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Medicare Funding

Summary

Medicare funding is available for wheelchairs and other durable medical equipment.

Medicare is a federal program that provides insurance for the elderly, and is managed through the Centers for Medicaid and Medicare Services.

For any equipment to be covered by Medicare, you must be covered by Medicare, and the equipment must be defined by Medicare to be reasonable and necessary for improving the functioning of a "malformed body."

In short, for Medicare to cover a wheelchair, you must be considered bed- or chair-bound without a wheelchair, and you must require the use of a wheelchair or functional seating for home or work. This is explained in greater detail in the tables below.

Medicare Requirements Information

Use these links to scroll down to the appropriate table on this page.

Information Is Provided By

The following information is provided for your education, and can be obtained in full at Palmetto GBA. We have excerpted relevant wheelchair definitions and eligibility information as provided for under Chapter 1, Section 10, "Fair Use", U.S. Copyright Law. Current Procedural Terminology (CPT®) is copyright 2003 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association.

 

Manual Wheelchair Bases
Primary Geographic Jurisdiction AL, AR, CO, FL, GA, KY, LA, MS, NC, NM, OK, PR, SC, TN, TX, VI
Indications and Limitations of Coverage and/or 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 an 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, the criteria for "reasonable and necessary" are defined by the following indications and limitations of coverage and/or medical necessity.

For an item to be covered by Medicare, a written signed and dated order must be received by the supplier before a claim is submitted to the DMERC. If the supplier bills for an item addressed in this policy without first receiving the completed order, the item will be denied as not medically necessary.

A wheelchair is covered if the patient's condition is such that without the use of a wheelchair, he would otherwise be bed or chair confined. An individual may qualify for a wheelchair and still be considered bed confined. This basic requirement must be met for coverage of any wheelchair.

An upgrade that is beneficial primarily in allowing the patient to perform leisure or recreational activities will be noncovered. Payment will be based on the allowance for the least costly medically acceptable alternative.

Payment is made for only one wheelchair at a time. Backup chairs are denied as not medically necessary. One month's rental of a wheelchair is covered if a patient-owned wheelchair is being repaired.

Reimbursement for wheelchair codes includes all labor charges involved in the assembly of the wheelchair. Reimbursement also includes support services such as emergency services, delivery, set-up, education, and on-going assistance with use of the wheelchair.

A standard hemi-wheelchair (K0002) is covered when the patient requires a lower seat height (17" to 18") because of short stature or to enable the patient to place his/her feet on the ground for propulsion.

A lightweight wheelchair (K0003) is covered when a patient:
    a. Cannot self-propel in a standard wheelchair using arms and/or legs and
    b. The patient can and does self-propel in a lightweight wheelchair.

A high strength lightweight wheelchair (K0004) is covered when a patient meets the criteria in (1) and/or (2):
    1. The patient self-propels the wheelchair while engaging in frequent activities that cannot be performed in a standard or lightweight wheelchair.
    2. The patient requires a seat width, depth, or height that cannot be accommodated in a standard, lightweight or hemi-wheelchair, and spends at least two hours per day in the wheelchair.

A high strength lightweight wheelchair is rarely medically necessary if the expected duration of need is less than three months (e.g., post-operative recovery).

Coverage of an ultralightweight wheelchair (K0005) is determined on an individual consideration basis.

If a K0005 wheelchair base is determined to be not medically necessary but criteria are met for a less costly wheelchair, payment will be based on the least costly alternative (K0001 - K0004). However, since K0005 is in a different payment category it will be denied as not medically necessary if billed as a purchase.

A heavy duty wheelchair (K0006) is covered if the patient weighs more than 250 pounds or the patient has severe spasticity.

An extra heavy duty wheelchair (K0007) is covered if the patient weighs more than 300 pounds.

