Wheelchairs can be described in HCPCS coding with
one code for the wheelchair base and then additional
codes for wheelchair options and accessories. The decision
for a particular wheelchair base may be influenced
by the chair's intended use, the patient's size or
level of disability, or based on specific features
that will be incorporated into the chair (for example,
a heavy-duty base with additional electronics features
may be needed to support a power tilt and/or recline
option.)
The following is a list of wheelchair bases and their
characteristics:
Power wheelchairs are battery powered mobility devices
with integrated or modular seating system, electronic
steering and four or more wheel non-highway construction. PWCs
are divided into six performance-based groups as follows:
The above six PWC groups are subdivided based on patient
weight capacity, seat type, portability and/or power
seating system capability.
Portable denotes a PWC that is built of lightweight
construction or can be disassembled into lightweight
components that allow easy placement into a vehicle
for use in a distant location.
Power options that may be added to a PWC to include
power tilt, recline, elevating legrests, seat elevators
or standing systems. There are three categories
of PWCs based on the capability to accept and operate
these power options:
Pediatric PWCs are uniquely sized for use with very
small individuals and have the capability for extensive
growth through frame adjustments (not just seating)
and special features to address developmental issues
(e.g., seat to floor placement, standing capability).
Each power wheelchair base code is intended to include
all of the following Basic Equipment Package items
on initial issue:
Adult manual wheelchairs (K0001, K0002, K0003, K0004,
K0005, K0006, K0007, K0009, E1161) are those which
have a seat width and a seat depth of 15" or greater.
Pediatric manual wheelchairs (E1229, E1231, E1232,
E1233, E1234, E1235, E1236, E1237, E1238,) are those
which have a seat width and a seat depth of 14"
or less.
In addition, specific codes are defined by the following
characteristics:
| 1. |
All of
the following general criteria must be
met for a wheelchair to be considered
for benefits. Following this section
there are specific criteria for manual,
motorized/power and backup wheelchairs
and wheelchair accessories. |
| |
A. |
The
patient’s ability to participate
in one or more activities of daily living
(ADLs) (e.g., toileting, feeding, dressing,
grooming, bathing) in customary locations in
the home are significantly impaired
due to mobility-related limitations which: |
| |
|
1) |
Prevent accomplishing ADLs
entirely, or |
| |
|
2) |
Place the patient at heightened
risk of morbidity or mortality secondary
to attempts to participate in ADLs, or |
| |
|
3) |
Prevent completion of ADLs
within a reasonable time frame. |
| |
|
4) |
The
requested wheelchair may be expected
to significantly improve or restore the
patient’s ability to perform or
participate in ADLs in the home setting; |
| |
|
|
|
|
|
| |
B. |
The
patient’s mobility deficit is of
a type and complexity such that other
mobility assistive devices (e.g., canes,
walkers, crutches, POV) would not sufficiently
resolve functional mobility limitations
in the home; |
| |
C. |
The
patient has not already been approved
for a power operated vehicle (POV). |
| |
D. |
The
patient has the ability and willingness
to safely operate a wheelchair in the
home setting; |
| |
E. |
The
patient is expected to be mobile for
at least two hours a day; |
| |
F. |
The
patient’s home environment
(e.g., physical layout, maneuvering
space, surfaces, obstacles) will
support the use of a wheelchair. |
