Article - Wheelchair Seating - Policy Article (A52505)

A pre-ischial bar or ridge which is placed anterior to the ischial tuberosities and prevents forward migration of the pelvis,Two lateral pelvic supports which are placed posterior to the trochanters and are intended to maintain the pelvis in a centered position in the seat and/or provide lateral stability to the pelvis,A medial thigh support which is placed in contact with the adductor region of the thigh and provides the prescribed amount of abduction and prevents adduction of the thighs,Two lateral thigh supports which are placed anterior to the trochanters and provide lateral stability to the lower extremities and prevent unwanted abduction of the thighs.It has two or more air compartments located in areas which address postural asymmetries, each of which must have a cell height of at least 50 mm, must allow the user to add or remove air, and must have a valve which retains the desired air volume; andIt has the following minimum performance characteristics:Simulation tests demonstrate a loaded contour depth of at least 25mm with an overload deflection of at least 5 mm, orHuman subject tests demonstrate an average peak pressure index that is less than 125% of that of a standard reference cushion within the area of the ischial tuberosities and sacrum/coccyx; andFollowing testing simulating 18 months of use:Simulation tests demonstrate an overload deflection of at least 5 mm, orHuman subject tests demonstrate an average peak pressure index that is less than 125% of those of a standard reference cushion within the area of the ischial tuberosities and sacrum/coccyx; andIt has a removable vapor permeable or waterproof cover or it has a waterproof surface; andThe cushion and cover meet the minimum standards of the California Bulletin 117, California Bulletin 133, or equivalent (such as standards established by the ASTM, the EPA, or other national or international standards agencies),for flame resistance; andIt has a permanent label indicating the model and the manufacturer; andIt has a warranty that provides for repair or full replacement if manufacturing defects are identified or the surface does not remain intact due to normal wear within 18 months.A positioning cushion may have materials or components that can be added or removed to help address orthopedic deformities or postural asymmetries. This definition includes cushions which have a planar surface but have positioning features within the cushion which are made of a firmer material than the surface material.A nonadjustable skin protection and positioning seat cushion (E2607, E2608) is a prefabricated cushion which has the following characteristics:It has the minimum structural features described in (a) or (b):The feature must be at least 25 mm in height in the pre-loaded state. It has two or more of the following:A pre-ischial bar or ridge which is placed anterior to the ischial tuberosities and prevents forward migration of the pelvis,Two lateral pelvic supports which are placed posterior to the trochanters and are intended to maintain the pelvis in a centered position in the seat and/or provide lateral stability to the pelvis,A medial thigh support which is placed in contact with the adductor region of the thigh and provides the prescribed amount of abduction and prevents adduction of the thighs,Two lateral thigh supports which are placed anterior to the trochanters and provide lateral stability to the lower extremities and prevent unwanted abduction of the thighs.It has two or more air compartments located in areas which address postural asymmetries, each of which must have a cell height of at least 50 mm, must allow the user to add or remove air, and must have a valve which retains the desired air volume; andIt has the following minimum performance characteristics:Simulation tests demonstrate a loaded contour depth of at least 40mm with an overload deflection of at least 5 mm, orHuman subject tests demonstrate an average peak pressure index that is less than 85% of that of a standard reference cushion within the area of the ischial tuberosities and sacrum/coccyx; andFollowing testing simulating 18 months of use:Simulation tests demonstrate an overload deflection of at least 5 mm, orHuman subject tests demonstrate an average peak pressure index that is less than 85% of those of a standard reference cushion within the area of the ischial tuberosities and sacrum/coccyx; andIt has a removable vapor permeable or waterproof cover or it has a waterproof surface; andThe cushion and cover meet the minimum standards of the California Bulletin 117, California Bulletin 133, or equivalent (such as standards established by the ASTM, the EPA, or other national or international standards agencies),for flame resistance; andIt has a permanent label indicating the model and the manufacturer; andIt has a warranty that provides for repair or full replacement if manufacturing defects are identified or the surface does not remain intact due to normal wear within 18 months.This definition includes cushions which have a planar surface but have positioning features within the cushion which are made of a firmer material than the surface material.An adjustable skin protection and positioning seat cushion (E2624, E2625) has all the characteristics of a E2607 or E2608 cushion and is determined to be adjustable by the PDAC. The adjustability feature only relates to the skin protection properties of the cushion.Wheelchair cushions containing a fluid medium (air, gas, liquid, or gel) that have the capability for the immersion characteristics of the cushion to be altered by addition or removal of fluid will be considered adjustable. The adjustment may be in the manner of direct addition or removal of the fluid (e.g. add or remove air) or indirectly by addition or removal of packets of fluid.Adjustment applies to the skin protection portion of the cushion's function only.All cushions are considered to be adjustable up to the point of delivery to the beneficiary. Fitting of the cushion to the individual beneficiary may involve various forms of adjustment. Adjustable as applied here, requires that the procedure is capable of being performed by the beneficiary or caregiver using items supplied at the time of initial issue of the device in response to the beneficiary's need for more or less skin protection because of weight loss or gain or muscle tone changes.A general use back cushion (E2611, E2612) is a prefabricated cushion, which has the following characteristics:It is planar or contoured; andIt has a removable vapor permeable or waterproof cover or it has a waterproof surface; andThe cushion and cover meet the minimum standards of the California Bulletin 117, California