evekhm/cms_iom_500 huggingface dataset:
Article - Power Mobility Devices - Policy Article (A52498)
MISCELLANEOUS:A custom motorized/power wheelchair base (K0013) must be uniquely constructed or substantially modified for a specific beneficiary according to the description and orders of the beneficiarys treating practitioner. The beneficiarys needs must not be able to be accommodated by any other existing PMD and accessories, including customized seating arrangements. See 42 CFR Section 414.224(a).If any POV or PWC is only for use outside the home, it will be denied as noncovered.Reimbursement for the wheelchair codes includes all labor charges involved in the assembly of the wheelchair. Reimbursement also includes support services, such as delivery, set-up, and education about the use of the PMD.Upgrades that are beneficial primarily in allowing the beneficiary to perform leisure or recreational activities are noncovered.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 DOCUMENTATIONIn 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.
Article - Power Mobility Devices - Policy Article (A52498)
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.If documentation of the medical necessity for a K0013 wheelchair is requested, contractors must be able to determine that the item delivered is a customized item. Documentation must include a description of the beneficiarys unique physical and functional characteristics that require a custom motorized/power 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 power wheelchair base that incorporates seating modifications or other options or accessories (prefabricated and/or custom). The documentation must demonstrate that the K0013 is so different from another power wheelchair base that the two items cannot be grouped together for pricing purposes.SPECIALTY EVALUATION:The specialty evaluation provides detailed information explaining why each specific option or accessory  i.e., power seating system, alternate drive control interface, or push-rim activated power assist  is needed to address the beneficiarys 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.)MODIFIERSKX, GA, GY, AND GZ MODIFIERS:If the requirements related to a face-to-face encounter have not been met, the GY modifier must be added to the codes for the power mobility device and all accessories.If the power mobility device or push-rim activated power assist device that is provided is only needed for mobility outside the home, the GY modifier must be added to the codes for the item and all accessories.A KX modifier may be added to the code for a power mobility device and all accessories only if one of the following conditions is met:If all of the coverage criteria specified in the related LCD have been met for the product that is provided; or
Article - Power Mobility Devices - Policy Article (A52498)
If all of the coverage criteria specified in the related LCD have been met for the product that is provided; orIf there is an affirmative Advance Determination of Medicare Coverage (ADMC) for the product that is provided.If the requirements for use of the KX modifier or GY modifier are not 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 GA on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or GZ if they have not obtained a valid ABN.Claim lines billed without a KX, GA, GY, or GZ modifier will be rejected as missing information.CODING GUIDELINESDEFINITIONS:Power Mobility Device (PMD) - Base codes include both integral frame and modular construction type power wheelchairs (PWCs) and power operated vehicles (POVs).Power Wheelchair - Chair-like battery powered mobility device for people with difficulty walking due to illness or disability, with integrated or modular seating system, electronic steering, and four or more wheel non-highway construction.Power Operated Vehicle - Chair-like battery powered mobility device for people with difficulty walking due to illness or disability, with integrated seating system, tiller steering, and three or four-wheel non-highway construction.Beneficiary Weight Capacity  The terms Standard Duty, Heavy Duty, etc., refer to weight capacity, not performance. For example, the term Group 3 heavy duty power wheelchair denotes that the PWC has Group 3 performance characteristics and beneficiary weight handling capacity between 301 and 450 pounds. A device is not required to carry all the weight listed in the class of devices, but must have a beneficiary weight capacity within the range to be included. For example, a PMD that has a weight capacity of 400 pounds is coded as a Heavy Duty device.Portable - A category of devices with lightweight construction or ability to disassemble into lightweight components that allows easy placement into a vehicle for use in a distant location.Performance Testing - Term used to denote the RESNA based test parameters used to test PMDs. The PMD is expected to meet or exceed the listed performance and durability figures for the category in which it is to be used when tested. There is no requirement to test the PMD with all possible accessories.