| |
|
| 2. |
Wheelchairs
and accessories are considered not medically
necessary when: |
| |
A. |
The
patient is capable of ambulation within
the home but requires a wheelchair for
movement outside the home |
| |
B. |
The
primary benefit of the wheelchair is
to allow the patient to perform leisure
or recreational activities |
| |
C. |
The
patient has been approved for a power
operated vehicle (POV) |
| |
D. |
The
accessory is used for the convenience
of the patient or caregiver and is not
necessary for performance of instrumental
activities of daily living |
| |
|
|
|
|
|
|
| 3. |
If all of
the above criteria are met, the following
guidelines apply: |
| |
|
|
| Manual
Wheelchair Base |
| |
|
|
|
| |
A. |
A
Standard Hemi-Wheelchair (K0002) may
be considered medically necessary when
the patient requires a lower seat height
(17"
-18") because of short stature or
feet placement for self-propulsion. |
| |
B. |
A
Lightweight Wheelchair (K0003) may be
considered medically necessary when both
of the following criteria are met: |
| |
|
1. |
The
patient is incapable of self-propulsion
in a standard wheelchair using arms and/or
legs; and |
| |
|
2. |
The
patient demonstrates the desire and ability
to self-propel in a lightweight wheelchair. |
| |
C. |
A
High Strength Lightweight Wheelchair
(K0004) is rarely medically necessary
if the expected duration of need is less
than 3 months (e.g., postoperative recovery). A High Strength Lightweight
Wheelchair may be considered medically
necessary when at least one of the following
criteria are met: |
| |
|
1. |
The
patient self-propels the wheelchair while
engaging in frequent activities that
cannot be performed in a standard or
lightweight wheelchair, and/or |
| |
|
2. |
The
patient requires a seat width, depth,
or height that cannot be accommodated
in a standard, lightweight or hemi-wheelchair
and spends at least 2 hours per day in
the wheelchair. |
| |
D. |
An
Ultra Lightweight Wheelchair (K0005),
which includes an adjustable axle (e.g.,
the K5), series is rarely medically necessary
for the patient to perform instrumental
activities of daily living. An
Ultra Lightweight Wheelchair (i.e., weight
less than 30 pounds) may be considered
medically necessary when documentation
by a licensed treating practitioner (i.e.,
physician, physician’s assistant,
nurse practitioner, clinical nurse specialist,
physical therapist, occupational therapist)
shows that all of the following criteria
are met: |
| |
|
1) |
The
patient’s ability to participate
in one or more ADLs (e.g., toileting,
feeding, dressing, grooming, bathing)
in customary locations in the home are
significantly impaired with either a
standard or lightweight wheelchair due
to mobility-related limitation as defined
in the general requirements in 1.A. above. |
| |
|
2) |
The
patient is incapable of self-propulsion
in a standard or lightweight wheelchair
using arms and/or legs |
| |
|
3) |
The
patient demonstrates the desire and ability
to self-propel in an ultra lightweight
wheelchair |
| |
E. |
A
Heavy Duty Wheelchair (K0006) may be
medically necessary if the patient weighs
more than 250 pounds or the patient has
severe spasticity. |
| |
F. |
An
Extra Heavy Duty Wheelchair (K0007) may
be medically necessary if the patient
weighs more than 300 pounds. |
| |
|
|
| Motorized/Power
Wheelchair Base and Power Options |
| |
|
|
|
| |
A. |
A
motorized/power wheelchair for
adults (K0010, K0012, K0014,
K0813-K0886) may be considered medically
necessary when all of the following criteria
are met: |
| |
|
1) |
The
patient's condition is such that a wheelchair
is medically necessary and the patient
is unable to operate the wheelchair manually.
