Or. Admin. Code § 410-122-0340 - Wheelchair Options/Accessories
(1)
Indications and limitations of coverage and medical appropriateness:
(a) The Division may cover options and
accessories for covered wheelchairs when the following criteria are met:
(A) The client has a wheelchair that meets
Division coverage criteria; and
(B)
The client requires the options/accessories to participate in one or more
mobility-related activities of daily living (MRADLs) in the home, community or
any non-institutional setting in which normal life activities take place. See
OAR 410-122-0010, Definitions for
definition of MRADLs.
(b) The Division does not cover
options/accessories whose primary benefit is allowing the client to perform
leisure or recreational activities;
(c) Armrests:
(A) Adjustable arm height option (E0973,
K0017, K0018, and K0020) may be covered when the client:
(i) Requires an arm height that is different
than what is available using nonadjustable arms; and
(ii) Spends at least two (2) hours per day in
the wheelchair.
(B) An
arm trough (E2209) is covered if the client has quadriplegia, hemiplegia, or
uncontrolled arm movements.
(d) Footrest/Legrest:
(A) Elevating legrests (E0990, K0046, K0047,
K0053, and K0195) may be covered when:
(i) The
client has a musculoskeletal condition or the presence of a cast or brace that
prevents 90 degree flexion at the knee;
(ii) The client has significant edema of the
lower extremities that requires having an elevating legrest; or
(iii) The client meets the criteria for and
has a reclining back on the wheelchair.
(B) Elevating legrests that are used with a
wheelchair that is purchased or owned by the patient are coded E0990. This code
is per legrest;
(C) Elevating
legrests that are used with a capped rental wheelchair base shall be coded
K0195. This code is per pair of legrests.
(D) A footbox (E0954) is a padded box
designed to position a client's foot. This item comes in multiple
configurations and may be for a single foot or for both feet. Regardless of
configuration, the unit of service is per foot. E0954 includes both
prefabricated and custom fabricated products. The code also includes all
mounting hardware so E1028 is not separately payable with this code.
(e) Nonstandard Seat Frame
Dimensions:
(A) For all adult wheelchairs,
payment for seat widths or seat depths of 15-19 inches is included in the
payment for the base code. These seat dimensions shall not be billed
separately;
(B) Codes E2201-E2204
and E2340-E2343 describe seat widths or depths of 20 inches or more for manual
or power wheelchairs;
(C) A
nonstandard seat width or depth (E2201-E2204 and E2340-E2343) is covered only
if the patient's dimensions justify the need.
(f) Rear Wheels for Manual Wheelchairs. Code
E2213 (flat free insert) is used to describe either:
(A) A removable ring of firm material that is
placed inside of a pneumatic tire to allow the wheelchair to continue to move
if the pneumatic tire is punctured; or
(B) Non-removable foam material in a foam
filled rubber tire;
(C) E2213 is
not used for a solid self-skinning polyurethane tire.
(g) Batteries/Chargers:
(A) Up to two batteries (E2359-E2365, E2371,
K0733) at any one time are allowed if required for a power
wheelchair;
(B) Batteries/chargers
(E2366) for power wheelchairs are payable separately from the purchased
wheelchair base.
(h)
Seating:
(A) The Division may cover a general
use seat cushion and a general-use wheelchair back-cushion for a client whose
wheelchair meets Division coverage criteria;
(B) A skin protection seat cushion may be
covered for a client who meets both of the following criteria:
(i) The client has a wheelchair that meets
Division coverage criteria; and
(ii) The client has either of the following:
(I) Current pressure ulcer or past history of
a pressure ulcer on the area of contact with the seating surface; or
(II) Absent or impaired sensation in the area
of contact with the seating surface or inability to carry out a functional
weight shift.
(C) A positioning seat cushion (E2605,
E2606), positioning back cushion (E2613-E2616, E2620, E2621), and positioning
accessory (E0953, E0955-E0957, E0960) may be covered for a client who meets
both of the following criteria:
(i) The client
has a wheelchair with a sling/solid seat/back and client meets Division
coverage criteria; and
(ii) The
client has any significant postural asymmetries.
