Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.09-037 - Prosthetics Update #133

Current through Register Vol. 49, No. 6, June, 2024
242.191
Specialized Wheelchairs and Wheelchair Seating Systems for Individuals
			 Age Two Through Adult
Procedure codes found in this section must be billed either
				electronically or on paper with modifier EP for beneficiaries under 21 years of
				age or modifier NU for beneficiaries age 21 and older. When a second modifier
				is listed, that modifier must be used in conjunction with either EP
				orNU.
Modifiers in this section are indicated by the headings Ml and
				M2. Prior authorization requirements are shown under the heading PA. If prior
				authorization is needed, that information is indicated with a "Y" in the
				column; if not, an "N" is shown.
Other coding information found in the chart:
The purchase of this component for beneficiaries age 21
				and older is limited to one per five-year period.
The purchase of this wheelchair component for
				beneficiaries under age 21 is limited to one per two-year period.
* The purchase of wheelchairs for beneficiaries age 21
				and older is limited to one per five-year period.
** Bill only for beneficiaries under age
				21.
' This procedure code is payable for beneficiaries ages 2
				through 20. Prior authorization is required through Utilization
				Review.
**** Items listed require prior authorization (PA) when
				used in combination with other items listed and the total combined value
				exceeds the $1,000.00 Medicaid maximum allowable reimbursement
				limit.
* Prior authorization is not required when other
				insurance pays at least 50% of the Medicaid maximum allowable reimbursement
				amount.
Note: W/C orw/c indicates wheelchair.
«%(...) This symbol, along with text in
				parentheses, indicates the Arkansas Medicaid description of the product. When
				using a procedure code with this symbol, the product must meet the indicated
				Arkansas Medicaid description.
Specialized Wheelchairs and Wheelchair Seating Systems
				for Individuals Age Two Through Adult (section
				242.191 )
Procedure Code
Ml
M2
Description
PA
Payment Method
E0700
NU EP
U1 U1
Safety equipment, e.g., belt, harness or vest
K 1 ****
Purchase
E0700
NU EP
U2 U2
***(Travel restraint auto safe harness, E-Z on vest, no
						  known comparable product) Safety equipment, e.g., belt, harness or vest
K 1 ****
Purchase
E0950
NU EP
***(Tray for W/C) W/C accessory, tray, each
Y
Purchase
E0950
NU EP
U2 U2
A(ABS tray, 4-SM 5-LG) W/C accessory, tray, each
Y
Purchase
E0950
NU EP
U3 U3
A(W/C Tray, Custom) W/C accessory, tray, each
Y
Purchase
E0950
NU EP
U4 U4
A(Tray, customized) W/C accessory, tray, each
N
Purchase
E0950
NU EP
U5 U5
A(Clear upper Ex support system) W/C accessory, tray,
						  each
Y
Purchase
E0950
NU EP
U6 U6
A(Lap Tray Switch Array) Wheelchair accessory, tray,
						  each
Y
Purchase
E0950
NU EP
U7 U7
Wheelchair accessory, tray, each
Y
Purchase
E0950
NU EP UE
U7 U7
A(Removable Hinged Overlay for Tray) W/C accessory,
						  tray, each
Y****
Purchase
E0950
NU EP
U8 U8
A(Lap Tray for Switch Array) Wheelchair accessory,
						  tray, each
Y
Purchase
E0951
NU EP
Heel loop/holder, with or without ankle strap,
						  each
N****
Purchase
E0952
NU EP
Toe loop/holder, each
N****
Purchase
E0955
NU EP
Wheelchair accessory, headrest, cushioned, any type,
						  including fixed mounting hardware, each
N
Purchase
E0956
NU EP
A(Trunk supports for any W/C, other than travel, with
						  hardware) Wheelchair accessory, lateral trunk or hip support, any type,
						  including fixed mounting hardware, each
N****
Purchase
E0956
NU EP
U1 U1
A(Lateral trunk supports, swing away, each) Wheelchair
						  accessory, lateral trunk or hip support, any type, including fixed mounting
