Contractor Name

AdminaStar Federal, Inc. 

Contractor Number

00635 

Contractor Type

DMERC 

LCD Database ID Number

L15809 

LCD Title

Wheelchair Seating 

Contractor's Determination Number

WCS 

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2003 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. CDT-4 codes and descriptions are © 2002 American Dental Association. All rights reserved.  

CMS National Coverage Policy

Primary Geographic Jurisdiction

DC
IL
IN
MD
MI
MN
OH
VA
WI
WV
 

Oversight Region

Region V 

CMS Consortium

Midwest 

DMERC Region LCD Covers

Region B 

Original Determination Effective Date

For services performed on or after 07/01/2004  

Original Determination Ending Date

Revision Effective Date

For services performed on or after 10/01/2004  

Revision Ending Date

Indications and Limitations of Coverage and/or Medical Necessity

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.

A general use seat cushion (K0650,K0651) and a general use wheelchair back cushion (K0660-K0661) 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.

A skin protection seat cushion (K0652,K0653) 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:
a) Current pressure ulcer (707.03, 707.04, 707.05) or past history of a pressure ulcer (707.03, 707.04, 707.05) on the area of contact with the seating surface; or
b) Absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift due to one of the following diagnoses: spinal cord injury resulting in quadriplegia or paraplegia (344.00-344.1), other spinal cord disease (336.0-336.3), multiple sclerosis (340), other demyelinating disease (341.0-341.9), cerebral palsy (343.0-343.9), anterior horn cell diseases including amyotrophic lateral sclerosis (335.0-335.21, 335.23-335.9), post polio paralysis (138), traumatic brain injury resulting in quadriplegia (344.09), spina bifida (741.00-741.93), childhood cerebral degeneration (330.0-330.9), Alzheimer’s disease (331.0), Parkinson’s disease (332.0).

A positioning seat cushion (K0654,K0655), positioning back cushion (K0662-K0665), and positioning accessory (E0955-E0957, E0960) 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).

A combination skin protection and positioning seat cushion (K0656,K0657) is covered for a patient who meets the criteria for both a skin protection seat cushion and a positioning seat cushion.

If a skin protection seat cushion, positioning seat cushion, or combination skin protection and positioning seat 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.

If a positioning back cushion is provided for a patient who does not meet the stated coverage criteria, but the coverage criteria for a general use back cushion are met, payment will be based on the allowance for the least costly medically appropriate alternative, K0660; if the criteria for a general use back cushion are not met, the provided cushion will be denied as not medically necessary.

If a positioning accessory is provided and the criteria are not met, the item will be denied as not medically necessary.

A custom fabricated seat cushion (K0658) is covered if criteria (1) and (3) are met. A custom fabricated back cushion (K0666) is covered if criteria (2) 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.

If 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 another type of cushion are not met, the custom fabricated cushion will be denied as not medically necessary.

A seat or back cushion that is provided for use with a transport chair (E1037, E1038) will be denied as not medically necessary.

The effectiveness of a powered seat cushion (K0659) has not been established. Claims for a powered seat cushion will be denied as not medically necessary.

A prefabricated seat cushion, a prefabricated positioning back cushion, or a brand name custom fabricated seat or back cushion which has not received a written coding verification from the SADMERC or which does not meet the criteria stated in the Coding Guidelines section (see Policy Article) will be denied as not medically necessary.
 

Coverage Topic

Durable Medical Equipment
Wheelchairs
 

CPT/HCPCS Codes

ICD-9 Codes that Support Medical Necessity

Diagnoses that Support Medical Necessity

Refer to previous section 

ICD-9 Codes that DO NOT Support Medical Necessity

For the specific HCPCS codes indicated above, all ICD-9 codes that are not specified in the preceding section.

For HCPCS codes K0659 and K0669, all ICD-9 codes

Diagnoses that DO NOT Support Medical Necessity

For the specific HCPCS codes indicated above, all diagnoses that are not specified in the previous section.