(D) A combination skin protection and
positioning seat cushion (E2607, E2608, E2624, E2625) may be covered when a
client meets the criteria for both a skin protection seat cushion and a
positioning seat cushion;
(E)
Separate payment is allowed for a seat cushion solid support base (E2231) with
mounting hardware when it is used on an adult manual wheelchair (K0001-K0009,
E1161). Separate payment is not allowed for the solid support base and mounting
hardware when it is used on a power wheelchair;
(F) There is no separate payment for a solid
insert (E0992) that is used with a seat or back cushion because a solid base is
included in the allowance for a wheelchair seat or back cushion;
(G) There is no separate payment for mounting
hardware for a seat or back cushion;
(H) There is no separate payment for a
headrest (E0955, E0966) on a captain's seat on a power wheelchair;
(I) A custom fabricated seat cushion (E2609)
and a custom fabricated back cushion (E2617) are cushions that are individually
made for a specific patient:
(i) Basic
materials include liquid foam or a block of foam and sheets of fabric or liquid
coating material:
(I) A custom fabricated
cushion may include certain prefabricated components (e.g., gel or
multi-cellular air inserts). These components may not be billed
separately;
(II) The cushion must
have a removable vapor permeable or waterproof cover or it must have a
waterproof surface.
(ii)
The cushion must be fabricated using molded-to-patient-model technique, direct
molded-to-patient technique, computer-aided design and computer-aided
manufacturing (CAD-CAM) technology, or detailed measurements of the patient
used to create a configured cushion:
(I) If
foam-in-place or other material is used to fit a substantially prefabricated
cushion to an individual client, the cushion must be billed as a prefabricated
cushion, not custom fabricated;
(II) The cushion must have structural
features that significantly exceed the minimum requirements for a seat or back
positioning cushion.
(iii) If a custom fabricated seat and back
are integrated into a one-piece cushion, code as E2609 plus E2617.
(J) A custom fabricated seat
cushion may be covered if criteria in subparagraph (i) and (iii) are met. A
custom fabricated back cushion may be covered if criteria subparagraph (ii) and
(iii) are met:
(i) Client meets all of the
criteria for a prefabricated skin protection seat cushion or positioning seat
cushion;
(ii) Client meets all of
the criteria for a prefabricated positioning back cushion;
(iii) There is a comprehensive written
evaluation by a licensed/certified medical professional, such as a physical
therapist (PT) or occupational therapist (OT), who is not an employee of or
otherwise paid by a durable medical equipment, prosthetics, orthotics and
supplies (DMEPOS) provider, which clearly explains why a prefabricated seating
system is not sufficient to meet the client's seating and positioning
needs.
(K) A
prefabricated seat cushion, a prefabricated positioning back cushion, or a
brand name custom fabricated seat or back cushion that has not received a
written coding verification as published by the Pricing, Data Analysis and
Coding (PDAC) contractor by the Centers for Medicare and Medicaid Services; or
that does not meet the criteria stated in this rule is not covered;
(L) A headrest extension (E0966) is a sling
support for the head. Code E0955 describes any type of cushioned
headrest;
(M) The code for a seat
or back cushion includes any rigid or semi-rigid base or posterior panel,
respectively, that is an integral part of the cushion;
(N) A solid insert (E0992) is a separate
rigid piece of wood or plastic that is inserted in the cover of a cushion to
provide additional support and is included in the allowance for a seat
cushion;
(O) A solid support base
for a seat cushion is a rigid piece of plastic or other material that is
attached with hardware to the seat frame of a wheelchair in place of a sling
seat. A cushion is placed on top of the support base. Use code E2231 for this
solid support base that is used with a manual wheelchair. A solid support base
is included in the allowance for power wheelchair codes. Separate payment is
not allowed for a solid support base and mounting hardware when it is used on a
power wheelchair;
(i)
The Division shall only cover accessories billed under the following codes when
PDAC makes written confirmation of use of the code for the specific product
being billed: E2601-E2608, E2610-E2616, E2620-E2625, E2609 and E2617
(brand-name products); K0108 (for wheelchair cushions):
(A) Information concerning the documentation
that must be submitted to PDAC for a Coding Verification Request can be found
on the PDAC website or by contacting PDAC;
(B) A product classification list with
products that have received a coding verification can be found on the PDAC
website.