						  hardware, each
N****
Purchase
E0956
NU EP
U2 U2
A(Med. Chest Panel Support) Wheelchair accessory,
						  lateral trunk or hip support, any type, including fixed mounting hardware,
						  each
N****
Purchase
E0956
NU EP
U3 U3
A(Chest/Thoracic Supports) Wheelchair accessory,
						  lateral trunk or hip support, any type, including fixed mounting hardware,
						  each
N****
Purchase
E0957
NU EP
Wheelchair accessory, medial thigh support, (*Vflip-up)
						  any type, including fixed mounting hardware, each
N
Purchase
E0958
NU EP
Manual W/C accessory, one-arm drive attachment,
						  each
N****
Purchase
E0959
NU EP
A(Amputee adapters for conventional chair, ea.) Manual
						  W/C accessory, adapter for amputee, each
N****
Purchase
E0959
NU EP
A(Amputee axle plate for high performance manual W/C,
						  ea.) Manual wheelchair accessory, adapter for amputee, each
N****
Purchase
E0959
NU EP
U1 U1
Manual W/C accessory, adapter for amputee, each
N
Purchase
E0960
NU EP
W/C accessory, shoulder harness/straps or chest strap
						  including any type mounting hardware
N
Purchase
E0961
NU EP
Manual W/C accessory, wheel lock brake extension
						  (handle), each
N****
Purchase
E0966
NU EP
Manual wheelchair accessory, headrest extension,
						  each
N****
Purchase
E0967
NU EP
A(Hand rim, any type) Manual W/C accessory, hand rim
						  w/projections, any type, replacement only, each
N****
Purchase
E0967
NU EP
U1 U1
A(Hand rim, any type) Manual W/C accessory, hand rim
						  w/projections, any type, replacement only, each
N****
Purchase
E0967
NU EP
U2 U2
A(Hand rim, any type) Manual W/C accessory, hand rim
						  w/projections, any type, replacement only, each
N****
Purchase
E0967
NU EP
U3 U3
A(Hand rim, any type) Manual W/C accessory, hand rim
						  w/projections, any type, replacement only, each
N****
Purchase
E0967
NU EP
U4 U4
A(Hand rim, any type) Manual W/C accessory, hand rim
						  w/projections, any type, replacement only, each
N****
Purchase
E0970
NU EP
No. 2 footplates, except for elevating legrest`
N****
Purchase
E0971
NU EP
Anti-tipping device W/C
N****
Purchase
E0973
NU EP
W/C accessory, adjustable height, detachable armrest,
						  complete assembly, each
N****
Purchase
E0973
NU EP
U1 U1
A(Height Adj. Arms, replacement) W/C accessory,
						  adjustable height, detachable armrest, complete assembly, each
N****
Purchase
E0974
NU EP
Manual wheelchair accessory, anti-rollback device
						  (
A
grade aids), each
N****
Purchase
E0978
NU EP
Wheelchair accessory, positioning belt/safety
						  belt/pelvic strap, each
N****
Purchase
E0978
NU EP
U1 U1
A(Belt, safety or chest, w/pad) Wheelchair accessory,
						  positioning belt/safety belt/ pelvic strap, each
N**** N
Purchase
E0978
NU EP
U2 U2
Wheelchair accessory, positioning belt/safety
						  belt/pelvic strap, each
N****
Purchase
E0980
NU EP
A(Chest panel, 21-SM 22-LG) Safety vest,
						  wheelchair
N****
Purchase
E0980
NU EP
U1 U1
A(Shoulder retractors) Safety vest, W/C
N****
Purchase
E0981
NU EP
W/C accessory, seat upholstery, replacement only,
						  each
N
Purchase
E0982
NU EP
W/C accessory, back upholstery, replacement only,
						  each
N****
Purchase
E0982
NU EP
U1 U1
A(Standard back upholstery replacement) W/C accessory,
						  back upholstery, replacement only, each
N****
Purchase
E0990
NU EP
A(Elevating foot, leg rest) W/C accessory, elevating
						  leg rest, complete assembly, each
N****
Purchase
E0990
NU EP
U1 U1
A(Elevating Leg Rest 90 Degree, 12" -16" Wdth) W/C
						  accessory, elevating leg rest, complete assembly, each
N****
Purchase
E0992
NU EP
A
(Manual wheelchair accessory, solid
						  seat)
N****
Purchase
E0992
NU EP
U1 U1
AManual w/c accessory, solid seat insert (Large
						  adjustable solid seat w/hardware)
N****
Purchase
E0992
NU EP
U2 U2