When the stated coverage criteria relating to medical necessity are not met, a claim will be considered for coverage if there is additional documentation which justifies the medical necessity for the item in the individual case. If the documentation does not support the medical necessity of the wheelchair which is billed, but does support the medical necessity of a lower level wheelchair, payment will be based on the allowance for the least costly medically acceptable alternative.
Reasons for Denials Items listed in this policy will be denied as not medically necessary when provided for conditions other than those listed in the "Indications and Limitations of Coverage and/or Medical Necessity" section unless it specifically states in that section that they will be denied as noncovered.
Coding Guidelines A standard wheelchair (K0001) is characterized by:
Weight: greater than 36 lbs.
Seat Width: 16" (narrow), 18" (adult)
Seat Depth: 16"
Seat Height: greater than or equal to 19" and less than or equal to 21"
Back Height: Non-adjustable 16" - 17"
Arm Style: Fixed or detachable
Footplate Extension: 16" - 21"
Footrests: Fixed or swingaway detachable

A standard hemi (low seat) wheelchair (K0002) is characterized by:
Weight: greater than 36 lbs.
Seat Width: 16" (narrow), 18" (adult)
Seat Depth: 16"
Seat Height: 17" - 18"
Back Height: Non-adjustable 16" - 17"
Arm Style: Fixed or detachable
Footplate Extension: 14" - 17 1/2"
Footrests: Fixed or swingaway detachable

A lightweight wheelchair (K0003) is characterized by:
Weight: less than or equal to 36 lbs.
Seat Width: 16" or 18"
Seat Depth: 16"
Seat Height: greater than or equal to 17" and less than 21"
Back Height: Non-adjustable 16" - 17"
Arm Style: Fixed height, detachable
Footplate Extension: 16" - 21"
Footrests: Fixed or swingaway detachable

A high strength, lightweight wheelchair (K0004) is characterized by:
Lifetime Warranty: On side frames and crossbraces
Weight: less than 34 lbs.
Seat Width: 14", 16", or 18"
Seat Depth: 14" (child), 16" (adult)
Seat Height: greater than or equal to 17" and less than 21"
Back Height: Sectional or adjustable 15" - 19"
Arm Style: Fixed or detachable
Footplate Extension: 16" - 21"
Footrests: Fixed or swingaway detachable

An ultralightweight wheelchair (K0005) is characterized by:
Lifetime Warranty: On side frames and crossbraces
Weight: less than 30 lbs.
Adjustable rear axle position
Seat Width: 14", 16", or 18"
Seat Depth: 14" (child), 16" (adult)
Seat Height: greater than or equal to 17" and less than 21"
Arm Style: Fixed or detachable
Footplate Extension: 16" - 21"
Footrests: Fixed or swingaway detachable

A heavy duty wheelchair (K0006) is characterized by:
Seat Width: 18"
Seat Depth: 16" or 17"
Seat Height: greater than 19" and less than 21"
Back Height: Non-adjustable 16" - 17"
Arm Style: Fixed height, detachable
Footplate Extension: 16" - 21"
Footrests: Fixed or swingaway detachable
Reinforced back and seat upholstery
Can support patient weighing greater than 250 pounds

An extra heavy duty wheelchair (K0007) is characterized by:
Seat Width: 18"
Seat Depth: 16" or 17"
Seat Height: greater than 19" and less than 21"
Back Height: Non-adjustable 16" - 17"
Arm Style: Fixed height, detachable
Footplate Extension: 16" - 21"
Footrests: Fixed or swingaway detachable
Reinforced back and seat upholstery
Can support patient weighing greater than 300 pounds

Wheelchair "poundage" (lbs.) represents the weight of the usual configuration of the wheelchair without frontriggings.

Codes E1050 - E1060, E1070 - E1200, E1220 - E1224, E1240 - E1295 should only be used to bill for maintenance and service for an item for which the initial claim was paid by the local carrier prior to transition to the DMERC.

Wheelchairs with individualized features which meet the needs of a particular patient are billed by selecting the correct code for the wheelchair base and then using appropriate codes for wheelchair options and accessories. (Refer to the Wheelchair Options and Accessories policy.) If the frame of the wheelchair is modified in a unique way to accommodate the patient, bill the code for the wheelchair base and bill the modification with code K0108 (wheelchair component or accessory, not otherwise specified).