(j) Code E1028
(swingaway or removable mounting hardware upgrade) may be billed in addition to
codes E0955-E0957. It shall not be billed in addition to codes E0950, E0954,
E0960, E1020 or E2325 as mounting hardware is included in the allowance for
these codes. It shall not be used for mounting hardware related to a wheelchair
seat cushion or back cushion code;
(k) Power seating systems:
(A) A power-tilt seating system (E1002):
(i) Includes all the following:
(I) A solid seat platform and a solid back;
any frame width and depth;
(II)
Detachable or flip-up fixed height or adjustable height armrests;
(III) Fixed or swingaway detachable
legrests;
(IV) Fixed or flip-up
footplates;
(V) Motor and related
electronics with or without variable speed programmability;
(VI) Switch control that is independent of
the power wheelchair drive control interface;
(VII) Any hardware that is needed to attach
the seating system to the wheelchair base.
(ii) It does not include a
headrest;
(iii) It must have the
following features:
(I) Ability to tilt to
greater than or equal to 20 degrees from horizontal;
(II) Ability for the supplier to adjust the
seat to back angle;
(III) Ability
to support patient weight of at least 250 pounds.
(B) A power recline seating system
(E1003-E1005):
(i) Includes all the following:
(I) A solid seat platform and a solid
back;
(II) Any frame width and
depth;
(III) Detachable or flip-up
fixed height or adjustable height arm rests;
(IV) Fixed or swingaway detachable
legrests;
(V) Fixed or flip-up
footplates;
(VI) A motor and
related electronics with or without variable speed programmability;
(VII) A switch control that is independent of
the power wheelchair drive control interface;
(VIII) Any hardware that is needed to attach
the seating system to the wheelchair base.
(ii) It does not include a
headrest;
(iii) It must have the
following features:
(I) Ability to recline to
greater than or equal to 150 degrees from horizontal;
(II) Back height of at least 20
inches;
(III) Ability to support
patient weight of at least 250 pounds.
(C) A power tilt and recline seating system
(E1006-E1008):
(i) Includes the following:
(I) A solid seat platform and a solid
back;
(II) Any frame width and
depth; detachable or flip-up fixed height or adjustable height
armrests;
(III) Fixed or swing-away
detachable legrests; fixed or flip-up footplates;
(IV) Two motors and related electronics with
or without variable speed programmability;
(V) Switch control that is independent of the
power wheelchair drive control interface;
(VI) Any hardware that is needed to attach
the seating system to the wheelchair base.
(ii) It does not include a
headrest;
(iii) It must have the
following features:
(I) Ability to tilt to
greater than or equal to 20 degrees from horizontal;
(II) Ability to recline to greater than or
equal to 150 degrees from horizontal;
(III) Back height of at least 20 inches;
ability to support patient weight of at least 250 pounds.
(D) Coding for a power tilt system
(E1002), power recline system (E1003-E1005), and tilt/recline system
(E1006-E1008) are all inclusive. Billing K0108 for additional heavy duty or
bariatric features is considered unbundling and not allowed;
(E) A mechanical shear reduction feature
(E1004 and E1007) consists of two separate back panels. As the posterior back
panel reclines or raises, a mechanical linkage between the two panels allows
the client's back to stay in contact with the anterior panel without sliding
along that panel;
(F) A power shear
reduction feature (E1005 and E1008) consists of two separate back panels. As
the posterior back panel reclines or raises, a separate motor controls the
linkage between the two panels and allows the client's back to stay in contact
with the anterior panel without sliding along that panel;
(G) A power leg elevation feature (E1010,
E1012) involves a dedicated motor and related electronics with or without
variable speed programmability that allows the legrest to be raised and lowered
independently of the recline and/or tilt of the seating system. It includes a
switch control that may or may not be integrated with the power tilt and
recline controls;
(l) A
center mount power elevating leg rest/platform includes all components of the
leg rest, including fixed angle footplates and foot platforms. Adjustable angle
footplates coded K0040 are separately payable when provided with leg rests
coded as E1012.(l) Codes E2300, E2310 and E2311 (Power Wheelchair Accessory):
(A) Describe the electronic components that
allow the client to control two or more of the following motors from a single
interface (e.g., proportional joystick, touchpad, or non-proportional
interface): Power wheelchair drive, power tilt, power recline, power shear
reduction, power leg elevation, power seat elevation, power standing;
(B) Include a function selection switch that
allows the client to select the motor that is being controlled and an indicator
feature to visually show which function has been selected;
