LCD for Power Mobility Devices (L23613)

Contractor Information

 

Contractor Name 

TrustSolutions 

Contractor Number 

77012 

Contractor Type 

DME PSC 

DME MAC this DME PSC is affiliated with 

Palmetto GBA  

 

LCD Information

 

LCD ID Number 

L23613 

 

LCD Title 

Power Mobility Devices 

 

Contractor's Determination Number

PMD 

 

AMA CPT / ADA CDT Copyright Statement 

CPT codes, descriptions and other data only are copyright 2005 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.  

 

CMS National Coverage Policy 

CMS Pub. 100-3, Medicare National Coverage Determinations Manual, Chapter 1, Sections 280.3 

 

Primary Geographic Jurisdiction 

Alabama
Arkansas
Colorado
Florida
Georgia
Louisiana
Mississippi
North Carolina
New Mexico
Oklahoma
Puerto Rico
South Carolina
Tennessee
Texas
Virgin Islands
 

 

Oversight Region 

Central Office 

 

DME Region LCD Covers 

Jurisdiction C 

 

Original Determination Effective Date 

For services performed on or after 10/01/2006  

 

Original Determination Ending Date 

 

Revision Effective Date

For services performed on or after 11/15/2006  

 

Revision Ending Date

 

Indications and Limitations of Coverage 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. For the items addressed in this medical policy, the criteria for "reasonable and necessary" are defined by the following indications and limitations of coverage and/or medical necessity.

Refer to the related Policy Article for statutory coverage information on orders and a face-to-face examination.

The term power mobility device (PMD) includes power operated vehicles (POVs) and power wheelchairs (PWCs).

BASIC COVERAGE CRITERIA:

All of the following basic criteria (A-C) must be met for a power mobility device (K0800-K0898) or a push-rim activated power assist device (E0986) to be covered. Additional coverage criteria for specific devices are listed below.

A) The patient has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. A mobility limitation is one that:

  • Prevents the patient from accomplishing an MRADL entirely, or
  • Places the patient at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or
  • Prevents the patient from completing an MRADL within a reasonable time frame.

B) The patient’s mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker.

C) The patient does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to perform MRADLs during a typical day.

  • Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function.
  • An optimally-configured manual wheelchair is one with an appropriate wheelbase, device weight, seating options, and other appropriate nonpowered accessories.

POWER OPERATED VEHICLES (K0800-K0808, K0812):

A POV is covered if all of the basic coverage criteria (A-C) have been met and if criteria D-I are also met.

D) The patient is able to:

  • Safely transfer to and from a POV, and
  • Operate the tiller steering system, and
  • Maintain postural stability and position while operating the POV in the home.


E) The patient’s mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) are sufficient for safe mobility using a POV in the home.

F) The patient’s home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the POV that is provided.

G) The patient’s weight is less than or equal to the weight capacity of the POV that is provided.

H) Use of a POV will significantly improve the patient’s ability to participate in MRADLs and the patient will use it in the home.

I) The patient has not expressed an unwillingness to use a POV in the home.

If a POV will be used inside the home and coverage criteria A-I are not met, it will be denied as not medically necessary.

Group 2 POVs (K0806-K0808) have added capabilities that are not needed for use in the home. Therefore, if a Group 2 POV is provided and coverage criteria for a POV are met, payment will be based on the allowance for the least costly medically appropriate alternative, the comparable Group 1 POV. (See Least Costly Alternative section for information relating to this and all subsequent LCA statements.)

If coverage criteria A-I are met and if a patient’s weight can be accommodated by a POV with a lower weight capacity than the POV that is provided, payment will be based on the allowance for the least costly medically appropriate alternative.

If a POV will only be used outside the home, see related Policy Article for information concerning noncoverage.

POWER WHEELCHAIRS (K0813-K0891, K0898):

A power wheelchair is covered if:

  1. All of the basic coverage criteria (A-C) are met; and
  2. The patient does not meet coverage criterion D, E, or F for a POV; and
  3. Either criterion J or K is met; and
  4. Criterion L, M, N, and O are met; and
  5. Any coverage criteria pertaining to the specific wheelchair type (see below) are met.