A patient who requires a power wheelchair
usually is totally nonambulatory and
has severe weakness, pain, deformity
or limitations in endurance, coordination
or range of motion of the upper extremities
due to a neurologic or muscular, or cardiopulmonary
disease/condition. |
| |
|
2) |
The
patient is capable of safely operating
the controls for the power wheelchair. |
| |
|
3) |
The
patient's condition is such that the
requirement for a power wheelchair is
long term (at least six months). |
| |
B. |
Motorized/power
wheelchairs for children (E1239,
K0890, K0891) two years of age or older
with severe motor disability may be considered
medically necessary when all the following
criteria have been met: |
| |
|
1) |
The
child's condition is such that a wheelchair
is medically necessary and the child
is unable to operate the wheelchair manually. |
| |
|
2) |
The
child has demonstrated the ability to
safely and effectively operate a motorized
wheelchair during a two month trial rental
period. |
| |
|
3) |
As
a result of the two month trial, there
must be evidence that the use of the
motorized wheelchair has enhanced the
child's overall development. |
| |
C. |
A
motorized/power wheelchair is considered
not medically necessary for either of
the following: |
| |
|
1) |
The
patient is capable of using a manual
wheelchair or other mobility assistive
device within the home but requires a
motorized/power wheelchair for movement
outside the home |
| |
|
2) |
The
primary benefit of the motorized/power
wheelchair is to allow the patient to
perform leisure or recreational activities |
| |
D. |
One
month's rental of a wheelchair may be
considered medically necessary when a
patient-owned wheelchair is being repaired. |
| |
E. |
When
the above criteria are met, the following
guidelines for PWC group and power options
apply: |
| |
|
1) |
A
Group 1 PWC (K0813-K0816) or Group 2
PWC (K0820-K0829), a push rim power assist
device (E0986) or a power-assisted wheelchair
may be considered medically necessary
when the wheelchair is appropriate for
the patient’s weight. |
| |
|
2) |
A
Group 2 PWC with single power option
(K0835 – K0840) may be considered
medically necessary when one or both
of the following criteria are met: |
| |
|
|
a. |
The
patient requires a drive control interface
other than a hand or chin-operated standard
proportional joystick (e.g. head control,
sip and puff, switch control) |
| |
|
|
b. |
The
patient meets criteria for a power tilt
or a power recline seating system and
the system is being used on the wheelchair |
| |
|
3) |
A
Group 2 PWC with multiple power options
(K0841 – K0843) may be considered
medically necessary when one or both
of the following criteria are met: |
| |
|
|
a. |
The
patient meets criteria for a power tilt
or a power recline seating system and
the system is being used on the wheelchair |
| |
|
|
b. |
The
patient uses a ventilator which is mounted
on the wheelchair |
| |
|
4) |
A
Group 3 PWC with no power options (K0848 – K0855)
may be considered medically necessary
when the patient's mobility limitation
is due to a neurological condition, myopathy
or congenital skeletal deformity. |
| |
|
5) |
A
Group 3 PWC with single power option
(K0856-K0860) may be considered medically
necessary when the patient's mobility
limitation is due to a neurological condition,
myopathy or congenital skeletal deformity
and one or both of the following criteria
are met: |
| |
|
|
a. |
The
patient requires a drive control interface
other than a hand or chin-operated standard
proportional joystick (e.g., head control,
sip and puff, switch control); OR |
| |
|
|
b. |
The
patient meets coverage criteria for a
power tilt or a power recline seating
system and the system is being used on
the wheelchair |
| |
|
6) |
A
Group 3 PWC with multiple power options
(K0861-K0864) may be considered medically
necessary when the patient's mobility
limitation is due to a neurological condition,
myopathy or congenital skeletal deformity
and one or both of the following criteria
are met: |
| |
|
|
a. |
The
patient meets coverage criteria for a
power tilt or a power recline seating
system and the system is being used on
the wheelchair, OR |
| |
|
|
b. |
The
