KNOW THE CODE.

Wheelchair Seating Evaluations and Claims
under the NEW Medicare Policy

Revised for Ju1y 1, 2006 – All 2006 revisions are in Red Italics

This document covers the following important information to assist you in operating under the rules and requirements of the new Medicare Policy for Wheelchair Seating:


We are happy to assist in helping you to understand these very important rules and regulations. Please feel free to contact us directly at 800-851-3449 for additional information.

If you are interested in receiving future updates via electronic mail, please provide the following information:



How to connect a beneficiary / patient with a specific seat cushion product

Two Choices

1) Start with the product selection process:
Or

2) Start with the patient qualification process:







Current wheelchair cushion HCPCS codes

E2601GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH
E2602GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH
E2603SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH
K0734 SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES, ANY DEPTH
E2604SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH
K0735SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22 INCHES OR GREATER, ANY DEPTH
E2605POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH
E2606POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH
E2607SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH
K0736SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES, ANY DEPTH
E2608SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH
K0737SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22 INCHES OR GREATER, ANY DEPTH
E2609CUSTOM FABRICATED WHEELCHAIR SEAT CUSHION, ANY SIZE






Clinical indicators (ICD-9 codes) and the corresponding HCPCS codes

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. For the items addressed in this medical policy, "reasonable and necessary" is defined by the following indications and limitations of coverage and/or medical necessity.

E2601 & E2602 - General Use Seat Cushion

K0734 & K0735- Adjustable Skin Protection Seat Cushion
or
E2603 & E2604 - Nonadjustable Skin Protection Seat Cushion

E2605 & E2606 - Positioning Seat Cushion

K0736 & K0737- Adjustable Combination Skin Protection and Positioning Seat Cushion
or
E2607 & E2608 - Nonadjustable Combination Skin Protection and Positioning Seat Cushion

E2609 - Custom Fabricated Seat Cushion




General Use Seat Cushion (E2601 & E2602)

A general use seat cushion (E2601, E2602) is covered for a patient who has a wheelchair which meets Medicare coverage criteria. If the patient does not have a covered wheelchair, then the cushion will be denied as not medically necessary.





Adjustable Skin Protection Seat Cushion (K0734 & K0735) or Nonadjustable Skin Protection Seat Cushion (E2603 & E2604)
A Nonadjustable Skin Protection Seat Cushion or an Adjustable Skin Protection Seat Cushion is covered for a patient who meets both of the following criteria:

1) The patient has a wheelchair and the patient meets Medicare coverage criteria for it

and

2) The patient has either of the following:
Qualifying ICD-9 Codes for HCPCS codes E2603, E2604, K0734 & K0735:







Positioning Seat Cushion (E2605 & E2606)

A positioning seat cushion (E2605,E2606), is covered for a patient who meets both of the following criteria:

1) The patient has a wheelchair and the patient meets Medicare coverage criteria for it

and

2) The patient has any significant postural asymmetries that are due to one of the diagnoses listed in criterion 2b above or to one of the following diagnoses: monoplegia of the lower limb (344.30-344.32, 438.40-438.42) or hemiplegia (342.00-342.92, 438.20-438.22) due to stroke, traumatic brain injury, or other etiology, muscular dystrophy (359.0, 359.1), torsion dystonias (333.4, 333.6, 333.7), spinocerebellar disease (334.0-334.9).

Qualifying ICD-9 codes for HCPCS codes E2605 and E2606:

138LATE EFFECTS OF ACUTE POLIOMYELITIS
330.0 - 330.9 CEREBRAL DEGENERATION USUALLY MANIFEST IN CHILDHOOD
331.0ALZHEIMER'S DISEASE
332.0PARALYSIS AGITANS
333.4HUNTINGTON'S CHOREA
333.6IDIOPATHIC TORSION DYSTONIA
333.7SYMPTOMATIC TORSION DYSTONIA
334.0 - 334.9 SPINOCEREBELLAR DISEASES
335.0 - 335.21 ANTERIOR HORN DISEASE (SMA)
335.23 - 335.9 OTHER MOTOR NEURON DISEASE
336.0 - 336.3 OTHER DISEASES OF THE SPINAL CORD
340MULTIPLE SCLEROSIS
341.0 - 341.9 OTHER DEMYLELINATING DISEASE OF THE CNS
342.00 - 342.92 HEMIPLEGIA AND HEMPARESIS
343.0 - 343.9 INFANTILE CEREBRAL PALSY
344.00 - 344.1 QUADRIPLEGIA, QUADRIPARESIS, PARAPLEGIA (LOWER LIMBS)
344.30 - 344.32 OTHER PARALYTIC SYNDROMES (MONOPLEGIA OF THE LOWER LIMBS)
359.0CONGENITAL HEREDITARY MUSCULAR DYSTROPHY
359.1HEREDITARY PROGRESSIVE MUSCULAR DYSTROPHY
438.20 - 438.22 HEMIPLEGIA- LATE EFFECTS OF CVD
438.40 - 438.42 MONOPLEGIS OF LOWER LIMBS – LATE EFFECTS OF CVD
741.00 - 741.93 SPINA BIFIDA







Adjustable Combination Skin Protection and Positioning Seat Cushion (K0736 & K0737) or Nonadjustable Combination Skin Protection and Positioning Seat Cushion (E2607 & E2608)

Within this category, the following ROHO cushions have been code verified by the SADMERC:
A nonadjustable combination skin protection and positioning seat cushion (E2607,E2608) or an adjustable combination skin protection and positioning seat cushion (K0736, K0737) is covered for a patient who meets the criteria for both a skin protection seat cushion and a positioning seat cushion.