(C) When the wheelchair drive function is
selected the indicator feature may also show the direction that is selected
(forward, reverse, left, right). This indicator feature may be in a separate
display box or may be integrated into the wheelchair interface;
(D) Payment for the code includes an
allowance for fixed mounting hardware for the control box and for the display
box (if present);
(E) When a switch
is medically appropriate and a client has adequate hand motor skills, a switch
shall be considered the least costly alternative;
(F) E2300, power seat elevation system, may
be covered for clients using complex power wheelchairs, when one of the
following criteria (i) or (ii) are met and (iii)-(iv) are met:
(i) The client must routinely transfer
between uneven surfaces and the seat elevation feature allows them to
accomplish transfers independently or with caregiver assistance; or
(ii) The client cannot be safely transferred
using a patient lift or standing transfer and can safely transfer with the seat
elevation feature; or
(iii) The
seat elevation feature has been demonstrated to allow the client to access
areas in the home or community necessary to perform their MRADLs; and
(iv) The client has had a specialty
evaluation that documents the medical need and client's ability to safely
operate the seat elevation equipment. This evaluation must be performed by a
licensed/certified medical professional, such as physical therapist (PT) or
occupational therapist (OT), or practitioner who has specific training and
experience in rehabilitation wheelchair evaluations; and
(v) Power seat elevation systems added to
complex rehabilitative power wheelchairs (K0835-K0864) and Group 5 power
wheelchairs (K0890, K0891) must use code E2300.
(vi) Code E2300 cannot be added to any
non-complex power wheelchair base (K0813-K0829). HCPCS codes K0830 and K0831
for Group 2 standard base wheelchairs (non-complex) include the seat elevation
feature and may be used if client meets criteria for the power wheelchair and
the seat elevation criteria are met.
(G) E2310 or E2311 may be covered when a
client does not have hand motor skills or presents with cognitive deficits,
contractures, or limitation of movement patterns that prevents operation of a
switch;
(H) In addition, an
alternate switching system must be medically appropriate and not hand
controlled (not running through a joystick).
(m) Power Wheelchair Drive Control Systems:
(A) The term interface in the code narrative
and definitions describes the mechanism for controlling the movement of a power
wheelchair. Examples of interfaces include but are not limited to joystick, sip
and puff, chin control, head control, etc.;
(B) A proportional interface is one in which
the direction and amount of movement by the client controls the direction and
speed of the wheelchair. One example of a proportional interface is a standard
joystick;
(C) A non-proportional
interface is one that involves a number of switches. Selecting a particular
switch determines the direction of the wheelchair, but the speed is
pre-programmed. One example of a non-proportional interface is a sip-and-puff
mechanism;
(D) The term controller
describes the microprocessor and other related electronics that receive and
interpret input from the joystick (or other drive control interface) and
convert that input into power output to the motor and gears in the power
wheelchair base;
(E) A
non-expandable controller has the following features:
(i) May have the ability to control up to 2
power seating actuators through the drive control (for example, seat elevator
and single actuator power elevating leg rests). Control of these items require
the use of an additional component, E2310 or E2311); and
(ii) Can accommodate only an integral
joystick or a standard proportional remote joystick; and
(iii) May allow for the incorporation of an
attendant control;
(F)
An expandable controller is capable of accommodating or operating one or more
of the following additional functions or devices:
(i) Other types of proportional input devices
(e.g., mini-proportional or compact joysticks, touchpads, chin control, head
control, etc);
(ii)
Non-proportional input devices (e.g., sip and puff, head array, etc);
(iii) Operate 3 or more powered seating
actuators through the drive control;
(iv) A separate display;
(v) Other electronic devices (e.g.,
augmentative communication device)
(vi) An attendant control;
(G) For power wheelchairs capable
of being upgraded to an expandable controller, E2377 is used if an expandable
controller is provided at the time of initial issue. Code E2376 is used with
complete replacement of an expandable controller;
(H) A harness (E2313) describes all of the
wires, fuse boxes, fuses, circuits, switches, etc. that are required for the
operation of an expandable controller. It includes all necessary fasteners,
connectors, and mounting hardware. Code E2313 is separately billable in
addition to an expandable controller both at initial issue and with complete
replacement.