Suppliers should contact the Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC) for guidance on the correct coding of these items.

Motorized/Power Wheelchair Bases
Primary Geographic Jurisdiction AL, AR, CO, FL, GA, KY, LA, MS, NC, NM, OK, PR, SC, TN, TX, VI
Indications and Limitations of Coverage and/or 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 an 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, the criteria for "reasonable and necessary" are defined by the following indications and limitations of coverage and/or medical necessity.

For an item to be covered by Medicare, a written signed and dated order must be received by the supplier before a claim is submitted to the DMERC. If the supplier bills for an item addressed in this policy without first receiving the completed order, the item will be denied as not medically necessary.

A power wheelchair is covered when all of the following criteria are met:
    1. The patient's condition is such that without the use of a wheelchair the patient would otherwise be bed or chair confined, and;
    2. The patient's condition is such that a wheelchair is medically necessary and the patient is unable to operate a wheelchair manually and;
    3. The patient is capable of safely operating the controls for the power wheelchair.

A patient who requires a power wheelchair usually is totally nonambulatory and has severe weakness of the upper extremities due to a neurologic or muscular disease/condition.

If the documentation does not support the medical necessity of a power wheelchair but does support the medical necessity of a manual wheelchair, payment is based on the allowance for the least costly medically appropriate alternative. However, if the power wheelchair has been purchased, and the manual wheelchair on which payment is based is in the capped rental category, the power wheelchair will be denied as not medically necessary.

Options that are beneficial primarily in allowing the patient to perform leisure or recreational activities are noncovered.

If the length of need for a power wheelchair is 6 months or less, only rental will be covered. In this situation, purchase will be denied as not medically necessary.

Payment is made for only one wheelchair at a time. Backup chairs are denied as not medically necessary. One month's rental of a wheelchair is covered if a patient-owned wheelchair is being repaired.

Reimbursement for the wheelchair codes includes all labor charges involved in the assembly of the wheelchair and all covered additions or modifications. Reimbursement also includes support services, such as emergency services, delivery, set-up, education, and on-going assistance with use of the wheelchair.
Reasons for Denials Items listed in this policy will be denied as not medically necessary when provided for conditions other than those listed in the "Indications and Limitations of Coverage and/or Medical Necessity" section unless it specifically states in that section that they will be denied as noncovered.
Coding Guidelines Motorized/power wheelchairs (K0010, K0011, K0012) are characterized by:
Seat Width: 14" - 18"
Seat Depth: 16"
Seat Height: greater than or equal to 19 and less than or equal to 21"
Back Height: Sectional 16" or 18"
Arm Style: Fixed height, detachable
Footplate Extension: 16" - 21"
Footrests: Fixed or swingaway detachable

In addition, a lightweight power wheelchair (K0012) is characterized by:
Weight less than 80 lbs. without battery
Folding back or collapsible frame

Wheelchair "poundage" (lbs.) represents the weight of the usual configuration of the wheelchair without frontriggings.

Wheelchairs with individualized features which meet the needs of a particular patient are billed by selecting the correct code for the wheelchair base and then using appropriate codes for wheelchair options and accessories. (Refer to the Wheelchair Options and Accessories policy.) If the frame of the wheelchair is modified in a unique way to accommodate the patient, bill the code for the wheelchair base and bill the modification with code K0108 (wheelchair component or accessory, not otherwise specified).

Codes K0010 - K0014 are not used for manual wheelchairs with add-on power packs. Use the appropriate code for the manual wheelchair base provided (K0001 - K0009) and code K0460.

Codes E1210 - E1220 should only be used to bill for maintenance and service for an item for which the initial claim was paid to the local carrier prior to the transition to the DMERC.

Suppliers should contact the Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC) for guidance on the correct coding of these items.

Wheelchair Options/Accessories
Primary Geographic Jurisdiction AL, AR, CO, FL, GA, KY, LA, MS, NC, NM, OK, PR, SC, TN, TX, VI
Indications and Limitations of Coverage and/or 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 an 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, the criteria for "reasonable and necessary" are defined by the following indications and limitations of coverage and/or medical necessity.