A(Foam and Plywood Flat Side Manual wheelchair
						  accessory, solid seat)
N****
Purchase
E0992
NU EP
U3 U3
A(Foam & Plywood Seat, MPI Like Manual wheelchair
						  accessory, solid seat)
N****
Purchase
E0992
NU EP
U4 U4
A(Adjustable solid standard seat with hardware Manual
						  wheelchair accessory, solid seat)
N****
Purchase
E0994
NU EP
Armrest, each
N****
Purchase
E1002
NU EP
W/C accessory power seating system, tilt only
Y
*
Purchase
E1004
NU EP
W/C accessory, power seating system, recline only, with
						  mechanical shear reduction
Y
*
Purchase
E1006
NU EP
W/C accessory, power seating system, combination tilt
						  and recline, w/o shear reduction
Y
Purchase
E1007
NU EP
Wheelchair accessory, power seating system, combination
						  tilt and recline, with mechanical shear reduction
Y
Purchase
E1010
NU EP
W/C accessory, addition to power seating system, power
						  leg elevation system, including leg rest, each
Y
Purchase
E1020
NU EP
A(Adjustable Contour Lateral Thigh Support) Residual
						  limb support system for W/C
N****
Purchase
E1029
NU EP
A(Ventilator Tray With Battery Tray) Wheelchair
						  accessory, ventilator tray, fixed
Y
Purchase
E1030
NU EP
Wheelchair accessory, ventilator tray, gimbaled
Y
Purchase
E1050*
NU EP
Full reclining W/C, fixed full-length arms, swing-away,
						  detachable elevating legrests
N****
Purchase
E1060*
NU EP
Full reclining W/C, detachable arms, desk or
						  full-length, swing-away detachable, elevating legrests
Y
*
Purchase
E1070#
EP
A(A maximum use of three months only) Fully-reclining
						  wheelchair, detachable arms, (desk or full-length) swing-away, detachable
						  footrest/elevated legrest
Y
Rental only
E1084*
NU EP
Hemi-W/C; detachable arms, desk or full-length,
						  swing-away, detachable, elevating leg rests
N****
Purchase
E1086*
NU EP
Hemi W/C; detachable arms, desk or full-length,
						  swing-away, detachable footrests
N****
Purchase
E1086*
NU EP
U1 U1
Hemi W/C, detachable arms, desk or full-length,
						  swing-away detachable footrests
Y
Purchase
E1088*
NU EP
High strength lightweight W/C; detachable arms, desk or
						  full-length, swing-away, detachable, elevating legrests
Y
*
Purchase
E1090
NU EP
High-strength lightweight W/C; detachable arms, desk or
						  full-length, swing-away, detachable footrests
N****
Purchase
E1092*
NU EP
Wide, heavy-duty W/C; detachable arms, desk or
						  full-length, swing-away, detachable, elevating legrests
Y
*
Purchase
E1093*
NU EP
Wide, heavy-duty W/C; detachable arms, desk or
						  full-length arms, swing-away, detachable footrests
Y
*
Purchase
E1110*
NU EP
Semi-reclining W/C; detachable arms, desk or
						  full-length, elevating legrest
Y
*
Purchase
E1161
NU EP
Manual adult size W/C, includes tilt in space
Y
*
Purchase
E1170*
NU EP
Amputee W/C; fixed full-length arms, swing-away,
						  detachable, elevating legrests
N****
Purchase
E1172*
NU EP
Amputee W/C; detachable arms, desk or full-length,
						  without footrests or legrests
Y
*
Purchase
E1180*
NU EP
Amputee W/C; detachable arms, desk or full-length,
						  swing-away, detachable footrests
Y
*
Purchase
E1200*
NU EP
Amputee W/C; fixed full-length arms, swing-away,
						  detachable footrests
N****
Purchase
E1220*
NU EP
W/C, specially sized or constructed
(indicate brand name, model number, if any, and
						  justification)
Y
Manually Priced
E1225
NU EP
***(Folding Backrest, 8 Degree Bend, Low, 15" - 16")
						  Manual W/C accessory, semi-reclining back, (recline greater than 15 degrees,
						  but less than 80 degrees), each
N****
Purchase
E1228
NU EP
***(Folding Backrest, Tall, 19" - 20") Special back
						  height for W/C
N****
Purchase
E1228
NU EP
***(Folding Straight Backrest, Low, (15" -16") Special
						  back height for W/C
N****
Purchase
E1228
NU EP