For HCPCS codes K0659 and K0669, all diagnoses. 

Documentation Requirements

Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider" (42 U.S.C. section 13951 (e)). It is expected that the patient's medical records will reflect the need for the care provided. The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available to the DMERC upon request.

An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available to the DMERC upon request.

Items delivered before a signed written order has been received by the supplier must be submitted with an EY modifier added to each affected HCPCS code.

The ICD-9 code which justifies the need for these items must be included on the claim.

For a skin protection seat cushion (K0652,K0653), a KX modifier should be added to the code if either criterion (a), (b), or (c) is met:
a) If there is a past history of or current pressure ulcer in the area of contact with the seating surface; or
b) If there is absent or impaired sensation in the area of contact with the seating surface due to one of the diagnoses listed as a covered diagnosis; or
c) If there is an inability to carry out a functional weight shift due to one of the diagnoses listed as a covered diagnosis.

For a positioning seat cushion (K0654,K0655), positioning back cushion (K0662-K0665), or positioning accessory (E0955-E0957, E0960), a KX modifier should be added to the code if the patient has significant postural asymmetries due to one of the diagnoses listed as a covered diagnosis.

For a combination skin protection and positioning seat cushion (K0656,K0657), a KX modifier should be added to the code if criterion (a) or (b) or (c) is met and criterion (d) is met:
a) If there is a past history or current pressure ulcer in the area of contact with the seating surface; or
b) If there is absent or impaired sensation in the area of contact with the seating surface due one of the diagnoses listed as a covered diagnosis for skin protection cushions (except 707.03, 707.04, 707.05); or
c) If there is an inability to carry out a functional weight shift due one of the diagnoses listed as a covered diagnosis for skin protection cushions (except 707.03, 707.04, 707.05); and
d) If the patient has significant postural asymmetries due one of the diagnoses listed as a covered diagnosis for skin protection cushions (except 707.03, 707.04, 707.05).

For a custom fabricated seat or back cushion (K0658, K0666), a KX modifier should be added to the code if criterion (a) is met and criterion (b), (c), or (d) is met:
a) For K0658 or K0666, there is a comprehensive written evaluation by a licensed clinician (who is not an employee of or otherwise paid by a supplier) which explains why a prefabricated seating system is not sufficient to meet the patient’s seating and positioning needs;
b) For K0658, there is a past history of or current pressure ulcer in the area of contact with the seating surface; or
c) For K0658, there is absent or impaired sensation in the area of contact with the seating surface or an inability to carry out a functional weight shift due to one of the diagnoses listed as a covered diagnosis for skin protection cushions;
d) For K0658 or K0666, the patient has significant postural asymmetries due to one of the diagnoses listed as a covered diagnosis for positioning cushions.

If the requirements for the KX modifier are not met, the supplier may submit additional documentation with the claim to justify coverage, but the KX modifier must not be used.

When code K0108 is billed, the claim must include a narrative description of the item, the manufacturer, the model name or number (if applicable), and information justifying the medical necessity of the item.

Refer to the Supplier Manual for more information on documentation requirements.
 

Appendices

Utilization Guidelines

Sources of Information and Basis for Decision

ANSI/ RESNA Subcommittee on Wheelchair Seating Standards, Wheelchair Seating-Part 2:Test methods for devices that manage tissue integrity - Seat Cushions, ISO16840-2, www.wheelchairstandards.pitt.edu

Brienza, et al, Seat Cushion Optimization: A comparison of interface pressure and tissue stiffness characteristics for spinal cord injured and elderly subjects, Arch Phys Med Rehabil, April 1998, 79:388-394

California Dept. of Consumer Affairs, Technical Bulletin 133, Requirements, Test Procedure and Apparatus for Testing the Flame Retardance of Resilient Materials Used in Upholstered Furniture, March 2000, www.dca.ca.gov/bhfti/bulletin.htm

Sprigle, et al, Development of uniform terminology and procedures to describe wheelchair cushion characteristics, J Rehabil Res Devel, July/Aug 2001, 38(4):449-461

Sprigle, et al, Reduction of Sitting Pressures with Custom Contoured Cushions, J Rehab Res Devel, 1990, 27(2):127-134
 

Advisory Committee Meeting Notes

Written comments received at the public meeting held on 1/16/02 are included with all other written comments received during the comment period.