For an item to be covered by Medicare, a written signed and dated order must be received by the supplier before a claim is submitted to the DMERC. If the supplier bills for an item addressed in this policy without first receiving the completed order, the item will be denied as not medically necessary.

Options and accessories for wheelchairs are covered if the following criteria are met:
    1. The patient has a wheelchair that meets Medicare coverage criteria, and
    2. The patient's condition is such that without the use of a wheelchair, he would otherwise be bed or chair confined (an individual may qualify for a wheelchair and still be considered bed confined), and;
    3. The options/accessories are necessary for the patient to perform one or more of the following activities:
      a. Function in the home;
      b. Perform instrumental activities of daily living.

An option/accessory that is beneficial primarily in allowing the patient to perform leisure or recreational activities is noncovered.
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 patient-owned POV meets coverage criteria, medically necessary replacement items are covered.

Adjustable arm height option (K0016-K0018, K0020) is covered if the patient requires an arm height that is different than that available using nonadjustable arms and the patient spends at least 2 hours per day in the wheelchair.

Reinforced back upholstery (K0022) or reinforced seat upholstery (K0029) is covered if used with a power wheelchair base (K0010-K0012) and the patient weighs more than 200 pounds. When used in conjunction with heavy duty (K0006) or extra heavy duty (K0007) wheelchair bases, the allowance for reinforced upholstery is included in the allowance for the wheelchair base. Reinforced back and seat upholstery are not medically necessary if used in conjunction with other manual wheelchair bases (K0001-K0005).

Hook-on headrest extension (K0025) is covered if the patient:
    1. Has weak neck muscles and needs a headrest for support, or
    2. Meets the criteria for and has a reclining back on the wheelchair.

A fully reclining back option (K0028) is covered if the patient spends at least 2 hours per day in the wheelchair and has one or more of the following conditions/needs:
    1. Quadriplegia;
    2. Fixed hip angle;
    3. Trunk or lower extremity casts/braces that require the reclining back feature for positioning;
    4. Excess extensor tone of the trunk muscles; and/or
    5. The need to rest in a recumbent position two or more times during the day and transfer between wheelchair and bed is very difficult.

A solid seat insert (K0030) is covered when the patient spends at least 2 hours per day in the wheelchair.

A safety belt/pelvic strap (K0031) is covered if the patient has weak upper body muscles, upper body instability or muscle spasticity which requires use of this item for proper positioning.

Elevating legrests (K0046-K0048, K0053, K0195) are covered if:
    1. The patient has a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee; or
    2. The patient has significant edema of the lower extremities that requires having an elevating legrest; or
    3. The patient meets the criteria for and has a reclining back on the wheelchair.

Swingaway, detachable footrests (K0052) are included in the allowance for the wheelchair base. They should be billed separately only when they are replacements.

A non-standard seat width, depth, or height (K0054-K0058) is covered only if:
    1. The ordered item is at least 2 inches greater than or less than a standard option, and
    2. The patient's dimensions justify the need.

Anti-rollback device (K0080) is covered if the patient propels himself/herself and needs the device because of ramps.

Up to two batteries (K0082-K0087) at any one time are allowed if required for a power wheelchair. A battery is separately payable from the wheelchair base.

A battery charger (K0088, K0089) is included in the allowance for a power wheelchair base (K0010-K0014). A battery charger should be billed separately only when it is a replacement. A dual mode charger (K0089) is not medically necessary; when it is provided as a replacement, payment is based on the allowance for the least costly medically appropriate alternative, K0088.

A one arm drive attachment (E0958) is covered if the patient propels the chair himself/herself with only one hand and the need is expected to last at least 6 months.

A crutch and cane holder (K0102) is not medically necessary.

An arm trough (K0106) is covered if patient has quadriplegia, hemiplegia, or uncontrolled arm movements.