***(Folding Straight Backrest, Tall, 19" -20") Special
						  back height for W/C
N****
Purchase
E1228
NU EP
U1 U1
***(High back contour seat) Special back height for
						  W/C
N****
Purchase
E1228
NU EP
U2 U2
***(Positioning tall back) Special back height for
						  W/C
N****
Purchase
E1230*
NU EP
Power operated vehicle (three- or four-wheel
						  nonhighway), specify brand name and model number
Y
*
Purchase
E1230
EP NU
U1 U1
Power operated vehicle (three- or four-wheel
						  nonhighway), specify brand name and model number
Y
*
Purchase
E1232*
EP
W/C, pediatric size, tilt-in-space, folding,
						  adjustable, with seating system
Y
*
Purchase
E1233*
EP
W/C, pediatric size, tilt-in-space, rigid, adjustable,
						  without seating system
Y
*
Purchase
E1234*
EP
W/C, pediatric size, tilt-in-space, folding,
						  adjustable, without seating system
Y
*
Purchase
E1235*
NU EP
Wheelchair, pediatric size, rigid, adjustable, with
						  seating system
Y
*
Purchase
E12352
EP
U1
A(Rigid W/C Frame) W/C, pediatric size, rigid,
						  adjustable with seating system
Y
Purchase
E1236
EP
Wheelchair, pediatric size, folding, adjustable, with
						  seating system
Y
Purchase
E1237*
EP
W/C, pediatric size, rigid, adjustable, without seating
						  system
Y
*
Purchase
E1238*
EP
W/C, pediatric size, folding, adjustable, without
						  seating system
Y
*
Purchase
E1240*
NU EP
Lightweight W/C; detachable arms, desk or full-length,
						  swing-away, detachable, elevating legrest
Y
*
Purchase
E1260*
NU EP
Lightweight W/C; detachable arms, desk or full-length,
						  swing-away, detachable footrests
N****
Purchase
E1280*
NU EP
Heavy-duty W/C; detachable arms, desk or full-length,
						  elevating legrests
Y
*
Purchase
E1290*
NU EP
Heavy-duty W/C; detachable arms, swing-away, detachable
						  footrests
Y
*
Purchase
E1340
NU EP
U1 U1
A(Labor Only; a maximum of twenty [20] units [20 units
						  = 5 hours of labor] per date of service is allowable.) Repair or nonroutine
						  service for durable medical equipment requiring the skill of a technician,
						  labor component, per 15 minutes
Y
Purchase
E1340
NU EP
U3 U3
A(Unlisted Repairs/Parts Only Wheelchairs;
applicable pages from the manufacturer's catalog must be attached to the
						  claim form.)
Repair or nonroutine service for durable medical equipment
						  requiring the skill of a technician, labor component, per 15 minutes
N****
Manually Priced
E2201
NU EP
A(Seat Width 20") Manual w/c accessory, nonstandard
						  seat frame width [GREATER THAN] than or equal to 20 inches and [LESS THAN] 24
						  inches
N****
Purchase
E2201
NU EP
U1 U1
A(Frame Wdth 14"-15") Manual w/c accessory, nonstandard
						  seat frame width[GREATER THAN]than or equal to 20 inches and [LESS THAN]24
						  inches
N****
Purchase
E2201
NU EP
U2 U2
A(Frame Wdth 19"-20") Manual w/c accessory, nonstandard
						  seat frame width[GREATER THAN]than or equal to 20 inches and [LESS THAN]24
						  inches
N****
Purchase
E2201
NU EP
U3 U3
Manual w/c accessory, nonstandard seat frame width
						  [GREATER THAN] than or equal to 20 inches and [LESS THAN]24 inches
N****
Manually Priced
E2203
NU EP
A(Seat Depth 15") Manual w/c accessory, nonstandard
						  seat frame depth, 20 to less than 22 inches
N****
Purchase
E2203
NU EP
U1 U1
A(Seat Depth 17" - 18") Manual w/c accessory,
						  nonstandard seat frame depth, 20 to less than 22 inches
N****
Purchase
E2203
NU EP
U2 U2
A(Frame, Long; 16", 17"3, 18", 19"3, 20" Depth) Manual
						  w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches
N****
Purchase
E2203
NU EP
U3 U3
A(Seat Depth 19" - 20") Manual w/c accessory,
						  nonstandard seat frame depth, 20 to less than 22 inches
N****
Purchase
E2203
NU EP
U4 U4
Manual w/c accessory, nonstandard seat frame depth, 20
						  to less than 22 inches
