Manual Wheelchair Bases - Policy Article

**NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES**  
  
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. Information provided in this policy article relates
to determinations other than those based on Social Security Act 1862(a)(1)(A)
provisions (i.e. "reasonable and necessary").  
  
Manual wheelchairs are covered under the Durable Medical Equipment benefit
(Social Security Act 1861(s)(6)). In order for a beneficiary's equipment to
be eligible for reimbursement the reasonable and necessary (R&N) requirements
set out in the related Local Coverage Determination must be met. In addition,
there are specific statutory payment policy requirements, discussed below,
that also must be met.  
  
If the manual wheelchair is only for use outside the home, it will be denied
as noncovered, no benefit, as the DME benefit requires use within the home for
coverage eligibility.  
  
Reimbursement for wheelchair codes includes all labor charges involved in the
assembly of the wheelchair. Reimbursement also includes support services such
as emergency services, delivery, set-up, education, and on-going assistance
with use of the wheelchair.  
  
A custom manual wheelchair base (K0008) must be uniquely constructed or
substantially modified for a specific beneficiary according to the description
and orders of the beneficiary's treating practitioner. The beneficiary's needs
cannot be accommodated by any other existing manual wheelchair and
accessories, including customized seating arrangements. See 42 CFR Section
414.224, and Internet-Only Manual, Publication 100-04, Medicare Claims
Processing Manual, Chapter 20, Section 30.3 for more information on customized
DME.  
  

**REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed.
Reg Vol 217)**

Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a
Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the
DME MACs provide a list of the specified codes, which is periodically updated.
The required Face-to-Face Encounter and Written Order Prior to Delivery List
is available [here](https://www.cms.gov/Research-Statistics-Data-and-
Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-
Review/FacetoFaceEncounterRequirementforCertainDurableMedicalEquipment).

Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol
217) that do not meet the face-to-face encounter and WOPD requirements
specified in the LCD-related Standard Documentation Requirements Article
(A55426) will be denied as not reasonable and necessary.

If a supplier delivers an item prior to receipt of a WOPD, it will be denied
as not reasonable and necessary. If the WOPD is not obtained prior to
delivery, payment will not be made for that item even if a WOPD is
subsequently obtained by the supplier. If a similar item is subsequently
provided by an unrelated supplier who has obtained a WOPD, it will be eligible
for coverage.

  
**POLICY SPECIFIC DOCUMENTATION REQUIREMENTS**  
  
In addition to policy specific documentation requirements, there are general
documentation requirements that are applicable to all DMEPOS policies. These
general requirements are located in the DOCUMENTATION REQUIREMENTS section of
the LCD.  
  
Refer to the LCD-related Standard Documentation Requirements article, located
at the bottom of this Policy Article under the Related Local Coverage
Documents section for additional information regarding GENERAL DOCUMENTATION
REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed
below.  
  
Information showing that the coverage criteria in the Coverage Indications,
Limitations, and/or Medical Necessity section of the related LCD have been met
must be present in the beneficiary's medical record. Information about whether
the beneficiary's home can accommodate the wheelchair (Criterion C), also
called the home assessment, must be fully documented in the medical record or
elsewhere by the supplier. For manual wheelchairs, the home assessment may be
done directly by visiting the beneficiary's home or indirectly based upon
information provided by the beneficiary or their designee. When the home
assessment is based upon indirectly obtained information, the supplier must,
at the time of delivery, verify that the item delivered meets the requirements
specified in criterion C. Issues such as the physical layout of the home,
surfaces to be traversed, and obstacles must be addressed by and documented in
the home assessment. Information from the beneficiary's medical record and the
supplier's records must be available upon request.  
  
If documentation of the medical necessity for a K0005 wheelchair is requested,
it must include a description of the beneficiary's routine activities. This
may include the types of activities the beneficiary frequently encounters and
whether the beneficiary is fully independent in the use of the wheelchair.
Describe the features of the K0005 base which are needed compared to the K0004
base.  
  