This policy does not reflect the sole opinion of the contractor or
contractor medical director. Although the final decision rests with the
contractor, this policy was developed in cooperation with advisory groups,
which includes representatives from relevant clinical groups and
the supplier community. 

Start Date of Comment Period

12/03/2001 

End Date of Comment Period

01/21/2002 

Start Date of Notice Period

03/01/2004 

Revision History Number

002 

Revision History Explanation

Revision Effective Date: 10/01/2004
INDICATIONS AND LIMITATIONS OF COVERAGE:
Revised acceptable diagnosis codes for decubitus ulcers
ICD-9 CODES SUPPORTING MEDICAL NECESSITY:
Changed acceptable ICD-9 codes for decubitus ulcers from 707.0 to 707.03, 707.04, 707.05
Corrected the diagnosis set for K0658 to match the narrative description in the Indications and Limitations of Coverage section
DOCUMENTATION REQUIREMENTS:
Revised general requirements in paragraph 1
Corrected the code range for positioning accessories
Revised acceptable diagnosis codes for decubitus ulcers

Revision Effective Date: 07/25/04

HCPCS CODES:

CMS corrected a non-substantive typographical error in code K0650.

Revision Effective Date: 07/01/2004
HCPCS CODES:
Added: E0966
DOCUMENTATION REQUIREMENTS:
Revised the criteria for use of the KX modifier for combination skin protection and positioning seat cushions.

Last Reviewed On

07/31/2004 

Related Documents

Article(s)
A17749 - Wheelchair Seating - Policy Article - Effective October 2004

LCD Attachments

Contractor Name

AdminaStar Federal, Inc. 

Contractor Number

00635 

Contractor Type

DMERC 

Article Database ID Number

A17749 

Article Type

Detailed Article

Article Title

Wheelchair Seating - Policy Article - Effective October 2004 

Primary Geographic Jurisdiction

DC
IL
IN
MD
MI
MN
OH
VA
WI
WV
 

DMERC Region Article Covers

Region B 

Article Publication Date

09/01/2004

Article Beginning Effective Date

10/01/2004

Article Text

NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES

For an item addressed in this policy to be covered by Medicare, a written signed and dated order must be received by the supplier prior to delivery of the item. If the supplier delivers the item prior to the receipt of a written order, it will be denied as noncovered. If the written order is not obtained prior to delivery, payment will not be made for that item even if a written order is subsequently obtained. If a similar item is subsequently provided by an unrelated supplier who has obtained a written order prior to delivery, it will be eligible for coverage.

There is separate payment for a seat cushion solid support base (see definition in Coding Guidelines) with mounting hardware when it is used on an adult manual wheelchair (K0001-K0009, E1161) or lightweight power wheelchair (K0012). There is no separate payment when this is used with other types of power wheelchairs (K0010, K0011, K0014) because those wheelchairs include a solid seat support base.

There is no separate payment for a solid insert (see definition in Coding Guidelines) that is used with a seat or back cushion because a solid base is included in the allowance for a wheelchair seat or back cushion.

There is no separate payment for mounting hardware for a seat or back cushion.

If a wheelchair seat or back cushion is billed for use with a rollabout chair (E1031), it will be denied as not separately payable.


CODING GUIDELINES

The following definitions of seat cushions include results of simulation testing or human subject testing. Details of the testing methodologies is found in the Appendices section.