N
Manually Priced
E2206
NU EP
Manual wheelchair accessory, wheel lock assembly,
						  complete, each
N
Purchase
E2207
NU EP
Wheelchair accessory, crutch and cane holder,
						  each
N****
Purchase
E2208
NU EP
Wheelchair accessory, cylinder tank carrier,
						  each
N
Purchase
E2209
NU EP
Wheelchair accessory, arm trough, each
N
Purchase
E2210
NU EP
Wheelchair accessory, bearings, any type, replacement
						  only, each
N
Purchase
E2211
NU EP
Manual wheelchair accessory, pneumatic propulsion tire,
						  any size, each
N
Purchase
E2212
NU EP
Manual wheelchair accessory, tube for pneumatic
						  propulsion tire, any size, each
N
Purchase
E2213
NU EP
Manual wheelchair accessory, insert for pneumatic
						  propulsion tire (removable), any type, any size, each
N
Purchase
E2214
NU EP
Manual wheelchair accessory, pneumatic caster tire, any
						  size, each
N
Purchase
E2215
NU EP
Manual wheelchair accessory, tube for pneumatic caster
						  tire, any size, each
N
Purchase
E2220
NU EP
Manual wheelchair accessory, solid (rubber/plastic)
						  propulsion tire, any size, each
N
Purchase
E2221
NU EP
Manual wheelchair accessory, solid (rubber/plastic)
						  caster tire (removable), any size, each
N
Purchase
E2226
NU EP
Manual wheelchair accessory, caster fork, any size,
						  replacement only, each
N
Purchase
E2291
EP
Back, planar, for pediatric-size wheelchair, including
						  fixed attaching hardware
N
Manually Priced
E2292
EP
Seat, planar, for pediatric-size wheelchair, including
						  fixed attaching hardware
N
Manually Priced
E2293
EP
Back, contoured, for pediatric-size wheelchair,
						  including fixed attaching hardware
N
Manually Priced
E2294
EP
Seat, contoured, for pediatric-size wheelchair,
						  including fixed attaching hardware
N
Manually Priced
E2310
NU EP
Power w/c accessory, electronic connection between
						  wheelchair controller and one power seating system motor, including all related
						  electronics, indicator feature, mechanical function selection switch, and fixed
						  mounting hardware
Y
Purchase
E2311
NU EP
Power w/c accessory, electronic connection between
						  wheelchair controller and two or more power seating system motors, including
						  all related electronics, indicator feature, mechanical function selection
						  switch, and fixed mounting hardware
Y
Purchase
E2322
NU EP
Power w/c accessory, hand control interface, multiple
						  mechanical switches, nonproportional, including all related electronics,
						  mechanical stop switch, and fixed mounting hardware
Y
Purchase
E2323
NU EP
Power w/c accessory, specialty joystick handle for hand
						  control interface, prefabricated
Y
Purchase
E2324
NU EP
Power w/c accessory, chin cup for chin control
						  interface
Y
Purchase
E2325
NU EP
Power w/c accessory, sip & puff interface
						  nonproportional, including all related electronics, mechanical stop switch, and
						  manual swingaway mounting hardware
Y
Purchase
E2326
NU EP
Power wheelchair accessory, breath tube kit for sip and
						  puff interface
A
(replacement only)
Y
Purchase
E2327
NU EP
Power w/c accessory, head control interface,
						  mechanical, proportional, including all related electronics, mechanical
						  direction change switch, and fixed mounting hardware
Y
Purchase
E2360
NU EP
Power w/c accessory, 22 NF non-sealed lead acid
						  battery, each
N
Purchase
E2361
NU EP
Power w/c accessory, 22 NF sealed lead acid battery,
						  each, (e.g., gel cell, absorbed glassmat)
N
Purchase
E2363
NU EP
Power w/c accessory, group 24 sealed lead acid battery,
						  each (e.g., gel cell, absorbed glassmat)
N
Purchase
E2363
NU EP
U1 U1
Power w/c accessory, group 24 sealed lead acid battery,
						  each (e.g., gel cell, absorbed glassmat)
N
Purchase
E2365
NU EP