(I) A switch is an
electronic device that turns power to a particular function either "on" or
"off." The external component of a switch may be either mechanical or
non-mechanical. Mechanical switches involve physical contact in order to be
activated. Examples of the external components of mechanical switches include
but are not limited to toggle, button, ribbon, etc. Examples of the external
components of non-mechanical switches include but are not limited to proximity,
infrared, etc. Some of the codes include multiple switches. In those
situations, each functional switch may have its own external component, or
multiple functional switches may be integrated into a single external switch
component, or multiple functional switches may be integrated into the
wheelchair control interface without having a distinct external switch
component;
(J) A stop switch allows
for an emergency stop when a wheelchair with a non-proportional interface is
operating in the latched mode. (Latched mode is when the wheelchair continues
to move without the patient having to continually activate the interface.) This
switch is sometimes referred to as a kill switch;
(K) A direction change switch allows the
client to change the direction that is controlled by another separate switch or
by a mechanical proportional head control interface. For example, it allows a
switch to initiate forward movement one time and backward movement another
time;
(L) A function selection
switch allows the client to determine what operation is being controlled by the
interface at any particular time. Operations may include but are not limited to
drive forward, drive backward, tilt forward, recline backward, etc.;
(M) An integrated proportional joystick and
controller is an electronics package in which a joystick and controller
electronics are in a single box that is mounted on the arm of the
wheelchair;
(N) The interfaces
described by codes E2312, E2321,E2322, E2325, and E2327-E2330, E2373-E2377 must
have programmable control parameters for speed adjustment, tremor dampening,
acceleration control, and braking;
(O) A mini-proportional (short-throw) remote
joystick (E2312) can only be used with an expandable controller. There is no
separate billing for control buttons, displays, switches, etc. There is no
separate billing for fixed mounting hardware, regardless of the body part used
to activate the joystick;
(P) A
remote joystick (E2321) is one in which the joystick is in one box that is
mounted on the arm of the wheelchair and the controller electronics are located
in a different box that is typically located under the seat of the
wheelchair;
(Q) When code E2321 is
used for a chin control interface, the chin cup is billed separately with code
E2324;
(R) Code E2322 describes a
system of 3-5 mechanical switches that are activated by the client touching the
switch. The switch that is selected determines the direction of the wheelchair.
A mechanical stop switch and a mechanical direction change switch, if provided,
are included in the allowance for the code;
(S) Code E2323 includes prefabricated
joystick handles that have shapes other than a straight stick, e.g., U shape or
T shape or that have some other nonstandard feature, e.g., flexible
shaft;
(T) A sip and puff interface
(E2325) is a non-proportional interface in which the client holds a tube in
their mouth and controls the wheelchair by either sucking in (sip) or blowing
out (puff). A mechanical stop switch is included in the allowance for the code.