J) The patient has the mental and physical capabilities to safely operate the power wheelchair that is provided; or

K) If the patient is unable to safely operate the power wheelchair, the patient has a caregiver who is unable to adequately propel an optimally configured manual wheelchair, but is available, willing, and able to safely operate the power wheelchair that is provided; and

L) The patient’s weight is less than or equal to the weight capacity of the power wheelchair that is provided.

M) The patient’s home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the power wheelchair that is provided.

N) Use of a power wheelchair will significantly improve the patient’s ability to participate in MRADLs and the patient will use it in the home. For patients with severe cognitive and/or physical impairments, participation in MRADLs may require the assistance of a caregiver.

O) The patient has not expressed an unwillingness to use a power wheelchair in the home.

If the PWC will be used inside the home and coverage criteria (a)-(e) are not met but the criteria for a POV are met, payment will be based on the allowance for the least costly medically appropriate alternative.

If the PWC will be used inside the home and coverage criteria (a)-(e) are not met and the criteria for a POV are not met, it will be denied as not medically necessary.

If a PWC will only be used outside the home, see related Policy Article for information concerning noncoverage.

SPECIFIC TYPES OF POWER WHEELCHAIRS:

  1. A Group 1 PWC (K0813-K0816) or a Group 2 PWC (K0820-K0829) is covered if all of the coverage criteria (a)-(e) for a PWC are met and the wheelchair is appropriate for the patient’s weight.

  2. A Group 2 Single Power Option PWC (K0835 – K0840) is covered if all of the coverage criteria (a)-(e) for a PWC are met and if:
    1. Criterion 1 or 2 is met; and
    2. Criterion 3 is met.

                            1.            The patient requires a drive control interface other than a hand or chin-operated standard proportional joystick (examples include but are not limited to head control, sip and puff, switch control).

                            2.            The patient meets coverage criteria for a power tilt or a power recline seating system (see Wheelchair Options and Accessories policy for coverage criteria) and the system is being used on the wheelchair.

                            3.            The patient has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features (see Documentation Requirements section). The PT, OT, or physician may have no financial relationship with the supplier.

If a Group 2 Single Power Option PWC is provided and if II(A) or II(B) is not met (including but not limited to situations in which it is only provided to accommodate a power seat elevation feature, a power standing feature, or only power elevating legrests) but the coverage criteria for a PWC are met, payment will be based on the allowance for the least costly medically appropriate alternative Group 2 PWC.

  1. A Group 2 Multiple Power Option PWC (K0841-K0843) is covered if all of the coverage criteria (a)-(e) for a PWC are met and if:
    1. Criterion 1 or 2 is met; and
    2. Criterion 3 is met.

                            1.            The patient meets coverage criteria for a power tilt and recline seating system (see Wheelchair Options and Accessories policy) and the system is being used on the wheelchair.

                            2.            The patient uses a ventilator which is mounted on the wheelchair.

                            3.            The patient has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features (see Documentation Requirements section). The PT, OT, or physician may have no financial relationship with the supplier.

If a Group 2 Multiple Power Option PWC is provided and if III(A) or III(B) is not met but the criteria for another PWC are met, payment will be based on the allowance for the least costly medically appropriate alternative Group 2 PWC.

  1. A Group 3 PWC with no power options (K0848-K0855) is covered if:
    1. All of the coverage criteria (a)-(e) for a PWC are met; and
    2. The patient’s mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity; and
    3. The patient has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features (see Documentation Requirements section). The PT, OT, or physician may have no financial relationship with the supplier.

If a Group 3 PWC is provided and criterion A is met but either criterion B or C is not met, payment will be based on the allowance for the least costly medically appropriate alternative Group 2 PWC.

  1. A Group 3 PWC with Single Power Option (K0856-K0860) or with Multiple Power Options (K0861-K0864) is covered if:
    1. The Group 3 criteria IV(A) and IV(B) are met; and
    2. The Group 2 Single Power Option (criteria II[A] and II[B]) or Multiple Power Options (criteria III[A] and III[B]) (respectively) are met.