patient uses a ventilator which is mounted
on the wheelchair |
| |
|
7) |
Group
4 PWCs (K0868-K0886) have added capabilities
that are considered not medically necessary
in the home (e.g., higher speed, longer
range, greater obstacle climb capabilities)
and are, therefore, considered an upgrade
of Group 2 and Group 3 PWCs. |
| |
|
8) |
A
Group 5 (Pediatric) PWC with Single Power
Option (K0890) may be considered medically
necessary when the patient is expected
to grow in height and one or both of
the following criteria are met: |
| |
|
|
a. |
The
patient requires a drive control interface
other than a hand or chin-operated standard
proportional joystick (e.g., head control,
sip and puff, switch control); OR |
| |
|
|
b. |
The
patient meets coverage criteria for a
power tilt or a power recline seating
and the system is being used on the wheelchair. |
| |
|
9) |
A
Group 5 (Pediatric) PWC with multiple
power options (K0891) may be considered
medically necessary when the patient
is expected to grow in height and one
or both of the following criteria are
met: |
| |
|
|
a. |
The
patient meets coverage criteria for a
power tilt or a power recline seating
system and the system is being used on
the wheelchair. |
| |
|
|
b. |
The
patient uses a ventilator which is mounted
on the wheelchair |
| |
| Manual
Backup Wheelchair and Transport Chair |
| |
|
|
| |
A. |
A
manual back-up wheelchair (E1130 or K0001)
or a transport chair (E1037, E1038, or
E0139) is rarely considered medically
necessary. A back-up standard manual
wheelchair may be considered medically
necessary when either of the two following
criteria are met: |
| |
|
1) |
The
patient’s motorized wheelchair
cannot be used in areas essential for
access |
| |
|
2) |
The
patient’s motorized wheelchair
cannot be transported using the usual
available transportation (e.g., family
car) |
| |
|
|
|
| |
| Non-standard
Wheelchair Options |
| |
|
|
| |
A. |
Arm
of Wheelchair |
| |
|
1) |
Adjustable
Arm Height (E0973, K0017, K0018, K0020)
may be considered medically necessary
when both of the following criteria
are met: |
| |
|
|
a. |
The
patient requires an arm height that is
different than that available using non-adjustable
arm |
| |
|
|
b. |
The
patient spends at least two hours per
day in the wheelchair. |
| |
|
2) |
An
Arm Trough (E2209) may be medically necessary
if the patient has quadriplegia, hemiplegia,
or uncontrolled arm movements. |
| |
B. |
Foot
and Legrests |
| |
|
1) |
Elevating
Legrests (E0990, E1083, E1084, E1087,
E1088, E1092, E1100, E1110, E1150, E1160,
E1170, E1190, E1195, E1222, E1224, E1240,
E1270, E1280, E1295, K0046, K0047, K0053,
K0195) may be considered medically necessary
if: |
| |
|
|
a. |
The
patient has a musculoskeletal condition
or the presence of a cast or brace which
prevents 90 degree flexion at the knee;
or |
| |
|
|
b. |
The
patient has significant lower extremity
edema that requires having an elevating
leg rest; or |
| |
|
|
c. |
The
patient meets the criteria for and has
a reclining back on the wheelchair. |
| |
|
2) |
Power
elevating leg rests may be considered
medically necessary if: |
| |
|
|
a. |
The
patient is unable to use upper extremities
to elevate leg rests independently, and |
| |
|
|
b. |
The
patient is left alone for periods of
two or more hours during the day or does
not have someone readily available to
assist with needed positioning such as
in a work or school setting. |
| |
|
3) |
Swingaway, Detachable Footrests (E1085,
E1086, E1088, E1089, E1090, E1092, E1093,
E1130, E1140, E1150, E1160, E1170, E1180,
E1190, E1195, E1200, E1240, E1250, E1260,
E1270, E1285, E1290, K0052) are included
with a wheelchair base and may be considered
medically necessary only as replacements. |
| |
|
4) |
An
Articulating (Telescoping) Elevating
Footrest (K0053) does not have significant
benefits compared to a standard (non-telescoping)
elevating leg rest and is not considered
medically necessary |
| |
C. |
Standing
Systems |
| |
|
1) |
Power
standing systems (E2301) are deluxe upgrades
and considered not medically necessary. |
| |
|
2) |
A
standing wheelchair or all-in-one wheelchair/stander
(e.g., Permobile® Chairman 2K, Redman
Chief Powerchair, Fena Design Vertran,