Article - Power Mobility Devices - Policy Article (A52498)
Test Standards - Performance and durability acceptance criteria defined by ANSI/RESNA standard testing protocols.Crash Testing - Successful completion of WC-19 testing.Top End Speed - Minimum speed acceptable for a given category of devices. It is to be determined by the RESNA test for maximum speed on a flat hard surface.Range - Minimum distance acceptable for a given category of devices on a single charge of the batteries. It is to be determined by the appropriate RESNA test for range.Obstacle Climb - Vertical height of a solid obstruction that can be climbed using the standing and/or 0.5 meter run-up RESNA test.Dynamic Stability Incline - The minimum degree of slope at which the PMD in the most common seating and positioning configuration(s) remains stable at the required beneficiary weight capacity. If the PMD is stable at only one configuration, the PMD may have protective mechanisms that prevent climbing inclines in configurations that may be unstable.Radius Pivot Turn  The distance required for the smallest turning radius of the PMD base. This measurement is equivalent to the minimum turning radius specified in the ANSI/RESNA bulletins.PWC Basic Equipment Package - Each power wheelchair code is required to include all these items on initial issue (i.e., no separate billing/payment at the time of initial issue, unless otherwise noted). The statement that an item may be separately billed does not necessarily indicate coverage.Lap belt or safety belt. Shoulder harness/straps or chest straps/vest may be billed separately.Battery charger, single modeComplete set of tires and casters, any typeLegrests. There is no separate billing/payment if fixed, swingaway, or detachable non-elevating legrests with or without calf pad are provided. Elevating legrests may be billed separately.Footrests/foot platform. There is no separate billing/payment if fixed, swingaway, or detachable footrests or a foot platform without angle adjustment are provided. There is no separate billing for angle adjustable footplates with Group 1 or 2 PWCs. Angle adjustable footplates may be billed separately with Group 3, 4 and 5 PWCs.Armrests. There is no separate billing/ payment if fixed, swingaway, or detachable non-adjustable height armrests with arm pad are provided. Adjustable height armrests may be billed separately.
Article - Power Mobility Devices - Policy Article (A52498)
Armrests. There is no separate billing/ payment if fixed, swingaway, or detachable non-adjustable height armrests with arm pad are provided. Adjustable height armrests may be billed separately.Any weight specific components (braces, bars, upholstery, brackets, motors, gears, etc.) as required by beneficiary weight capacity.Any seat width and depth. Exception: For Group 3 and 4 PWCs with a sling/solid seat/back, the following may be billed separately:For Standard Duty, seat width and/or depth greater than 20 inches;For Heavy Duty, seat width and/or depth greater than 22 inches;For Very Heavy Duty, seat width and/or depth greater than 24 inches;For Extra Heavy Duty, no separate billingAny back width. Exception: For Group 3 and 4 PWCs with a sling/solid seat/back, the following may be billed separately:For Standard Duty, seat back width greater than 20 inches;For Heavy Duty, back width greater than 22 inches;For Very Heavy Duty, back width greater than 24 inches;For Extra Heavy Duty, no separate billingController and Input DeviceThere is no separate billing/payment if a non-expandable controller and a standard proportional joystick (integrated or remote) is provided. An expandable controller, a nonstandard joystick (i.e., nonproportional or mini, compact or short throw proportional), or other alternative control device may be billed separately.Refer to the bundling table in the Wheelchair Options/Accessories Policy Article for a list of codes that are not separately billable at the time of initial issue of a PWC.POV Basic Equipment Package - Each POV is to include all these items on initial issue (i.e., no separate billing/payment at the time of initial issue):Battery or batteries required for operationBattery charger, single modeWeight appropriate upholstery and seating systemTiller steeringNon-expandable controller with proportional response to inputComplete set of tiresAll accessories needed for safe operationCross Brace Chair - A type of construction for a power wheelchair in which opposing rigid braces hinge on pivot points to allow the device to fold.