Bulletin 133, or equivalent (such as standards established by the ASTM, the EPA, or other national or international standards agencies),for flame resistance; andIt has a permanent label indicating the model and the manufacturer; andIt has a warranty that provides for repair or full replacement if manufacturing defects are identified or the surface does not remain intact due to normal wear within 12 months.A positioning back cushion (E2613, E2614, E2615, E2616, E2620, E2621) is a prefabricated cushion which has the following characteristics:For codes E2613, E2614, E2615, E2616, there is at least 25 mm of posterior contour in the pre-loaded state. A posterior contour is a backward curve measured from a horizontal line in the midline of the cushion; andFor posterior-lateral cushions (E2615, E2616) and for planar cushions with lateral supports (E2620, E2621), there is at least 75 mm of lateral contour in the pre-loaded state. A lateral contour is a backward curve measured from a horizontal line connecting the lateral extensions of the cushion; andFor posterior pelvic cushions (E2613, E2614), there is mounting hardware that is adjustable for horizontal position, depth, and angle; andIt has a removable vapor permeable or waterproof cover or it has a waterproof surface; andThe cushion and cover meet the minimum standards of the California Bulletin 117, California Bulletin 133, or equivalent (such as standards established by the ASTM, the EPA, or other national or international standards agencies),for flame resistance; andIt has a permanent label indicating the model and the manufacturer; andIt has a warranty that provides for repair or full replacement if manufacturing defects are identified or the surface does not remain intact due to normal wear within 18 months.Included in this definition are cushions which have a planar surface but have positioning features within the cushion which are made of a firmer material than the surface material.A positioning back cushion may have materials or components that may be added or removed to help address orthopedic deformities or postural asymmetries.A custom fabricated seat cushion (E2609) and a custom fabricated back cushion (E2617) are cushions that are individually made for a specific beneficiary starting with basic materials including:liquid foam or a block of foam andsheets of fabric or liquid coating material.The cushion must be fabricated using one or more of the following techniques to capture the individual shape of the beneficiary:molded-to-beneficiary-model technique;direct molded-to-beneficiary technique;CAD/CAM technology, which:allows for the use of direct digital scanning of the beneficiary or of a mold made directly from the beneficiary;allows for direct milling of either (1) a beneficiary-specific model used to shape the cushion contour or (2) the cushion contours; ordetailed measurements of the beneficiary used to create a configured cushion.The cushion must have structural features that significantly exceed the minimum requirements for a seat or back positioning cushion. The cushion must have a removable vapor permeable or waterproof cover or it must have a waterproof surface. A custom fabricated cushion may include certain prefabricated components (e.g., gel or multi-cellular air inserts); these components must not be billed separately. If a custom fabricated seat and back are integrated into a one-piece cushion, code as E2609 plus E2617.If foam-in-place or other material is used to fit a substantially prefabricated cushion to an individual beneficiary, the cushion must be billed as a prefabricated cushion, not custom fabricated.A powered wheelchair seat cushion (E2610) is a battery-powered, prefabricated cushion in which an air pump provides either sequential inflation or deflation of the air cells or a low interface pressure throughout the cushion. One type of powered seat cushion is an alternating pressure cushion.Pediatric seating system codes E2291, E2292, E2293, E2294 may only be billed with pediatric wheelchair base codes.A headrest extension (E0966) is a sling support for the head. Code E0955 describes any type of cushioned headrest.A headrest (E0955) describes any type of cushioned headrest which may contain one or more cushions to position the head and fixed mounting hardware.Lateral positioning items are used to provide lateral thigh or knee support (E0953) or lateral trunk or hip support (E0956). These are provided in a variety of shapes and sizes to suit the needs of the user.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.A solid insert is a separate rigid piece of wood or plastic which is inserted in the cover of a cushion to provide additional support. If a supplier chooses to bill separately for a solid insert used with a seat cushion use code E0992 whether it is a manual or a power wheelchair. Code A9900 must be used for a solid insert used with a back cushion.A solid support base for a seat cushion is a rigid piece of plastic or other material which 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 a solid support base that is used with a manual wheelchair. A solid support base is included in the allowance for the power wheelchair codes. There should be no separate billing with power wheelchairs.If a supplier chooses to bill separately for mounting hardware, either nonadjustable or adjustable, for a seat or back cushion or solid support base, code A9900 must be used.The only products which may be billed using codes E2601, E2602, E2603, E2604, E2605, E2606, E2607, E2608, E2610, E2611, E2612, E2613, E2614, E2615, E2616, E2620, E2621, and E2622, E2623, E2624, E2625 and the only brand name products that may be billed using codes E2609 or E2617 are those products for which a written coding verification review (CVR) has been made by the Pricing, Data Analysis, and Coding (PDAC) contractor. Information concerning the documentation that must be submitted to the PDAC for a written CVR can be found on the PDAC web site or by contacting the PDAC. A Product Classification List (PCL) with products which have received a written CVR can be found on the PDAC web site.If the prefabricated seat cushion, prefabricated back cushion, or a brand name custom fabricated seat or back cushion has not received a written CVR from the PDAC or if the PDAC has reviewed and determined that the product does not meet the criteria for the code, then it must be billed with code K0669.If a product is billed to Medicare using one of the HCPCS codes 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.Pediatric size positioning accessories are billed with the codes described in this policy. Codes E1025, E1026, E1027 (lateral thoracic and lateral/anterior supports) are invalid for claim submission.