E2325 does not include the breath tube kit that is described by code
E2326;
(U) A proportional,
mechanical head control interface (E2327) is one in which a headrest is
attached to a joystick-like device. The direction and amount of movement of the
client's head pressing on the headrest control the direction and speed of the
wheelchair. A mechanical direction control switch is included in the
code;
(V) A proportional,
electronic head control interface (E2328) is one in which a client's head
movements are sensed by a box placed behind the client's head. The direction
and amount of movement of the client's head (which does not come in contact
with the box) control the direction and speed of the wheelchair. A
proportional, electronic extremity control interface (E2328) is one in which
the direction and amount of movement of the client's arm or leg control the
direction and speed of the wheelchair;
(W) A non-proportional, contact switch head
control interface (E2329) is one in which a client activates one of three
mechanical switches placed around the back and sides of their head. These
switches are activated by pressure of the head against the switch. The switch
that is selected determines the direction of the wheelchair. A mechanical stop
switch and a mechanical direction change switch are included in the allowance
for the code;
(X) A
non-proportional, proximity switch head control interface (E2330) is one in
which a client activates one of three switches placed around the back and sides
of their head. These switches are activated by movement of the head toward the
switch, though the head does not touch the switch. The switch that is selected
determines the direction of the wheelchair. A mechanical stop switch and a
mechanical direction change switch are included in the allowance for the
code;
(Y) Code K0108 may not be
used for additional features of a joystick. K0108 is appropriately used at the
time of replacement in the following situations:
(i) An integrated proportional joystick and
controller box are being replaced due to damage; or
(ii) An interface other than a remote
joystick (e.g., sip and puff, head control) is being replaced but the
controller is not being replaced; or
(iii) There is no specific E code which
describes the type of drive control interface system which is
provided;
(Z) The KC
modifier (replacement of special power wheelchair interface) shall not be used
at the time of initial issue of a wheelchair but may be used in the following
situations:
(i) Due to a change in the
client's condition an integrated joystick and controller is being replaced by
another drive control interface, e.g., remote joystick, head control, sip and
puff, etc.; or
(ii) The client has
a drive control interface described by codes E2320-E2322, E2325, or E2327-E2330
and both the interface (e.g., joystick, head control, sip and puff), and the
controller electronics are being replaced due to irreparable damage.
(n) Other power
wheelchair accessories. An electronic interface (E2351) to allow a speech
generating device to be operated by the power wheelchair control interface may
be covered if the client has a covered speech generating device (See chapter
410, division 129, Speech-Language Pathology, Audiology and Hearing Aid
Services.);
(o) Miscellaneous
accessories:
(A) Anti-rollback device (E0974)
is covered if the client propels himself and needs the device because of
ramps;
(B) A safety belt/pelvic
strap (E0978) is covered if the client has weak upper body muscles, upper body
instability, or muscle spasticity that requires use of this item for proper
positioning;
(C) A shoulder
harness/straps or chest strap (E0960) and a safety belt/pelvic strap (E0978)
are covered only to treat a client's medical symptoms:
(i) A medical symptom is defined as an
indication or characteristic of a physical or psychological
condition;
(ii) E0960 and E0978 are
not covered when intended for use as a physical restraint or for purposes
intended for discipline or convenience of others.
(D) 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 client could perform a
slide transfer to a chair or bed;
(E) A manual fully reclining back option
(E1226) is covered if the client spends at least two hours per day in the
wheelchair and has one or more of the following conditions:
(i) The client is at high risk for
development of a pressure ulcer and is unable to perform a functional weight
shift; or
(ii) The client utilizes
intermittent catheterization for bladder management and is unable to
independently transfer from the wheelchair to the bed;
(iii) Trunk or lower extremity casts/braces
that require the reclining back feature for positioning;
(iv) Excess extensor tone of the trunk
muscles; or
(v) The need to rest in
a recumbent position two or more times during the day, and transfer between
wheelchair and bed is very difficult.
(2) Documentation Requirements.
Submit documentation that supports coverage criteria in this rule are met and
the specified information as follows with the prior authorization (PA) request:
(a) When code K0108 is billed, a narrative
description of the item, the manufacturer, the model name or number (if
applicable), and information justifying the medical appropriateness for the
item;
(b) Options/accessories for
individual consideration might include documentation on the client's diagnosis,
the client's abilities and limitations as they relate to the equipment (e.g.,
degree of independence/dependence, frequency and nature of the activities the
client performs, etc.), the duration of the condition, the expected prognosis,
past experience using similar equipment;
(c) For a custom-fabricated seat cushion:
(A) A comprehensive written evaluation by a
licensed clinician (who is not an employee of or otherwise paid by a DMEPOS
provider) that clearly explains why a prefabricated seating system is not
sufficient to meet the client's seating and positioning needs;
(B) Diagnostic reports that support the
medical condition;
(C) Dated and
clear photographs;
(D) Body contour
measurements.
(d)
Documentation that the coverage criteria in this rule have been met must be
present in the client's medical record. This documentation and any additional
medical information from the DMEPOS provider must be made available to the
Division upon request.
(3) Table 122-0340 - 1.
(4) Table 122-0340 - 2.
Notes
To view attachments referenced in rule text, click here to view rule.
Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
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