If a Group 3 Single Power Option or Multiple Power Options PWC is provided and Criterion IV(A) is met but all of the other coverage criteria are not met, payment will be based on the allowance for the least costly medically appropriate alternative Group 2 or Group 3 PWC.

  1. Group 4 PWCs (K0868-K0886) have added capabilities that are not needed for use in the home. Therefore, if these wheelchairs are provided and coverage criteria for a Group 2 or Group 3 PWC are met, payment will be based on the allowance for the least costly medically appropriate alternative.

If a Group 4 PWC is billed with a KX modifier (see Documentation Requirements section), payment at the time of initial automated processing will be based on the allowance for the comparable Group 3 PWC.

  1. A Group 5 (Pediatric) PWC with Single Power Option (K0890) or with Multiple Power Options (K0891) is covered if:
    1. All the coverage criteria (a)-(e) for a PWC are met; and
    2. The patient is expected to grow in height; and
    3. The Group 2 Single Power Option (criteria II[A] and II[B]) or Multiple Power Options (criteria III[A] and III[B]) (respectively) are met.

If a Group 5 PWC is provided but all the coverage criteria are not met, payment will be based on the allowance for the least costly medically appropriate alternative.

  1. A push-rim activated power assist device (E0986) for a manual wheelchair is covered if all of the following criteria are met:
    1. All of the criteria for a power mobility device listed in the Basic Coverage Criteria section are met; and
    2. The patient has been self-propelling in a manual wheelchair for at least one year; and
    3. The patient has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the need for the device in the patient’s home. The PT, OT, or physician may have no financial relationship with the supplier.

If all of the coverage criteria are not met, it will be denied as not medically necessary.

LEAST COSTLY ALTERNATIVE:

Coverage criteria for power mobility devices are based on a stepwise progression of medical necessity. If coverage criteria for the device that is provided are not met and if there is another device that meets the patient’s medical needs (as defined in this policy), payment will be based on the allowance for the least costly medically appropriate alternative.


Determinations of least costly alternative will take into account the patient’s weight, seating needs, and needs for other special features (i.e., power seating systems, alternative drive controls, ventilators).

Based on the criteria defined in this policy, some types of PMDs will never be paid in full but will always be either paid as a least costly alternative (if coverage criteria are met) or denied (if coverage criteria for a PMD are not met). In those situations, the first level least costly alternative determination will be made by an automated system edit. However in many situations, the final determination of a least costly alternative can only be made at the time of manual review of a claim during medical review or a fraud investigation. Therefore, even if a payment reduction is made at the time of an initial claim determination, this does not preclude subsequent further adjustment in payment or denial based on the application of all coverage criteria in this policy at the time of post-payment manual claim review.

MISCELLANEOUS:

A POV or power wheelchair with Captain’s Chair is not appropriate for a patient who needs a separate wheelchair seat and/or back cushion. If a skin protection and/or positioning seat or back cushion that meets coverage criteria (see Wheelchair Seating LCD) is provided with a POV or a power wheelchair with Captain’s Chair, the POV or PWC will be denied as not medically necessary. (Refer to Wheelchair Seating LCD and Policy Article for information concerning coverage of general use, skin protection, or positioning cushions when they are provided with a POV or power wheelchair with Captain’s Chair.)

If a patient needs a seat and/or back cushion but does not meet coverage criteria for a skin protection and/or positioning cushion, it is appropriate to provide a Captain’s Chair seat (if the code exists) rather than a sling/solid seat/back and a separate general use seat and/or back cushion. If a general use seat and/or back cushion is provided with a power wheelchair with a sling/solid seat/back, total payment for those items will be based on the allowance for the least costly medically appropriate alternative – e.g., the code for the comparable power wheelchair with Captain’s Chair, if that code exists.

If a patient’s weight can be accommodated by a PWC with a lower weight capacity than the wheelchair that is provided, payment will be based on the allowance for the least costly medically appropriate alternative.