Superstand, LifeStand®) has not been
shown to have significant benefit compared
with separate wheelchair and stander
and are considered not medically necessary. |
| |
|
3) |
Gliders
are considered exercise equipment and
do not meet the definition of durable
medical equipment. |
| |
D. |
Back
and Seating Systems |
| |
|
1) |
A
power seat elevation feature (E2300)
and power wheelchair attendant control
(E2331) are not considered medically
necessary. If a wheelchair has an electrical
connection device described by code E2310
or E2311 and if the sole function of
the connection is for a power seat elevation
or a power wheelchair attendant control,
it is considered not medically necessary. |
| |
|
2) |
Power
seating system with power tilt and/or
recline features (E1002, E1003, E1004,
E1005, E1006, E1007, E1008, E1009, E1010)
may be considered medically necessary
when all of the following criteria are
met: |
| |
|
|
a. |
Patient
is wheelchair confined |
| |
|
|
b. |
Patient
is unable to perform a functional weight
shift or transfer independently from
wheelchair to bed |
| |
|
|
c. |
Patient
cannot operate a manual tilt |
| |
|
|
d. |
Patient
is left alone for periods of 2 or more
hours during the day or does not have
someone readily available to assist with
needed positioning such as in a work
or school setting |
| |
|
3) |
A manual fully reclining back or manual
Tilt-in-Space wheelchair or wheelchair
option (E1014, E1050, E1060, E1070, E1083,
E1084, E1085, E1086, E1161, E1226, E1231,
E1232, E1233, E1234), may be considered
medically necessary if the patient spends
at least 2 hours per day in the wheelchair
and has one or more of the following
conditions/needs: |
| |
|
|
a. |
Quadriplegia |
| |
|
|
b. |
Fixed
hip angle |
| |
|
|
c. |
Trunk
or lower extremity casts/braces that
require the reclining back feature for
positioning |
| |
|
|
d. |
Excess
extensor tone of the trunk muscles |
| |
|
|
e. |
The
need to rest in a recumbent position
two or more times during the day and
transfer between wheelchair and bed is
very difficult. |
| |
|
4) |
A
Prefabricated Back and/or Seat Module
which is incorporated into a wheelchair
base may be considered medically necessary. |
| |
|
5) |
Prefabricated
Inner Frame Back Support systems are
not generally accepted as being reasonable
and necessary to provide trunk support
in patients in wheelchairs and are not
considered medically necessary. |
| |
|
6) |
A
Custom Fabricated Seating System, Back
and/or Seat Module (e.g., Ride™,
Invacare® PinDot® ContourU®)
may be considered medically necessary
when all of the following criteria
are met: |
| |
|
|
a. |
The
patient has a significant spinal deformity
and/or severe weakness of the trunk muscles; |
| |
|
|
b. |
The
patient's need for prolonged sitting
tolerance, postural support to permit
functional activities, or pressure reduction
cannot be met adequately by a prefabricated
seating system; and |
| |
|
|
c. |
The
patient is expected to be in the wheelchair
at least two hours per day. |
| |
|
7) |
A
Custom fabricated seating system with
all-in-one back, seat and side support
(e.g., Aspen®) has not been shown
to have significant benefit compared
to a standard custom fabricated seating
module and is considered not medically
necessary. |
| |
|
8) |
A
solid seat insert added to a seat cushion
to provide a firm base is considered
an integral part of a seat cushion. |
| |
E. |
Cushions
and Positioning Accessories |
| |
|
1) |
A
powered seat cushion (E2610) is considered
not medically necessary because effectiveness
has not been established. |
| |
|
2) |
A
skin protection seat cushion (E2603,
E2604, K0734, K0735) may be medically
necessary on a wheelchair with a sling
or solid seat or back when one or more
of the following criteria are met: |
| |
|
|
a. |
Patient
has current or past history of pressure
ulcer on the area of contact with the
seating surface |
| |
|
|
b. |
Patient
has absent or impaired sensation in the
area of contact with the seating surface
or inability to perform functional weight
shift |
| |
|
3) |
A
general use seat cushion (E2601, E2602),
general use back cushion (E2611, E2612),
positioning seat cushion (E2605, E2606),