A general use seat cushion (K0650,K0651) is a prefabricated cushion, which has the following characteristics:
1) It has the following minimum performance characteristics:
a) Simulation tests demonstrate a loaded contour depth of at least 25mm with an overload deflection of at least 5 mm, or
b) Human subject tests demonstrate an average peak pressure index
that is less than 125% of that of a standard reference cushion within the area of the ischial tuberosities and sacrum/coccyx; and
2) Following testing simulating 12 months of use:
a) Simulation tests demonstrate an overload deflection of at least 5 mm, or
b) Human subject tests demonstrate an average peak pressure index that is less than 125% of those of a standard reference cushion within the area of the ischial tuberosities and sacrum/coccyx; and
3) It has a removable vapor permeable or waterproof cover or it has a waterproof surface; and
4) The cushion and cover meet the minimum standards of the California Bulletin 117 or 133 for flame resistance; and
5) It has a permanent label indicating the model and the manufacturer; and
6) It has a warranty that provides for repair or full replacement if manufacturing defects are identified or the surface does not remain intact due to normal wear within 12 months.

A skin protection seat cushion (K0652,K0653) is a prefabricated cushion, which has the following characteristics:
1) It has the following minimum performance characteristics:
a) Simulation tests demonstrate a loaded contour depth of at least 40 mm with an overload deflection of at least 5 mm, or
b) Human subject tests demonstrate an average peak pressure index that is less than 85% of that of a standard reference cushion within the area of the ischial tuberosities and sacrum/coccyx; and
2) Following testing simulating 18 months of use:
a) Simulation tests demonstrate an overload deflection of at least 5 mm, or
b) Human subject tests demonstrate an average peak pressure index that is less than 85% of those of a standard reference cushion within the area of the ischial tuberosities and sacrum/coccyx; and
3) It has a removable vapor permeable or waterproof cover or it has a waterproof surface; and
4) The cushion and cover meet the minimum standards of the California Bulletin 117 or 133 for flame resistance; and
5) It has a permanent label indicating the model and the manufacturer; and
6) It has a warranty that provides for repair or full replacement if manufacturing defects are identified or the surface does not remain intact due to normal wear within 18 months.
A skin protection cushion may have materials or components that can be added or removed to help promote pressure reduction.

A positioning seat cushion (K0654,K0655) is a prefabricated cushion that has the following characteristics:
1) It has the minimum structural features described in (a) or (b):
a) It has two or more of the following:
i) A pre-ischial bar or ridge which is placed anterior to the ischial tuberosities and prevents forward migration of the pelvis,
ii) Two lateral pelvic supports which are placed posterior to the trochanters and are intended to maintain the pelvis in a centered
position in the seat and/or provide lateral stability to the pelvis,
iii) A medial thigh support which is placed in contact with the adductor region of the thigh and provides the prescribed amount of abduction and prevents adduction of the thighs ,
iv) Two lateral thigh supports which are placed anterior to the trochanters and provide lateral stability to the lower extremities and prevent unwanted abduction of the thighs.
The feature must be at least 25 mm in height in the pre-loaded state. Included in this definition are cushions which have a planar surface but have positioning features within the cushion which are made of a firmer material than the surface material; or
b) It has two or more air compartments located in areas which address postural asymmetries, each of which must have a cell height of at least 50 mm, must allow the user to add or remove air, and must have a valve which retains the desired air volume; and
2) It has the following minimum performance characteristics:
a) Simulation tests demonstrate a loaded contour depth of at least 25mm with an overload deflection of at least 5 mm, or
b) Human subject tests demonstrate an average peak pressure index that is less than 125% of that of a standard reference cushion within the area of the ischial tuberosities and sacrum/coccyx; and
3) Following testing simulating 18 months of use:
a) Simulation tests demonstrate an overload deflection of at least 5 mm, or
b) Human subject tests demonstrate an average peak pressure index that is less than 125% of those of a standard reference cushion within the area of the ischial tuberosities and sacrum/coccyx; and
4) It has a removable vapor permeable or waterproof cover or it has a waterproof surface; and
5) The cushion and cover meet the minimum standards of the California Bulletin 117 or 133 for flame resistance; and
6) It has a permanent label indicating the model and the manufacturer; and
7) It has a warranty that provides for repair or full replacement if manufacturing defects are identified or the surface does not remain intact due to normal wear within 18 months.
A positioning cushion may have materials or components that can be added or removed to help address orthopedic deformities or postural asymmetries.