A seat elevator is a noncovered option on a power wheelchair. Therefore, if a Group 2 Seat Elevator PWC (K0830, K0831) is provided and if all of the criteria (a)-(e) for a PWC are met, payment will be based on the allowance for the least costly medically appropriate alternative Group 2 PWC without seat elevator.

 The delivery of the PMD must be within 120 days following completion of the face-to face examination. (Exception: For PWCs that go through the Advance Determination of Medicare Coverage (ADMC) process and receive an affirmative determination, the delivery must be within 6 months following the determination.)

An add-on to convert a manual wheelchair to a joystick-controlled power mobility device (E0983) or to a tiller-controlled power mobility device (E0984) will be denied as not medically necessary.

Payment is made for only one wheelchair at a time. Backup chairs are denied as not medically necessary.

One month's rental of a PWC or POV (K0462) is covered if a patient-owned wheelchair is being repaired. Payment is based on the type of replacement device that is provided but will not exceed the rental allowance for the power mobility device that is being repaired.

A power mobility device will be denied as not medically necessary if the underlying condition is reversible and the length of need is less than 3 months (e.g., following lower extremity surgery which limits ambulation).

For claims with dates of service on or after April 1, 2008, the specialty evaluation required for patients receiving a Group 2 single power option or multiple power option PWC, any Group 3 or Group 4 PWC, or a push rim activated power assist device for a manual wheelchair must be performed by a RESNA-certified Assistive Technology Practitioner (ATP) specializing in wheelchairs or a physician who is board-certified in Physical Medicine and Rehabilitation. The ATP or physician may not have any financial relationship with the supplier. In addition, the wheelchair must be provided by a supplier that employs a RESNA-certified Assistive Technology Supplier (ATS) specializing in wheelchairs who is directly involved in the wheelchair selection for the patient.

A POV or PWC which has not been reviewed by the SADMERC or which has been reviewed by the SADMERC and found not to meet the definition of a specific POV/PWC (K0899) will be denied as not medically necessary.
 

Coverage Topic 

Durable Medical Equipment
Motorized/Power Wheelchairs
Power Operated Vehicles (POVs)
Wheelchairs
 

 

Coding Information

 

CPT/HCPCS Codes

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
GY – Item or service statutorily excluded or doesn’t meet the definition of any Medicare benefit category
KX – Specified required documentation on file

HCPCS CODES:

K0800   POWER OPERATED VEHICLE, GROUP 1 STANDARD, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

K0801   POWER OPERATED VEHICLE, GROUP 1 HEAVY DUTY, PATIENT WEIGHT CAPACITY, 301 TO 450 POUNDS

K0802   POWER OPERATED VEHICLE, GROUP 1 VERY HEAVY DUTY, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS

K0806   POWER OPERATED VEHICLE, GROUP 2 STANDARD, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

K0807   POWER OPERATED VEHICLE, GROUP 2 HEAVY DUTY, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS

K0808   POWER OPERATED VEHICLE, GROUP 2 VERY HEAVY DUTY, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS

K0812   POWER OPERATED VEHICLE, NOT OTHERWISE CLASSIFIED

K0813   POWER WHEELCHAIR, GROUP 1 STANDARD, PORTABLE, SLING/SOLID SEAT AND BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

K0814   POWER WHEELCHAIR, GROUP 1 STANDARD, PORTABLE, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

K0815   POWER WHEELCHAIR, GROUP 1 STANDARD, SLING/SOLID SEAT AND BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

K0816   POWER WHEELCHAIR, GROUP 1 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACTIY UP TO AND INCLUDING 300 POUNDS

K0820   POWER WHEELCHAIR, GROUP 2 STANDARD, PORTABLE, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

K0821   POWER WHEELCHAIR, GROUP 2 STANDARD, PORTABLE, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

K0822   POWER WHEELCHAIR, GROUP 2 STANDARD, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

K0823   POWER WHEELCHAIR, GROUP 2 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

K0824   POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS

K0825   POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS

K0826   POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS

K0827   POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS

K0828   POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 601 POUNDS OR MORE

K0829   POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 601 POUNDS OR MORE