positioning back cushion (E2613, E2614,
E2615, E2616, E2620, E2621) and positioning
accessories (E0955, E0956, E0957, E0960)
on a wheelchair with a sling or solid
seat or back may be considered medically
necessary for patients with significant
postural asymmetries. |
| |
|
4) |
A
separate seat and/or back cushion with
a power wheelchair with a captain’s
seat is considered not medically necessary. |
| |
|
5) |
A
combination skin protection and positioning
seat cushion (E2607, E2608, K0736, K0737)
may be considered medically necessary
when all of the criteria for both a skin
protection seat cushion and a positioning
seat cushion are met. |
| |
|
6) |
A
custom fabricated seat cushion (E2609)
and/or custom fabricated back cushion
E2617) may be considered medically necessary
if both of the following criteria are
met: |
| |
|
|
a. |
The
patient meets the criteria for general
use or positioning seat and/or back cushion
(criterion 3.E).3) above) |
| |
|
|
b. |
There
is documentation which clearly explains
why a prefabricated seating system is
not sufficient to meet the patient’s
needs. |
| |
|
7) |
A
headrest (E0955) may be considered medically
necessary for a manual tilt-in-space
wheelchair, manual reclining back on
a manual or power wheelchair or a power
tilt and/or recline power seating system. |
| |
|
|
A
headrest or other positioning accessories
for a power wheelchair with a captain’s
chair seat is considered not medically
necessary. |
| |
|
|
|
|
| |
F. |
Batteries
and Battery Chargers |
| |
|
1. |
Up
to two sealed batteries (E2361, E2363,
E2365, E2371, K0733) may be considered
medically necessary at any one time if
required for a power wheelchair. |
| |
|
2. |
A
non-sealed battery (E2360, E2362, E2364,
E2372) is considered not medically necessary. |
| |
|
3. |
A
single mode Battery Charger (E2366) is
included with a power wheelchair base
and may be considered medically necessary
only as a replacement. |
| |
|
4. |
A
dual mode charger (E2367) is considered
not medically necessary. |
| |
G. |
Miscellaneous
Wheelchair Options and Accessories |
| |
|
1. |
A
headrest with mounting (E0955) may be
considered medically necessary when one
of the following criteria is met: |
| |
|
|
a. |
The
patient has weak neck muscles and needs
a headrest for support |
| |
|
|
b. |
The
patient meets the criteria for and has
a reclining back on the wheelchair |
| |
|
2. |
A
Safety Belt/Pelvic Strap (E0978) may
be medically necessary if the patient
has weak upper body muscles, upper body
instability or muscle spasticity which
requires use of this item for proper
positioning. |
| |
|
3. |
An
Anti-Rollback Device (E0974) and an Anti-tipping
Device (E0971) may be medically necessary
if the patient self-propels and needs
the device because of ramps. |
| |
|
4. |
Upgraded
and specialty wheels (e.g., Spinergy®)
are considered not medically necessary
because they are not required for performance
of instrumental activities of daily living. |
| |
|
5. |
A
Crutch and Cane Holder (E2207) may be
medically necessary for patients who
are ambulatory for short distances. |
| |
|
6. |
A
Wheelchair Tray Table (E0950) attached
to the wheelchair may be medically necessary
if the patient has weak upper body muscles,
upper body instability or muscle spasticity
which require the use of this item for
proper positioning. |
| |
|
7. |
An
electronic interface (E2351) to allow
a speech generating device to be operated
with the power wheelchair control interface
may be medically necessary if the patient
has a medically necessary speech generating
device (see Medical Policy, DME, No.
52). |
| |
|
8. |
Electronic
interfaces for lights or other electronic
devices are considered not medically
necessary. |
| |
|
9. |
Various
individual wheelchair options and accessories
that are not otherwise listed above may
be considered medically necessary when
both of the following criteria are met: |
| |
|
|
a. |
The
option/accessory is necessary for the
patient to perform instrumental activities
of daily living; and |
| |
|
|
b. |
The
option/accessory is not primarily for
the purpose of allowing the patient to
perform leisure or recreational activities. |
Durable Medical Equipment Section Table of
Contents 