Qualifying ICD-9 codes for HCPCS codes E2607, E2608 and K0736, K0737:

either

1) One of the following ICD-9 codes:

138LATE EFFECTS OF ACUTE POLIOMYELITIS
330.0 - 330.9 CEREBRAL DEGENERATION USUALLY MANIFEST IN CHILDHOOD
331.0ALZHEIMER'S DISEASE
332.0PARALYSIS AGITANS
335.0 - 335.21 ANTERIOR HORN CELL DISEASE (SMA)
335.23 - 335.9 OTHER MOTOR NEURON DISEASE
336.0 - 336.3 OTHER DISEASE OF THE SPINAL CORD
340MULTIPLE SCLEROSIS
341.0 - 341.9 OTHER DEMYLELINATING DISEASE OF THE CNS
343.0 - 343.9 INFANTILE CEREBRAL PALSY
344.00 - 344.1 QUADRIPLEGIA, QUADRIPARESIS, PARAPLEGIA (LOWER LIMBS)
741.00 - 741.93 SPINA BIFIDA
or

2) A combination of ICD-9 code 707.03, 707.04, or 707.05 AND one of the following ICD-9 codes:

333.4HUNTINGTON'S CHOREA
333.6IDIOPATHIC TORSION DYSTONIA
333.7SYMPTOMATIC TORSION DYSTONIA
334.0 - 334.9 SPINOCEREBELLAR DISEASE
342.00 - 342.92 HEMIPLEGIA AND HEMIPARESIS
344.30 - 344.32 MONOPLEGIA OF THE LOWER LIMBS
359.0CONGENITAL HEREDITARY MUSCULAR DYSTROPHY
359.1HEREDITARY PROGRESSIVE MUSCULAR DYSTROPHY
438.20 - 438.22 HEMIPLEGIA – LATE EFFECTS OF CVD
438.40 - 438.42 MONOPLEGIA LOWER LIMBS – LATE EFFECTS OF CVD







Custom Fabricated Seat Cushion (E2609)

Within this category, the following ROHO cushions have been code verified by the SADMERC:
A custom fabricated seat cushion (E2609) is covered if criteria (1) and (3) are met:

1) Patient meets all of the criteria for a prefabricated skin protection seat cushion or positioning seat cushion;

2) Patient meets all of the criteria for a prefabricated positioning back cushion;

3) There is a comprehensive written evaluation by a licensed clinician (who is not an employee of or otherwise paid by a supplier) which clearly explains why a prefabricated seating system is not sufficient to meet the patient's seating and positioning needs.


Qualifying ICD-9 codes for HCPCS code E2609:
138LATE EFFECTS OF ACUTE POLIOMYELITIS
330.0 - 330.9 CEREBRAL DEGENERATION USUALLY MANIFEST IN CHILDHOOD
331.0ALZHEIMER'S DISEASE
332.0PARALYSIS AGITANS
333.4HUNTINGTON'S CHOREA
333.6IDIOPATHIC TORSION DYSTONIA
333.7SYMPTOMATIC TORSION DYSTONIA
334.0 - 334.9 SPINOCEREBELLAR DISEASE
335.0 - 335.21 ANTERIOR HORN CELL DISEASE (SMA)
335.23 - 335.9 OTHER MOTOR NEURON DISEASE
336.0 - 336.3 OTHER DISEASE OF THE SPINAL CORD
340MULTIPLE SCLEROSIS
341.0 - 341.9 OTHER DEMYLELINATING DISEASE OF THE CNS
342.00 - 342.92 HEMIPLEGIA AND HEMIPARESIS
343.0 - 343.9 INFANTILE CEREBRAL PALSY
344.00 - 344.1 QUADRIPLEGIA, QUADRIPARESIS, PARAPLEGIA (LOWER LIMBS)
344.30 - 344.32 MONOPLEGIA OF THE LOWER LIMB
359.0CONGENITAL HEREDITARY MUSCULAR DYSTROPHY
359.1HEREDITARY PROGRESSIVE MUSCULAR DYSTROPHY
438.20 - 438.22 HEMIPLEGIA – LATE EFFECTS OF CVD
438.40 - 438.42 MONOPLEIGA OF LOWER LIMB – LATE EFFECTS OF CVD
707.03DECUBITUS ULCER, LOWER BACK
707.04DECUBITUS ULCER, HIP
707.05DECUBITUS ULCER, BUTTOCK
741.00 - 741.93 SPINA BIFIDA

Note:
If a skin protection seat cushion, positioning seat cushion, combination skin protection and positioning seat cushion or a custom fabricated cushion is provided for a patient who does not meet the stated coverage criteria, but the coverage criteria for another type of cushion are met, payment will be based on the allowance for the least costly medically appropriate alternative; if the criteria for a another type of seat cushion are not met, the provided cushion will be denied as not medically necessary.





Manufacturer, make and model of cushions available based upon specific HCPCS code
Review the current SADMERC Product Classification List (see link below). The following are the current SADMERC Product Classifications and corresponding Medicare Allowables for ROHO cushions:





Documentation for claims filing






Links to DMERC Medical Policies and SADMERC Product Classification List