K0830   POWER WHEELCHAIR, GROUP 2 STANDARD, SEAT ELEVATOR, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

K0831   POWER WHEELCHAIR, GROUP 2 STANDARD, SEAT ELEVATOR, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

K0835   POWER WHEELCHAIR, GROUP 2 STANDARD, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

K0836   POWER WHEELCHAIR, GROUP 2 STANDARD, SINGLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

K0837   POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS

K0838   POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SINGLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS

K0839   POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS

K0840   POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 601 POUNDS OR MORE

K0841   POWER WHEELCHAIR, GROUP 2 STANDARD, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

K0842   POWER WHEELCHAIR, GROUP 2 STANDARD, MULTIPLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

K0843   POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS

K0848   POWER WHEELCHAIR, GROUP 3 STANDARD, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

K0849   POWER WHEELCHAIR, GROUP 3 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

K0850   POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS

K0851   POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS

K0852   POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS

K0853   POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY, 451 TO 600 POUNDS

K0854   POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 601 POUNDS OR MORE

K0855   POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 601 POUNDS OR MORE

K0856   POWER WHEELCHAIR, GROUP 3 STANDARD, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

K0857   POWER WHEELCHAIR, GROUP 3 STANDARD, SINGLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

K0858   POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS

K0859   POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, SINGLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS

K0860   POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS

K0861   POWER WHEELCHAIR, GROUP 3 STANDARD, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

K0862   POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS

K0863   POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS

K0864   POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 601 POUNDS OR MORE

K0868   POWER WHEELCHAIR, GROUP 4 STANDARD, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

K0869   POWER WHEELCHAIR, GROUP 4 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

K0870   POWER WHEELCHAIR, GROUP 4 HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS

K0871   POWER WHEELCHAIR, GROUP 4 VERY HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS

K0877   POWER WHEELCHAIR, GROUP 4 STANDARD, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

K0878   POWER WHEELCHAIR, GROUP 4 STANDARD, SINGLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

K0879   POWER WHEELCHAIR, GROUP 4 HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS

K0880   POWER WHEELCHAIR, GROUP 4 VERY HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT 451 TO 600 POUNDS

K0884   POWER WHEELCHAIR, GROUP 4 STANDARD, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

K0885   POWER WHEELCHAIR, GROUP 4 STANDARD, MULTIPLE POWER OPTION, CAPTAINS CHAIR, WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

K0886   POWER WHEELCHAIR, GROUP 4 HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS

K0890   POWER WHEELCHAIR, GROUP 5 PEDIATRIC, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 125 POUNDS

K0891   POWER WHEELCHAIR, GROUP 5 PEDIATRIC, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 125 POUNDS

K0898   POWER WHEELCHAIR, NOT OTHERWISE CLASSIFIED

K0899   POWER MOBILITY DEVICE, NOT CODED BY SADMERC OR DOES NOT MEET CRITERIA

E0983

MANUAL WHEELCHAIR ACCESSORY, POWER ADD-ON TO CONVERT MANUAL WHEELCHAIR TO MOTORIZED WHEELCHAIR, JOYSTICK CONTROL

E0984

MANUAL WHEELCHAIR ACCESSORY, POWER ADD-ON TO CONVERT MANUAL WHEELCHAIR TO MOTORIZED WHEELCHAIR, TILLER CONTROL

E0986

MANUAL WHEELCHAIR ACCESSORY, PUSH ACTIVATED POWER ASSIST, EACH

 

ICD-9 Codes that Support Medical Necessity

Not specified.

 

Diagnoses that Support Medical Necessity 

Not specified. 

 

ICD-9 Codes that DO NOT Support Medical Necessity 

Not specified. 

Diagnoses that DO NOT Support Medical Necessity 

Not specified. 

 

General 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" (42 U.S.C. section 1395(l)). It is expected that the patient's medical records will reflect the need for the care provided. The patient's medical records include the physician'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 to the DMERC upon request.