If documentation of the medical necessity for a K0008 wheelchair is requested,
contractors must be able to determine that the item delivered is a customized
item. Documentation must include a description of the beneficiary's unique
physical and functional characteristics that require a customized manual
wheelchair base. This must include a detailed description of the manufacturing
of the wheelchair base, including types of materials used in custom
fabricating or substantially modifying it, and the construction process and
labor skills required to modify it. The record must document that the needs of
the beneficiary cannot be met using another manual wheelchair base that
incorporates seating modifications or other options or accessories
(prefabricated and/or custom). The documentation must demonstrate that the
K0008 is so different from another wheelchair base that the two items cannot
be grouped together for pricing purposes.  
  
If documentation of the medical necessity for a transport chair (E1037, E1038
and E1039) is requested, it must include a description of why the beneficiary
is unable to make use of a standard manual wheelchair (K0001, K0002, K0003,
K0004, and K0005) on their own, and provide specific information that the
beneficiary has a caregiver who is available, willing, and able to provide
assistance with the wheelchair.

SPECIALTY EVALUATION:

The specialty evaluation provides detailed information explaining why the
particular wheelchair and the special features of the wheelchair are necessary
to address the beneficiary's mobility limitation. There must be a written
report of this evaluation available on request. The PT, OT, or practitioner
who performs the specialty evaluation may have no financial relationship with
the supplier. (Exception: If the supplier is owned by a hospital, the PT, OT,
or practitioner working in the inpatient or outpatient hospital setting may
perform the specialty evaluation.)

  
**MODIFIERS**  
  
KX, GA, GY, AND GZ MODIFIERS:  
  
Suppliers must add a KX modifier to the code for the manual wheelchair base
only if all of the coverage criteria in the Coverage Indications, Limitations,
and/or Medical Necessity section of the related LCD have been met and evidence
of such is retained in the supplier's files and available to the DME MAC upon
request. If the coverage criteria are not met, the KX modifier must not be
used.  
  
If all of the coverage criteria in the Coverage Indications, Limitations,
and/or Medical Necessity section of the related LCD have not been met, the GA
or GZ modifier must be added to the code. When there is an expectation of a
medical necessity denial, suppliers must enter the GA modifier on the claim
line if they have obtained a properly executed Advance Beneficiary Notice
(ABN) or the GZ modifier if they have not obtained a valid ABN.  
  
If the wheelchair is only to be used for mobility outside the home, the GY
modifier must be added to the code.  
  
Claim lines billed without a KX, GA, GY, or GZ modifier will be rejected as
missing information.  
  
  
 **CODING GUIDELINES**

For Medicare coding purposes, all manual wheelchair base codes describe a
complete product. This includes items described by HCPCS codes:

  * Rollabout Chair (E1031)

  * Transport Chairs (E1037, E1038, E1039)

  * Manual Wheelchair Bases (E1161, E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0009)

A complete manual wheelchair base includes:

  * A complete frame

  * Propulsion wheels

  * Casters

  * Brakes

  * A sling seat, seat pan which can accommodate a wheelchair seat cushion, or a seat frame structured in such a way as to be capable of accepting a seating system

  * A sling back, other seat back support which can accommodate a wheelchair back cushion, or a back frame structured in such a way as to be capable of accepting a back system

  * Standard leg and footrests

  * Armrests

  * Safety accessories (other than those separately billable in the Wheelchair Accessories Local Coverage Determination)

Adult manual wheelchairs (K0001, K0002, K0003, K0004, K0005, K0006, K0007,
K0008, K0009, E1161) are those which have a seat width and a seat depth of 15"
or greater. For codes K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0008,
K0009, the wheels must be large enough and positioned such that the wheelchair
could be propelled by the user. In addition, specific codes are defined by the
following characteristics:  
  
Standard wheelchair (K0001)  
Weight: Greater than 36 lbs.  
Seat Height: 19 inches or greater  
Weight capacity: 250 pounds or less  
  