A(U-1 gel cell battery, each) Power wheelchair
						  accessory, U-1 sealed lead acid battery, each, (e.g., gel cell, absorbed
						  glassmat)
N
Purchase
E2365
NU EP
U1 U1
Power w/c accessory, U-1 sealed lead acid battery,
						  each, gel cell
N
Purchase
E2366
NU EP
A(24-Volt Battery Charger - Standard, Replacement)
						  Power w/c accessory, battery charger, single mode, for use with only one
						  battery type, sealed or non-sealed, each
N
Purchase
E2367
NU EP
A(24-Volt Battery Charger - Dual Mode, Replacement)
						  Power w/c accessory, battery charger, dual mode, sealed or non-sealed,
						  each
N
Purchase
E2368
NU EP
Power wheelchair component, motor, replacement
						  only
N
Purchase
E2369
NU EP
Power wheelchair component, gear box, replacement
						  only
N
Purchase
E2370
NU EP
Power wheelchair component, motor and gear box
						  combination, replacement only
Y
Purchase
E2372
NU EP
Power wheelchair accessory, group 27 non-sealed lead
						  acid battery, each
Y
Purchase
E2373
NU EP
Power wheelchair accessory, hand or chin control
						  interface, mini-proportional, compact, or short throw remote joystick or
						  touchpad, proportional, including all related electronics and fixing mounting
						  hardware.
Y
Purchase
E2375
NU EP
Power wheelchair accessory, nonexpandable controller,
						  including all related electronics and mounting hardware, replacement
						  only
Y
Purchase
E2376
NU EP
Power wheelchair accessory, expandable controller,
						  including all related electronics and mounting hardware, replacement
						  only
Y
Purchase
E2377
NU EP
Power wheelchair accessory, expandable controller,
						  including all related electronics and mounting hardware, upgrade provided at
						  initial issue
Y
Purchase
E2381
NU EP
Power wheelchair accessory, pneumatic drive wheel tire,
						  any size, replacement only, each
Y
Purchase
E2382
NU EP
Power wheelchair accessory, tube for pneumatic drive
						  wheel tire, any size, replacement only, each
Y
Purchase
E2383
NU EP
Power wheelchair accessory, insert for pneumatic drive
						  wheel tire (removable), any type, any size, replacement only, each
Y
Purchase
E2384
NU EP
Power wheelchair accessory, pneumatic caster tire, any
						  size, replacement only, each
Y
Purchase
E2385
NU EP
Power wheelchair accessory, tube for pneumatic caster
						  tire, any size, replacement only, each
Y
Purchase
E2386
NU EP
Power wheelchair accessory, foam filled drive wheel
						  tire, any size, replacement only, each
Y
Purchase
E2387
NU EP
Power wheelchair accessory, foam caster tire, any size,
						  replacement only, each
Y
Purchase
E2601
NU EP UE
General use wheelchair seat cushion, width less than 22
						  in., any depth
N
Purchase
E2602
NU EP UE
General use wheelchair seat cushion, width 22 in. or
						  greater, any depth
N
Purchase
E2611
NU EP UE
General use wheelchair back cushion, width less than 22
						  in., any height, including any type mounting hardware
N
Purchase
E2612
NU EP UE
General use wheelchair back cushion, width 22 in. or
						  greater, any height, including any type mounting hardware
N
Purchase
E2619
NU EP
Replacement cover for wheelchair seat cushion or back
						  cushion, each
N
Purchase
K0004
NU EP
High-strength lightweight wheelchair
Y****
Purchase
K0005*
NU EP
A(High-performance manual W/C-adult) Ultralightweight
						  W/C
Y
*
Purchase
K0005*
NU EP
U1 U1
A(High-performance manual W/C with growth
						  adjustability-child) Ultralightweight W/C
Y
*
Purchase
K0010
NU EP
A(Motorized, standard frame, DA, swing away footrests)
						  Standard weight frame motorized/power W/C
Y
*
Purchase
K0010
NU EP
U1 U1
A(Motorized, standard frame, DA, swing away ELR)
						  Standard weight frame motorized/power W/C
Y
*
Purchase
K0011
NU EP
