (HCPCS code 2610) as not reasonable and necessary because the effectiveness of a powered seat cushion hasn’t been shown. 

We deny a prefabricated seat cushion, a prefabricated positioning back cushion, or a brand name custom fabricated seat or back cushion as not reasonable and necessary if it hasn’t gotten a written coding verification from the Pricing, Data Analysis, and Coding contractor or that doesn’t meet the criteria stated in the Coding Guidelines section of A52505.

Documentation Requirements

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

For wheelchair seating, we require a face-to-face encounter and written order prior to delivery of the items to the patient.

Example of Improper Payments Due to Medical Necessity for Wheelchair Seating

A supplier bills the claim for HCPCS code E2603 (Skin protection wheelchair seat cushion, width less than 22 inches, any depth) and submits the following documentation per the review contractor’s request:

• Medical record
• Documentation of patient owning a power wheelchair

What Documentation Was Missing?

According to medical records, the patient:

• Doesn’t have any pressure ulcers or a history of pressure ulcers
• Has no sensation impairments in the area of contact with the seating surface

The provider didn’t send proof that the patient has either:

• Current pressure ulcer or history of a pressure ulcer on the area of contact with the seating surface
• Absent or impaired sensation in the area of contact with the seating surface or the inability to carry out a functional weight shift

What Happens Next?

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

Recommendation

To avoid billing errors and improper payments, the certifying physician must include all medical necessity documentation in the patient’s medical record for DMEPOS.