Standard hemi (low seat) wheelchair (K0002)  
Weight: Greater than 36 lbs  
Seat Height: Less than 19 inches  
Weight capacity: 250 pounds or less  
  
Lightweight wheelchair (K0003)  
Weight: 34-36 lbs  
Weight capacity: 250 pounds or less  
  
High strength, lightweight wheelchair (K0004)  
Weight: Less than 34 lbs  
Lifetime Warranty on side frames and crossbraces  
  
Ultralightweight wheelchair (K0005)  
Weight: Less than 30 lbs  
Adjustable rear axle position  
Lifetime Warranty on side frames and crossbraces  
  
Heavy duty wheelchair (K0006)  
Weight capacity: Greater than 250 pounds  
  
Extra heavy duty wheelchair (K0007)  
Weight capacity: Greater than 300 pounds  
  
Custom manual wheelchair/base (K0008)  
  
In addition to meeting the statutory criteria above in the "Non-Medical
Necessity Coverage and Payment Rules", custom manual wheelchairs must also
have a lifetime warranty on side frames and crossbraces.  
  
Adult tilt-in-space wheelchair (E1161)  
Ability to tilt the frame of the wheelchair greater than or equal to 20
degrees from horizontal while maintaining the same back to seat angle.
Lifetime Warranty: On side frames and crossbraces  
  
Wheelchairs with less than 20 degrees of tilt must not to be coded based upon
the tilt feature. The appropriate base product must be coded as K0001, K0002,
K0003, K0004, K0005, K0006, or K0007. The product must not be coded as E1161
or K0108.  
  
"Weight" represents the weight of the wheelchair itself in pounds without the
front rigging as in the case of the K0001, K0002, K0003, K0004, and K0005.
"Weight capacity" represents the carrying capacity or the amount of weight
(beneficiary plus all accessories) that the wheelchair can carry for safe
operation as in the case of the K0001, K0002, K0003, K0006 and K0007.  
  
The following features are included in the allowance for all adult manual
wheelchairs:  
  
Seat Width: 15" - 19"  
Seat Depth: 15" - 19"  
Arm Style: Fixed, swingaway, or detachable; fixed height  
Footrests: Fixed, swingaway, or detachable  
  
Codes K0003, K0004, K0005, K0006, K0007, K0008 and E1161 include any seat
height.  
  
Manual wheelchair bases (K0001, K0002, K0003, K0004, K0005, K0006, K0007,
K0008, and K0009) include construction of any type material, including but not
limited to, titanium, carbon, or any other lightweight high strength material.
Suppliers must not bill HCPCS code K0108 in addition to the base wheelchair
for construction materials or for a "heavy duty package" reflecting the type
of material used to construct the manual wheelchair base. Billing for
construction material is considered incorrect coding - unbundling.  
  
Refer to the medical policy on Wheelchair Options and Accessories for
information on other features included in the allowance for the wheelchair
base.  
  
Effective for claims with dates of service on or after June 1, 2013, the only
products which may be billed to Medicare using HCPCS code K0009, are those for
which a written coding verification review (CVR) has been made by the Pricing,
Data Analysis, and Coding (PDAC) contractor and subsequently published on the
Product Classification List (PCL).  
  
If a product is billed to Medicare using a HCPCS code that requires written
CVR, but the product is not on the PCL for that particular HCPCS code, then
the claim line will be denied as incorrect coding.  
  
A manual wheelchair with a seat width and/or depth of 14" or less is
considered a pediatric size wheelchair and is billed with codes E1231, E1232,
E1233, E1234, E1235, E1236, E1237, E1238 or E1229.  
  
Manual wheelchairs with additional options and accessories, other than tilt,
are billed by selecting the correct code for the wheelchair base and then
using appropriate codes for wheelchair options and accessories. (Refer to the
Wheelchair Options and Accessories policy.)  
  
Suppliers should contact the PDAC contractor for guidance on the correct
coding of these items.