ORDERS:

The order that the supplier must receive within 45 days after completion of the face-to-face examination (see Policy Article) must contain all of the following elements:
1) Beneficiary’s name
2) Description of the item that is ordered. This may be general – e.g., “power operated vehicle”, “power wheelchair”, or “power mobility device”– or may be more specific.
3) Date of completion of the face-to-face examination
4) Pertinent diagnoses/conditions that relate to the need for the POV or power wheelchair
5) Length of need
6) Physician’s signature
7) Date of physician signature

A date stamp or equivalent must be used to document receipt date.

If a written order containing all of these required elements is not received by the supplier within 45 days after completion of the face-to-face examination an EY modifier must be added to the HCPCS codes for the power mobility device and all accessories. The order must be available on request.

Once the supplier has determined the specific power mobility device that is appropriate for the patient based on the physician’s order, the supplier must prepare a written document (termed a detailed product description) that lists the specific base (HCPCS code and either a narrative description of the item or the manufacturer name/model) and all options and accessories that will be separately billed. The supplier must list their charge and the Medicare fee schedule allowance for each separately billed item. If there is no fee schedule allowance, the supplier must enter “not applicable”. The physician must sign and date this detailed product description and the supplier must receive it prior to delivery of the PWC or POV. A date stamp or equivalent must be used to document receipt date. The detailed product description must be available on request.

FACE-TO-FACE EXAMINATION:

The report of the face-to-face examination (see Policy Article) should provide information relating to the following questions.

For POVs and PWCs

What is this patient’s mobility limitation and how does it interfere with the performance of activities of daily living?

For POVs and PWCs

Why can’t a cane or walker meet this patient’s mobility needs in the home?

For POVs and PWCs

Why can’t a manual wheelchair meet this patient’s mobility needs in the home?

For POVs

Does this patient have the physical and mental abilities to transfer into a POV and to operate it safely in the home?

For PWCs

Why can’t a POV (scooter) meet this patient’s mobility needs in the home?

For PWCs

Does this patient have the physical and mental abilities to operate a power wheelchair safely in the home?


The report should provide pertinent information about the following elements, but may include other details. Each element would not have to be addressed in every evaluation.

  • Symptoms
  • Related diagnoses
  • History
    • How long the condition has been present
    • Clinical progression
    • Interventions that have been tried and the results
    • Past use of walker, manual wheelchair, POV, or power wheelchair and the results
  • Physical exam
    • Weight
    • Impairment of strength, range of motion, sensation, or coordination of arms and legs
    • Presence of abnormal tone or deformity of arms, legs, or trunk
    • Neck, trunk, and pelvic posture and flexibility
    • Sitting and standing balance
  • Functional assessment – any problems with performing the following activities including the need to use a cane, walker, or the assistance of another person
    • Transferring between a bed, chair, and PMD
    • Walking around their home – to bathroom, kitchen, living room, etc. – provide information on distance walked, speed, and balance

A date stamp or equivalent must be used to document receipt date. The written report of this examination must be available on request.

Physicians shall document the examination in a detailed narrative note in their charts in the format that they use for other entries. The note must clearly indicate that a major reason for the visit was a mobility examination.

Many suppliers have created forms which have not been approved by CMS which they send to physicians and ask them to complete. Even if the physician completes this type of form and puts it in his/her chart, this supplier-generated form is not a substitute for the comprehensive medical record as noted above. Suppliers are encouraged to help educate physicians on the type of information that is needed to document a patient’s mobility needs.

Physicians shall also provide reports of pertinent laboratory tests, x-rays, and/or other diagnostic tests (e.g., pulmonary function tests, cardiac stress test, electromyogram, etc.) performed in the course of management of the patient.

If the report of a licensed/certified medical professional (LCMP) examination is to be considered as part of the face-to-face examination (see Policy Article), there must be a signed and dated attestation by the supplier that the LCMP has no financial relationship with the supplier. (Note: Evaluations performed by an LCMP who has a financial relationship with the supplier may be submitted to provide additional clinical information, but will not be considered as part of the face-to-face examination by the physician.)

Although patients who qualify for coverage of a power mobility device may use that device outside the home, because Medicare’s coverage of a wheelchair or POV is determined solely by the patient’s mobility needs within the home, the examination must clearly distinguish the patient’s abilities and needs within the home from any additional needs for use outside the home.