A(Motorized, power base or convention frame w/c
						  DA/swing away footrests, programmable electronics and custom options)
						  Standard-weight frame motorized/power, W/C with programmable control parameters
						  for speed adjustment, tremor dampening, acceleration control and braking
al Y
*
Purchase
K0011
NU EP
U1 U1
A(Motorized, power base or convention frame w/c
						  DA/swing away footrests, programmable electronics and custom options)
						  Standard-weight frame motorized/power, W/C with programmable control parameters
						  for speed adjustment, tremor dampening, acceleration control and braking
al Y
*
Purchase
K0012
NU EP
A(Motorized folding frame, DA, swing away footrests)
						  Lightweight portable motorized/power W/C
Y
*
Purchase
K0012
NU EP
U1 U1
A(Motorized folding frame, DA, swing away ELR)
						  Lightweight portable motorized/power W/C
Y
*
Purchase
K00141,2
NU EP
Other motorized/ power W/C base
Y
*
Purchase
K00141,2
NU EP
U1 U1
A(Center Drive power base) Other motorized/ power W/C
						  base
Y
*
Purchase
K00141,2
NU EP
U3 U3
A
(Motorized, Power Base or conventional
						  frame W/C DA/swing away foot rests, programmable electronics and custom
						  options) Other motorized/ power W/C base
Y
*
Purchase
K00141,2
NU EP
U4 U4
A
(Motorized, Power Base or conventional
						  frame W/C DA/swing away elevated foot rests, programmable electronics and
						  custom options) Other motorized/ power W/C base
Y
*
Purchase
K0017
NU EP
***(Receiver for height adjustable arms) Detachable,
						  adjustable height armrest, base, each
N****
Purchase
K0017
NU EP
U1 U1
A(Dual post and adjustable height DA) Detachable,
						  adjustable height armrest, base, each
N****
Purchase
K0019
NU EP
Arm pad, each
N
Purchase
K0020
NU EP
Fixed, adjustable height armrest, pair
N****
Purchase
K0038** K0038
EP
NU EP
U1
A(Knee strap) Leg strap, each
A(Single leg strap, each) Leg strap, each
N N****
Purchase Purchase
K0038
NU EP
U2 U2
A(Foot straps, pair) Leg strap, each
N****
Purchase
K0039
NU EP
Leg strap, H style, each
N****
Purchase
K0040
NU EP
Adjustable angle footplate, each
N****
Purchase
K0043
NU EP
A(SWFR, replacement) Footrest, lower extension tube,
						  each
N
Purchase
K0044
NU EP
A(SWFR Hanger bracket, replacement) Footrest, upper
						  hanger bracket, each
N****
Purchase
K0045
NU EP
A(Padded custom foot box) Footrest, complete
						  assembly
N****
Purchase
K0047
NU EP
Elevating legrest, upper hanger bracket, each
N****
Purchase
K0056
NU EP
Seat height less than 17 inches or equal to or greater
						  than 21 inches for a high-strength, lightweight, or ultralightweight W/C
N****
Manually Priced
K0056
NU EP
U1 U1
A(Seat height 19.5"5) Seat height less than 17 inches
						  or equal to or greater than 21 inches for a high strength, lightweight or
						  ultralightweight W/C
N****
Purchase
K0065
NU EP
Spoke protectors, each
N****
Purchase
K0070
NU EP
A(Wheel assembly, complete with pneumatic tires,
						  20"/22"/24"/26"/ea. replacement) Rear wheel assembly, complete with pneumatic
						  tire, spokes or molded, each
N****
Purchase
K0071
NU EP
U1 U1
A(Wheel assembly with pneumatic tires, 22", pair, rear
						  wheels) Front caster assembly, complete, with pneumatic tire, each
N****
Purchase
K0071
NU EP
A(Polyurethane casters, 5", pair, front casters) Front
						  caster assembly, complete, with pneumatic tire, each
N****
Purchase
K0072
NU EP
A(Polyurethane casters, 5", pair, front casters) Front
						  caster assembly, complete, with semipneumatic tire, each
N****
Purchase
K0073
NU EP
Caster pin lock, each
N****
Purchase
K0077
NU EP
Front caster assembly, complete, with solid tire,
						  each
N
Purchase
K0108
NU EP
A(W/C miscellaneous equipment;
applicable pages
						  from the manufacturer's catalog must be attached to the claim form.)