Article - Power Mobility Devices - Policy Article (A52498)
Complete set of tiresAll accessories needed for safe operationCross Brace Chair - A type of construction for a power wheelchair in which opposing rigid braces hinge on pivot points to allow the device to fold.Power Options - Tilt, recline, elevating legrests, seat elevators, or standing systems that may be added to a PWC to accommodate a beneficiarys specific need for seating assistance.No Power Options  A category of PWCs that is incapable of accommodating a power tilt, recline, or standing system. If a PWC can only accept power elevating legrests and/or seat elevation, it is considered to be a No Power Option chair.Single Power Option - A category of PWCs with the capability to accept and operate a power tilt or power recline or power standing or, for Groups 3, 4, and 5, a power seat elevation system, but not a combination power tilt and recline seating system. It may be able to accommodate power elevating legrests, seat elevator, and/or standing system in combination with a power tilt or power recline. A PMD does not have to be able to accommodate all features to qualify for this code. For example, a power wheelchair that can only accommodate a power tilt could qualify for this code.Multiple Power Options - A category of PWCs with the capability to accept and operate a combination power tilt and recline seating system. It may also be able to accommodate power elevating legrests, a power seat elevator, and/or a power standing system. A PWC does not have to accommodate all features to qualify for this code.Actuator  A motor that operates a specific function of a power seating system  i.e., tilt, back recline, power sliding back, elevating legrest(s), seat elevation, or standing.Proportional Control Input Device - A device that transforms a user's drive command (a physical action initiated by the wheelchair user) into a corresponding and comparative movement, both in direction and in speed, of the wheelchair. The input device shall be considered proportional if it allows for both a non-discrete directional command and a non-discrete speed command from a single drive command movement. (Note: In the Wheelchair Options/Accessories policy, the term interface is used instead of control input device.)
Article - Power Mobility Devices - Policy Article (A52498)
Non-Proportional Control Input Device - A device that transforms a user's discrete drive command (a physical action initiated by the wheelchair user, such as activation of a switch) into perceptually discrete changes in the wheelchair's speed, direction, or both.Alternative Control Device - A device that transforms a users drive commands by physical actions initiated by the user to input control directions to a power wheelchair that replaces a standard proportional joystick. Includes mini-proportional, compact, or short throw joysticks, head arrays, sip and puff and other types of different input control devices.Non-Expandable Controller - An electronic system that controls the speed and direction of the power wheelchair drive mechanism. Only a standard proportional joystick (used for hand or chin control) can be used as the input device. This system may be in the form of an integral controller or a remotely placed controller. The non-expandable controller: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 legrests). (Note: Control of the power seating actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.)May allow for the incorporation of an attendant control.Expandable Controller - An electronic system that is capable of accommodating one or more of the following additional functions:Proportional input devices (e.g., mini, compact, or short throw joysticks, touchpads, chin control, head control, etc.) other than a standard proportional joystick.Non-proportional input devices (e.g., sip and puff, head array, etc.)Operate 3 or more powered seating actuators through the drive control. (Note: Control of the power seating actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.)An expandable controller may also be able to operate one or more of the following:A separate display (i.e., for alternate control devices)Other electronic devices (e.g., control of an augmentative speech device or computer through the chairs drive control)An attendant control
Article - Power Mobility Devices - Policy Article (A52498)
A separate display (i.e., for alternate control devices)Other electronic devices (e.g., control of an augmentative speech device or computer through the chairs drive control)An attendant controlIntegral Control System - Non-expandable wheelchair control system where the joystick is housed in the same box as the controller. The entire unit is located and mounted near the hand of the user. A direct electrical connection is made from the Integral Control box to the motors and batteries through a high power wire harness.Remotely Placed Controller - Non-expandable or expandable wheelchair control system where the joystick (or alternative control device) and the controller box are housed in separate locations. The joystick (or alternative control device) is connected to the controller through a low power wire harness. The separate controller connects directly to the motors and batteries through a high power wire harness.Codes E2310 and E2311 describe electronic components that allow the patient to control two or more of the following motors from a single interface, e.g., proportional joystick, touchpad, or nonproportional interface:Power tiltPower recline, with or without shear reductionCombination power tilt and recline, with or without shear reductionPower leg elevation with or without articulation, power center mount elevating foot platform with or without articulating properties.The interface includes a function selection switch that allows the patient to select the motor that is being controlled and an indicator feature to visually show which function has been selected. When the wheelchair drive function has been selected, the indicator feature may also show the direction that has been selected (forward, reverse, left, right). This indicator feature may be in a separate display box or may be integrated into the wheelchair interface. Payment for the interface code includes an allowance for fixed mounting hardware for the control box and the display box, if present.A harness (E2313) describes all the wires, fuse boxes, fuses, circuits, switches, etc. that are required for the operation of an expandable controller (E2377). It also includes all the necessary fasteners, connectors, and mounting hardware.Sling Seat/Back - Flexible cloth, vinyl, leather or equal material designed to serve as the support for buttocks or back of the user respectively. They may or may not have thin padding but are not intended to provide cushioning or positioning for the user.