SPECIALTY EVALUATION:

The specialty evaluation that is required for patients who receive a Group 2 Single Power Option or Multiple Power Options PWC, any Group 3 or Group 4 PWC, or a push-rim activated power assist device is in addition to the requirement for the face-to-face examination. The specialty evaluation provides detailed information explaining why each specific option or accessory – i.e., power seating system, alternate drive control interface, or push-rim activated power assist – is needed to address the patient’s mobility limitation. There must be a written report of this evaluation available on request.

HOME ASSESSMENT:

Prior to or at the time of delivery of a POV or PWC, the supplier or practitioner must perform an on-site evaluation of the patient’s home to verify that the patient can adequately maneuver the device that is provided considering physical layout, doorway width, doorway thresholds, and surfaces. There must be a written report of this evaluation available on request.

MISCELLANEOUS:

If the requirements related to a face-to-face examination (see related Policy Article) have not been met, the GY modifier must be added to the codes for the power mobility device and all accessories.

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

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

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

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

3)   If a Group 4 PWC is provided and if all of the coverage criteria for a comparable Group 3 PWC have been met.

 
The following power wheelchairs are eligible for Advance Determination of Medicare Coverage (ADMC):

1)   A Group 2, 3, 4 or 5 Single Power Option or Multiple Power Options wheelchair (K0835-K0843, K0856-K0864, K0877-K0891) – whether or not a power seating system will be provided at the time of initial issue.

2)   A Group 3 or 4 No Power Option wheelchair (K0848-K0855, K0868-K0871) that will be provided with an alternative drive control interface at the time of initial issue.

Refer to the ADMC section in the Supplier Manual for details concerning the ADMC process.

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

Appendices 

 

Utilization Guidelines 

Refer to Indications and Limitations of Coverage and/or Medical Necessity 

 

Sources of Information and Basis for Decision 

CMS Decision Memorandum on Mobility Assistive Equipment.
Information received from multiple sources during the comment period.
 

Advisory Committee Meeting Notes 

Written comments received at the Open Meeting are included in the Response to Comments document with all other written comments received during the comment period. 

 

Start Date of Comment Period 

09/14/2005 

 

End Date of Comment Period 

10/31/2005 

 

Start Date of Notice Period 

08/15/2006 

 

Revision History Number

002

 

Revision History Explanation 

Revision Effective Date: 11/15/2006 (November Publication)

INDICATIONS AND LIMITATIONS OF COVERAGE:

Revised criterion for Single Power Option PWCs to remove the reference to the number of actuators.

Revised criterion for Multiple Power Option PWCs to indicate that coverage is determined by the need for a combination power tilt and recline power seating system regardless of the number of actuators.

Removed the inability to stand and pivot to transfer as a coverage criterion for Group 3 PWCs and added congenital orthopedic deformities to the list of covered conditions.

HCPCS CODES:

Corrected narrative description for K0825

DOCUMENTATION REQUIREMENTS:

Revised chairs that are available for ADMC.

 

Revision Effective Date: 11/15/2006  (September Publication)

Implementation of the LCD has been changed from 10/1/2006

INDICATIONS AND LIMITATIONS OF COVERAGE:

Eliminated downcoding of Group 2 to Group 1 PWCs.

Indicated that if a Group 3 or Group 4 PWC were downcoded to a lower level PWC, it would be a Group 2 PWC.

Deleted several statements in the Least Costly Alternative section.

Eliminated downcoding of portable to nonportable wheelchairs.

Indicated that a Group 2 PWC with seat elevator would be downcoded to a Group 2 PWC without seat elevator.

DOCUMENTATION REQUIREMENTS:

Revised instructions for detailed product description.

Revised instructions for use of KX modifier. 

 

Related Documents 

Article(s)
A41136 - Power Mobility Devices - Policy Article – Effective October 2006

 

LCD Attachments

Response to Comments - Aug. 2006

 

 

Article for Power Mobility Devices - Policy Article – Effective November 2006 (November Publication) (A41136)