Wheelchair Options/Accessories - Policy Article

NON-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”). Wheelchair options and accessories are covered under the Durable Medical Equipment benefit (Social Security Act §1861(s)(6)). In order for a beneficiary’s equipment to be eligible for reimbursement the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met. The allowance for a power operated vehicle (POV) includes all options and accessories that are provided at the time of initial issue, including but not limited to batteries, battery chargers, seating systems, etc. If a beneficiary-owned POV meets coverage criteria, medically necessary replacement items are covered. The allowance for a rollabout chair includes all options and accessories that are provided at the time of initial issue. The allowance for a transport chair includes all options and accessories that are provided at the time of initial issue except for elevating legrests (E0990, K0195). If a rollabout chair or transport chair are covered, medically necessary replacement items are covered. An option/accessory that is beneficial primarily in allowing the beneficiary to perform leisure or recreational activities is non-covered. If an option or accessory that is included in another code is billed separately, the claim line will be denied as not separately payable. (Refer to Coding Guidelines section for additional information on correct coding.) BATTERIES/ CHARGERS: A sealed battery (E2359, E2361, E2363, E2365, E2371, E2397, K0733) is separately payable from a power wheelchair base. There is no additional/separate payment when a dual mode battery charger is provided at the time of initial issue of a power wheelchair. A battery charger (E2366, E2367) is included in the allowance for a power wheelchair base. POWER STANDING SYSTEM: A power standing feature (E2301) is non-covered because it is not primarily medical in nature. If a wheelchair has an electrical connection device described by code E2310 or E2311 and if the sole function of the connection is for a power standing feature, it will be denied as non-covered. POWER WHEELCHAIR DRIVE CONTROL SYSTEMS: If an attendant control (E2331) is provided in addition to a beneficiary-operated drive control system, it will be denied as non-covered. (See the related LCD for situations in which it is provided in place of a beneficiary-operated system.) OTHER POWER WHEELCHAIR ACCESSORIES: An electronic interface used to control lights or other electrical devices is non-covered because it is not primarily medical in nature. The following features of a power wheelchair will be denied as non-covered: stair climbing (A9270), electronic balance (A9270), ability to elevate the seat by balancing on two wheels (A9270), and remote operation (A9270). MISCELLANEOUS ACCESSORIES: Swingaway, retractable, or removable hardware (E1028, E1032) is non-covered if the primary indication for its use is to allow the beneficiary to move close to desks or other surfaces. If it is ordered for this indication, a GY modifier must be added to the code. A manual standing system for a manual wheelchair (E2230) is non-covered (no benefit category) because it is not primarily medical in nature. A wheelchair transportation securement system (E1022) and a wheelchair transit securement system (E1023) are non-covered as they do not meet the definition of DME. 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 available here . 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 REQUIREMENTS In 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 provides detailed information explaining why each option and accessory – e.g., power tilt and/or recline seating systems, or gear reduction drive wheel – is needed to address the beneficiary’s 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.) ASSISTIVE TECHNOLOGY PROFESSIONAL (ATP) ASSESSMENT: The documentation provides evidence that a Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) certified professional, employed by the supplier, had direct in-person involvement in the selection of the power mobility device and accessories for the beneficiary. The supplier ATP assessment date must be on or after the beginning of the face-to-face process with the treating practitioner and/or licensed/certified medical professional (LCMP). MODIFIERS KX, GA, GY, GZ, LT, and RT MODIFIERS: For accessories for a power mobility device (PMD), if the requirements related to a standard written order (SWO) for the PMD base and 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 accessories. For accessories 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 accessories. If the conditions for use of the GY modifier are not met, the KX modifier must be added to the code for the accessory only if (a) the coverage criteria that are specified in the Manual Wheelchair Bases or Power Mobility Devices LCD have been met and (b) any specific coverage criteria for the accessory in the related LCD have been met. If the coverage criteria are not met, the KX modifier must not be used. If the conditions for use of the GY modifier are not met and if the requirements for use of the KX modifier are not met, the GA or GZ modifier must be added to a claim line for the 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. The right (RT) and left (LT) modifiers are optional on claim lines billed for wheelchair options and accessories. Effective for claims with dates of service (DOS) on or after 3/1/2019, if RT and LT modifiers are appended to claim lines billed for bilateral wheelchair options and accessories (left and right) and the unit of service of the code is “each,” then bill each item on two separate claim lines with the RT modifier on one line and the LT modifier on the other, and 1 unit of service (UOS) on each claim line. If the RT and LT are appended, do not use the RTLT modifier on the same claim line and billed with 2 UOS. Claims with RTLT on the same claim line and 2 UOS will be rejected as incorrect coding. If RT and LT modifiers are not appended, then the bilateral items (left and right) with a unit of service “each” may be billed on a single claim line with 2 UOS. If bilateral items are provided and the unit of service is “pair,” the LT and RT modifiers are not applicable. CODING GUIDELINES GENERAL: Power Wheelchair 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 mode Complete set of tires and casters, any type Legrests. There is no separate billing/payment if fixed, swingaway, or detachable non-elevating legrests with or without calf pad are provided.