A skin protection and positioning seat cushion (K0656,K0657) is a prefabricated cushion which has the following characteristics:
1) It has the minimum structural features described in (a) or (b):
a) It has two or more of the following:
i) A pre-ischial bar or ridge which is placed anterior to the ischial tuberosities and prevents forward migration of the pelvis,
ii) Two lateral pelvic supports which are placed posterior to the trochanters and are intended to maintain the pelvis in a centered position in the seat and/or provide lateral stability to the pelvis,
iii) A medial thigh support which is placed in contact with the adductor region of the thigh and provides the prescribed amount of abduction and prevents adduction of the thighs ,
iv) Two lateral thigh supports which are placed anterior to the trochanters and provide lateral stability to the lower extremities and prevent unwanted abduction of the thighs.
The feature must be at least 25 mm in height in the pre-loaded state. Included in this definition are cushions which have a planar surface but have positioning features within the cushion which are made of a firmer material than the surface material; or
b) It has two or more air compartments located in areas which address postural asymmetries, each of which must have a cell height of at least 50 mm, must allow the user to add or remove air, and must have a valve which retains the desired air volume; and
2) It has the following minimum performance characteristics:
a) Simulation tests demonstrate a loaded contour depth of at least 40mm with an overload deflection of at least 5 mm, or
b) Human subject tests demonstrate an average peak pressure index that is less than 85% of that of a standard reference cushion within the area of the ischial tuberosities and sacrum/coccyx; and
3) Following testing simulating 18 months of use:
a) Simulation tests demonstrate an overload deflection of at least 5 mm, or
b) Human subject tests demonstrate an average peak pressure index that is less than 85% of those of a standard reference cushion within the area of the ischial tuberosities and sacrum/coccyx; and
4) It has a removable vapor permeable or waterproof cover or it has a waterproof surface; and
5) The cushion and cover meet the minimum standards of the California Bulletin 117 or 133 for flame resistance; and
6) It has a permanent label indicating the model and the manufacturer; and
7) It has a warranty that provides for repair or full replacement if manufacturing defects are identified or the surface does not remain intact due to normal wear within 18 months.
A positioning and skin protection cushion may have materials or components that can be added or removed to help address orthopedic deformities or postural asymmetries or promote pressure reduction.

A general use back cushion (K0660,K0661) is a prefabricated cushion, which has the following characteristics:
1) It is planar or contoured; and
2) It has a removable vapor permeable or waterproof cover or it has a waterproof surface; and
3) The cushion and cover meet the minimum standards of the California Bulletin 117 or 133 for flame resistance; and
4) It has a permanent label indicating the model and the manufacturer; and
5) It has a warranty that provides for repair or full replacement if manufacturing defects are identified or the surface does not remain intact due to normal wear within 12 months.

A positioning back cushion (K0662-K0665) is a prefabricated cushion which has the following characteristics:
1) For all cushions, there is at least 25 mm of posterior contour in the pre-loaded state. A posterior contour is a backward curve measured from a vertical line in the midline of the cushion; and
2) For posterior-lateral cushions (K0664,K0665), there is at least 75 mm of lateral contour in the pre-loaded state. A lateral contour is backward curve measured from a horizontal line connecting the lateral extensions of the cushion; and
3) For posterior pelvic cushions (K0662,K0663), there is mounting hardware that is adjustable for vertical position, depth, and angle.
4) It has a removable vapor permeable or waterproof cover or it has a waterproof surface; and
5) The cushion and cover meet the minimum standards of the California Bulletin 117 or 133 for flame resistance; and
6) It has a permanent label indicating the model and the manufacturer; and
7) It has a warranty that provides for repair or full replacement if manufacturing defects are identified or the surface does not remain intact due to normal wear within 18 months.
Included in this definition are cushions which have a planar surface but have positioning features within the cushion which are made of a firmer material than the surface material.
A positioning back cushion may have materials or components that may be added or removed to help address orthopedic deformities or postural asymmetries.