Back support systems described by code K0114 are not generally accepted as being reasonable and necessary to provide trunk support to patients in wheelchairs. An adequate seating system would allow the patient to function appropriately in the wheelchair. Code K0114 will be denied as not medically necessary.

A custom fabricated back module or combined back and seat module(K0115, K0116) is covered when:
    1. The patient has a significant spinal deformity and/or severe weakness of the trunk muscles, and
    2. The patient's need for prolonged sitting tolerance, postural support to permit functional activities, or pressure reduction cannot be met adequately by a prefabricated seating system, and
    3. The patient is expected to be in the wheelchair at least 2 hours per day.

The medical necessity for all options and accessories must be documented in the patient's medical record and be available to the DMERC on request.
Reasons for Denials Items listed in this policy will be denied as not medically necessary when provided for conditions other than those listed in the "Indications and Limitations of Coverage and/or Medical Necessity" section unless it specifically states in that section that they will be denied as noncovered.
Coding Guidelines Codes A4631, E0950, E0952-E0954, E0959, E0961, E0966, E0967, E0969-E0970, E0972-E1001, E1065-E1069, E1226, E1227, E1296-E1298 are not valid for claims submitted to the DMERC. Codes E0958, E0968, E1225, and E1228 should only be used to bill for maintenance and service for an item for which the initial claim was paid by the local carrier prior to transition to the DMERC.

A table in the Appendices section defines the bundling guidelines for wheelchair bases and options/accessories. Codes listed in Column II are not separately payable from the wheelchair base and must not be billed separately at the time of initial purchase or rental of the wheelchair.
A replacement option/accessory for a power operated vehicle (POV) is billed using a wheelchair option/accessory code. All options and accessories provided at the time of initial issue of a POV are not separately billable.

When options or accessories are billed as a replacement of a previously used part of the same type which has been worn or damaged, add modifier RP to the code for the part.

The right (RT) and left (LT) modifiers must be used when appropriate. When the same code for bilateral items (left and right) are billed on the same date of service, bill both items on the same claim line using the LTRT modifiers and 2 units of service.

Code K0028 is for a fully reclining back which is manually operated. A power reclining back is billed using the miscellaneous accessory code K0108.

A prefabricated back seating module which is incorporated into a wheelchair base is billed using the wheelchair back accessory codes - K0023, K0024, or K0108.

Elevating legrests that are used with a wheelchair that is purchased or owned by the patient are coded K0048. This code is per legrest. Elevating legrests that are used with a capped rental wheelchair bases should be coded K0195. This code is per pair of legrests.

When a wheelchair is provided with seat dimensions that are different than those included in the wheelchair base code, use the code for the appropriate wheelchair base plus a code or codes for the nonstandard seat dimensions (K0054-K0058). Other combinations, which are listed in the manufacturer's order form or price list, should be coded K0108. The submitted charge for code K0108 should represent the incremental additional charge for the nonstandard dimensions not included in other submitted codes.

Code K0114 describes a device with the following characteristics:
    1. Plastic frame which is padded and covered with cloth, or other material
    2. Designed to be attached to a wheelchair base; doesn't completely replace the wheelchair back
    3. Limited degree of custom fitting/molding possible

Codes K0115 and K0116 describe custom fabricated seating components which are incorporated into a wheelchair base. Custom fabricated means the item is individually made for a patient using (a) a plaster model of the patient, (b) a computer generated model of the patient (CAD-CAM technology), or (c) detailed measurements of the patient used to create a carved foam custom fabricated component. These codes are not used for seating components that are ready made but subsequently modified to fit an individual patient. Code K0116 is used for either a one piece system or when there are separate back and seat components.
Miscellaneous options, accessories, or replacement parts for wheelchairs that do not have a specific HCPCS code should be coded K0108. If multiple miscellaneous accessories are provided, each should be billed on a separate claim line using code K0108. When billing more than one line item with code K0108, ensure that the additional information can be matched to the appropriate line item on the claim. It is also helpful to reference the line item to the submitted charge.

Suppliers should contact the Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC) for guidance on the correct coding of these items.

 

 


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