Article - Wheelchair Seating - Policy Article (A52505)

CMS National Coverage PolicyN/AArticle TextNON-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).There is no separate payment for a solid insert (E0992) (see definition in Coding Guidelines) 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.There is no separate payment for mounting hardware for a seat or back cushion.There is no separate payment for a wheelchair seat or back cushion when it is used with a rollabout chair (E1031).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 availablehere.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 REQUIREMENTSIn 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.SPECIALTY EVALUATION:The specialty evaluation (also known as a comprehensive written evaluation) provides detailed information explaining why a prefabricated seating system is not sufficient to meet the beneficiarys seating and positioning needs. 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.)MODIFIERSKX MODIFIER:For a skin protection seat cushion (E2603, E2604, E2622, E2623), a KX modifier must be added to the code only if one of the following criteria (a), (b), or (c) is met:There is a past history of, or current, pressure ulcer in the area of contact with the seating surface (refer to the Group 1 codes in the ICD-10 code list section); orThere is absent or impaired sensation in the area of contact with the seating surface due to one of the diagnoses listed as a covered diagnosis in the Group 2 ICD-10 code list section; orThere is an inability to carry out a functional weight shift due to one of the diagnoses listed as a covered diagnosis in the Group 2 ICD-10 code list section.For a positioning seat cushion (E2605, E2606), positioning back cushion (E2613, E2614, E2615, E2616, E2620, E2621), or positioning accessory (E0953, E0956, E0957, E0960), a KX modifier must be added to the code only if the beneficiary has significant postural asymmetries due to one of the diagnoses listed as a covered diagnosis in Group 2 or Group 3 of the ICD-10 code list section.For a headrest (E0955), a KX modifier must be added to the code only if one of the coverage criteria specified in the Coverage Indications, Limitations and/or Medical Necessity section of the related LCD has been met.For a combination skin protection and positioning seat cushion (E2607, E2608, E2624, E2625), a KX modifier must be added to the code only if criterion (a) or (b) or (c) is met and criterion (d) is met:There is a past history of, or current, pressure ulcer in the area of contact with the seating surface (refer to the Group 1 codes in the ICD-10 code list section); orThere is absent or impaired sensation in the area of contact with the seating surface due to one of the diagnoses listed as a covered diagnosis for skin protection cushions (refer to the Group 2 codes in the ICD-10 code list section); orThere is an inability to carry out a functional weight shift due one of the diagnoses listed as a covered diagnosis for skin protection cushions (refer to the Group 2 codes in the ICD-10 code list section); andThe beneficiary has significant postural asymmetries due to one of the diagnoses listed as a covered diagnosis for positioning cushions (refer to the Group 2 and Group 3 codes in the ICD-10 code list section).For a custom fabricated seat or back cushion (E2609, E2617), a KX modifier must be added to the code only if criterion (a) is met and criterion (b), (c), or (d) is met:For E2609 or E2617, there is a comprehensive written evaluation by a licensed/certified medical professional, such as a PT or OT (who has no financial relationship with the supplier) which explains why a prefabricated seating system is not sufficient to meet the beneficiarys seating and positioning needs; andFor E2609, there is a past history of, or current, pressure ulcer in the area of contact with the seating surface; orFor E2609, there is absent or impaired sensation in the area of contact with the seating surface or an inability to carry out a functional weight shift due to one of the diagnoses listed as a covered diagnosis for skin protection cushions (refer to the ICD-10 code list section); orFor E2609 or E2617, the beneficiary has significant postural asymmetries due to one of the diagnoses listed as a covered diagnosis for positioning cushions (refer to the ICD-10 code list section).In addition to meeting the specific requirements listed above, for all seat and back cushions and positioning accessories, the KX modifier must be added to the code only if the item is being used with a wheelchair that meets coverage criteria specified in the Manual Wheelchair Bases or Power Mobility Devices LCD.GA, GY, AND GZ MODIFIERS:For a cushion or positioning accessory that is used with a power mobility device (PMD), if the requirements related to astandard written order (SWO) for the PMD baseand face-to-face encounter in the Power Mobility Devices Policy Article have not been met, the GY modifier must be added to the codes for all items.For items provided with a manual wheelchair or power mobility device, if it is only needed for mobility outside the home, the GY modifier must be added to the codes for all items.In all of the situations above describing use of the KX modifier, if all of the specific coverage criteria have not been met or if the wheelchair that it is being used with does not meet the coverage criteria in the Manual Wheelchair Bases or Power Mobility Devices LCD, the GA or GZ modifier must be added to a claim line for the seat or back cushion or positioning accessory.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 GY modifier is used, the KX, GA, and GZ modifiers should not be used.Claim lines billed without a GA, GY, GZ, or KX modifier will be rejected as missing information.MiscellaneousWhen billing for a custom fabricated cushion (E2609, E2617), the claim must include the manufacturer and model name/ number of the product (if applicable), or if not, a detailed description of the product that was provided.Refer to the Supplier Manual for additional information on documentation requirements.CODING GUIDELINES:The following definitions of seat cushions include results of simulation testing or human subject testing. See the Testing Methodologies section for technical information about the required testing.A general use seat cushion (E2601, E2602) is a prefabricated cushion, which has the following characteristics:It 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 12 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 American Society for Testing and Materials (ASTM), the Environmental Protection Agency (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 nonadjustable skin protection seat cushion (E2603, E2604) is a prefabricated cushion, which has the following characteristics:It has the following minimum performance characteristics:Simulation tests demonstrate a loaded contour depth of at least 40 mm 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.An adjustable skin protection seat cushion (E2622, E2623) has all the characteristics of a E2603 or E2604 cushion and is determined to be adjustable by the PDAC.A positioning seat cushion (E2605, E2606) is a prefabricated cushion that 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 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, or