A custom fabricated seat cushion (K0658) and a custom fabricated back cushion (K0666) are cushions that are individually made for a specific patient starting with basic materials including: a) liquid foam or a block of foam and b) sheets of fabric or liquid coating material. The cushion must be fabricated using molded-to-patient-model technique, direct molded-to-patient technique, CAD-CAM technology, or detailed measurements of the patient used to create a configured cushion. The cushion must have structural features that significantly exceed the minimum requirements for a seat or back positioning cushion. The cushion must have a removable vapor permeable or waterproof cover or it must have a waterproof surface. A custom fabricated cushion may include certain prefabricated components (e.g., gel or multi-cellular air inserts); these components must not be billed separately. If a custom fabricated seat and back are integrated into a one-piece cushion, code as K0658 plus K0666.

If foam-in-place or other material is used to fit a substantially prefabricated cushion to an individual patient, the cushion must be billed as a prefabricated cushion, not custom fabricated.

A powered wheelchair seat cushion (K0659) is a battery-powered, prefabricated cushion in which an air pump provides either sequential inflation and deflation of the air cells or a low interface pressure throughout the cushion. One type of powered seat cushion is an alternating pressure cushion.

A headrest extension (E0966) is a sling support for the head. Code E0955 describes any type of cushioned headrest.

The code for a seat or back cushion includes any rigid or semi-rigid base or posterior panel, respectively, that is an integral part of the cushion.

A solid insert is a separate rigid piece of wood or plastic which is inserted in the cover of a cushion to provide additional support. If a supplier chooses to bill separately for a solid insert used with a seat cushion use code E0992 whether it is a manual or a power wheelchair. Code A9900 must be used for a solid insert used with a back cushion.

A solid support base for a seat cushion is a rigid piece of plastic or other material which is attached with hardware to the seat frame of a wheelchair in place of a sling seat. A cushion is placed on top of the support base. Use code K0108 for this solid support base.

If a supplier chooses to bill separately for mounting hardware, either nonadjustable or adjustable, for a seat or back cushion or solid support base, code A9900 must be used.

The only products which may be billed using codes K0650-K0657 and K0660-K0665 and the only brand name products that may be billed using codes K0658 or K0666 are those products for which a written coding verification has been made by the Statistical Analysis DME Regional Carrier (SADMERC). Information concerning the documentation that must be submitted to the SADMERC for a Coding Verification Request can be found on the SADMERC web site or by contacting the SADMERC. A Product Classification List with products which have received a coding verification can be found on the SADMERC web site.

If a nonpowered, prefabricated seat cushion, a prefabricated back cushion, or a brand name custom fabricated seat or back cushion has not received a written coding verification from the SADMERC or if it is determined that the cushion does not meet the criteria for the code, it must be billed with code K0669.

Pediatric size cushions and positioning accessories are billed with the codes described in this policy. Codes E1012 (Integrated seating system , planar, for pediatric wheelchair) E1013 (Integrated seating system, contoured, for pediatric wheelchair), and E1025-E1027 (lateral thoracic and lateral/anterior supports) are invalid for claim submission to the DMERC.

Code E1028 (swingaway or removable mounting hardware upgrade) may be billed in addition to codes E0955-E0957. It must not be billed in addition to code E0960. It must not be used for mounting hardware related to a wheelchair seat cushion or back cushion code.

Codes E0176 (air cushion), E0177 (water cushion), E0178 (gel or gel-like cushion), E0179 (foam cushion), E0192 (low pressure and positioning equalization pad), E0962-E0965 (cushion for wheelchair, 1”, 2”, 3”, and 4”, respectively), K0023 and K0024 (solid back inserts), K0114 (back support system for use with a wheelchair, with inner frame, prefabricated), K0115 and K0116 (custom fabricated seating systems) and K0667 (mounting hardware, any type, for seat cushion or seat support base attached to a manual wheelchair or lightweight power wheelchair, per cushion/base) are invalid for claim submission to the DMERC.