Article - Power Mobility Devices - Policy Article (A52498)
Solid Seat/Back - Rigid metal or plastic material usually covered with cloth, vinyl, leather or equal material, with or without some padding material designed to serve as the support for the buttocks or back of the user respectively. They may or may not have thin padding but are not intended to provide cushioning or positioning for the user. PWCs with an automotive-style back and a solid seat pan are considered as a solid seat/back system, not a captains chair.Captains chair - A one or two-piece automotive-style seat with rigid frame, cushioning material in both seat and back sections, covered in cloth, vinyl, leather or equal as upholstery, and designed to serve as a complete seating, support, and cushioning system for the user. It may have armrests that can be fixed, swingaway, or detachable. It may or may not have a headrest, either integrated or separate.Stadium Style Seat - A one or two piece stadium-style seat with rigid frame and cushioning material in both seat and back sections, covered in cloth, vinyl, leather or equal as upholstery, and designed to serve as a complete seating, support, and cushioning system for the user. It may have armrests that can be fixed, swingaway, or detachable. It will not have a headrest. Chairs with stadium style seats are billed using the captains chair codes.Highway Use - Mobility devices that are powered and configured to operate legally on public streets.Push-rim activated power assist (E0986)  An option for a manual wheelchair in which sensors in specially designed wheels determines the force that is exerted by the beneficiary upon the wheel. Additional propulsive and/or braking force is then provided by motors in each wheel. E0986 is all-inclusive. All components, e.g., drive wheels, batteries, chargers, controls, mounting hardware, etc, for a manual wheel chair conversion are considered as included in 1 UOS of the code.CODE-SPECIFIC REQUIREMENTS:There are five PWC Groups and two POV Groups. Groups are divided based on performance. Each group of PMDs has subdivisions based on beneficiary weight capacity, seat type, portability, and/or power seating system capability.
Article - Power Mobility Devices - Policy Article (A52498)
There are five PWC Groups and two POV Groups. Groups are divided based on performance. Each group of PMDs has subdivisions based on beneficiary weight capacity, seat type, portability, and/or power seating system capability.All POVs (K0800, K0801, K0802, K0806, K0807,K0808, K0812) must have the specified components and meet the following requirements:Have all components in the POV Basic Equipment PackageSeat Width: Any width appropriate to weight groupSeat Depth: Any depth appropriate to weight groupSeat Height: Any height (adjustment requirements-none)Back Height: Any height (minimum back height requirement-none)Seat to Back Angle: Fixed or adjustable (adjustment requirements  none)Meet the following testing requirements:Fatigue test  200, 000 cyclesDrop test  6,666 cyclesGroup 1 POVs (K0800, K0801,K0802) must meet the following requirements:Length - less than or equal to 48 inchesWidth - less than or equal to 28 inchesMinimum Top End Speed - 3 MPHMinimum Range - 5 milesMinimum Obstacle Climb - 20 mmRadius Pivot Turn - less than or equal to 54 inchesDynamic Stability Incline - 6 degreesGroup 2 POVs (K0806, K0807,K0808) must meet the following requirements:Length - less than or equal to 48 inchesWidth - less than or equal to 28 inchesMinimum Top End Speed - 4 MPHMinimum Range - 10 milesMinimum Obstacle Climb - 50 mmRadius Pivot Turn - less than or equal to 54 inchesDynamic Stability Incline - 7.5 degreesThe following requirements describe the configurations of power wheelchairs as they are coded by the Pricing, Data Analysis, and Coding (PDAC) contractor. Items provided to the beneficiary may include upgraded components which are substituted for the basic component and are billed separately. One example is a power seating system. When this is provided, the base code used should be that with a sling/solid seat/back. Another example is the provision of an expandable controller when the base code includes a non-expandable controller but is capable of an upgrade.