Other accessories
N****
Manually Priced
S1002
EP
A(Wheelchair, custom molded seating system only)
						  Customized item, list in addition to code for basic item
N****
Manually Priced
S1002
NU EP
U1 U1
A(Foam-in-place seat, Pindot quick foam contour system)
						  Customized item, list in addition to code for basic item
N****
Purchase
The following procedure codes may only be billed on
				paper.
Specialized Wheelchairs and Wheelchair Seating Systems
				for Individuals Age Two Through Adult (section
				242.191 )
No
National
Code
Bill on paper
M1
NU EP
M2
Local Code
Z1613
Description
One-piece footboard (each)
PA
N****
Payment Method
Purchase
Bill on paper
NU EP
Z1793
Custom foot platform
N****
Purchase
Bill on paper
EP
Z1824**
PC Car Seat/Snug Seat
Y
Purchase
Bill on paper
NU EP
Z2137
Adjustable Rem. Abductor w/hardware (ea)
N****
Purchase
Bill on paper
NU EP
Z2138
Adjustable Flip Down Abductor w/hardware (ea)
N****
Purchase
Bill on paper
NU EP
Z2139
Lateral Hip/Thigh support w/hardware (ea)
N****
Purchase
Bill on paper
NU EP
Z2140
Adductor - no hardware
N****
Purchase
Bill on paper
NU EP
Z2141
Abductor - no hardware
N****
Purchase
Bill on paper
NU EP
Z2142
Hip guides - no hardware
N
Purchase
Bill on paper
NU EP
Z2143
Fluid supplement
N
Purchase
Bill on paper
NU EP
Z2145
Laterals - no hardware
N****
Purchase
Bill on paper
NU
Z2158
Air Exchange Seat Cover for Cushions
						  (Replacement)
N
Purchase
Bill on paper
NU EP
Z2159
Fluid Flo-lite pad (Replacement)
N
Purchase
Bill on paper
NU EP
Z2175
Power W/C Sleeve Top or Bottom Stem Bearing
						  (Replacement)
N****
Purchase
Bill on paper
NU EP
Z2178
SWFR Pivot Saddle (Replacement)
N
Purchase
Bill on paper
NU EP
Z2180
SWFR Latch Block (Replacement)
N
Purchase
Bill on paper
NU EP
Z2181
SWFR Composite Foot Plate (Replacement)
N****
Purchase
Bill on paper
NU EP
Z2183
Shoe Holders S/M/L/XL
N****
Purchase
Bill on paper
NU EP
Z2184
X-Tube Assembly Folding W/C (Replacement)
N****
Purchase
Bill on paper
NU EP
Z2185
Rigid Wheelchair Growth Kit
N
Purchase
Bill on paper
NU EP
Z2186
Rigid Side Guard
N****
Purchase
Bill on paper
NU EP
Z2187
Fabric Side Guard
N****
Purchase
Bill on paper
NU EP
Z2188
Sub Occipital Three Piece Head Set W/REM
						  Hardware
N****
Purchase
Bill on paper
NU EP
Z2189
Forehead Strap System
N****
Purchase
Bill on paper
NU EP
Z2190
Regular Links
N****
Purchase
Bill on paper
NU EP
Z2196
Swing Away Adj. Stroller Handles
N****
Purchase
Bill on paper
NU EP
Z2203
Elbow Block w/Bracket
N****
Purchase
Bill on paper
NU EP
Z2582
Quick Release Axle
N****
Purchase
Bill on paper
NU EP
Z2585
Growing Seat Pan
N****
Purchase
Bill on paper
NU EP
Z2586
Growing Back Upholstery
N****
Purchase
Bill on paper
NU EP
Z2588
Deep Contour Back 20" Width
N****
Purchase
Bill on paper
NU EP
Z2589
Adjustable Contour Lateral Pelvic Support
N****
Purchase
Bill on paper
NU EP
Z2592
Remote Joystick Module
N****
Purchase
Bill on paper
NU EP
Z2599
Transit Option
N****
Purchase
Bill on paper
NU EP
Z2604
Adjustable Back Upholstery
N****
Purchase
Bill on paper
NU EP
Z2616
Swing Away Mount (Joystick)
N****
Purchase