TESTING METHODOLOGY

There are two testing methods that may be used to document wheelchair seat cushion criteria: the simulation method and the human subject method. Simulation tests are used to measure loaded contour depth and bottoming out. Human subject tests are used to measure peak interface pressure.

Simulation Test

Simulation tests measure loaded contour depth and bottoming out. They use standardized models of the human buttocks known as cushion-loading indenters (CLIs). There are two CLIs that are used for simulation testing, a 25 mm CLI and a 40 mm CLI. Specific design features of acceptable CLIs can be found on the SADMERC web site.

Test method for determining 25 mm and 40 mm of contour depth:
1) Place the test cushion on a flat, horizontal surface. Cushions with curved bases must be stable during contour measurement testing.
2) Align the CLI so that it is centered from the sides of the cushion and so that the ischial tuberosities of the models are 11-15 cm from the rear edge of the cushion. The ischial tuberosity portion of the CLI should be aligned with the analogous portion of the test cushion.
3) Load the CLI to 140 Newtons (31 pounds) & wait 5 minutes.
4) Contact of the lateral buttons with the cushion indicates that the cushion has contoured to 25 or 40 mm depending on the CLI used – i.e., that it has passed the test for that trial.
5) Repeat the test two times waiting 5 minutes between trials

A cushion must pass the respective contour test during all trials to meet the minimum criteria specified in the cushion definition section.

Overload test method for measuring bottoming out:
1) Record the height of the CLI from the horizontal surface at the end of the loaded contour depth test described above.
2) Add 47 Newtons (10 pounds) to the CLI and record the height from the horizontal surface after 1 minute.
3) Subtract the height at overload (#2) from the height at standard load (#1).
4) Round the value in #3 to the nearest 5mm.
5) Remove the overload weight and repeat the test twice, waiting 5 minutes between tests and measuring the height in #1 and #2 each time.
6) Determine the median of the three values recorded in #4. This is the “overload deflection”.
If the overload deflection is greater than or equal to 5mm, then the cushion is determined not to have bottomed out during the test.

Simulated use testing:

There must be simulation of 12 or 18 months of use of the cushion (depending on the cushion type – see Definitions section). Following simulated use, the measurements for loaded contour depth and overload as described above must be repeated.

Test report:

There must be a report of the tests which includes:
1) The name and address of the facility performing the tests and the date(s) of the tests; and
2) The manufacturer and brand name/number of the test cushion; and
3) The weight of the cushion to the nearest 250 gm; and
4) The width and length of the cushion; and
5) The temperature and relative humidity of the room where the tests are conducted; and
6) Identification of which CLI was used (25 mm or 40mm); and
7) The results of the three loaded contour depth tests and the overload deflection test prior to simulated used testing; and
8) A description of the method used to simulate cushion use;
9) A statement specifying the number of months of use that were simulated; and
10) Measurements as described in #7 obtained after simulated use testing; and
11) A statement attesting that the testing methodology described in this policy was followed; and
12) The printed name and signature of the person performing or supervising the tests and the signature date.

Human Subject Tests

The ability to demonstrate that there is an important reduction in interface pressure in comparison with a standard reference cushion when tested with human subjects is the basis for this approach. Human subject tests must be performed by an entity that has received human subject testing approval from an Institutional Review Board approved by the US Department of Health and Human Services. Ten (10) wheelchair users must be studied, at least five of which must be clinically insensate on the body surface contacting the cushion.

Interface pressure measurements are taken with each subject seated on the cushion being tested as well as on a standardized reference cushion (see below). The measurements are obtained with a transducer placed on top of the cushion. Subjects must be seated on the cushion and interface pressure transducer for at least 60 seconds before data is collected. The subject should be positioned in their typical posture as determined by query and independent facility judgment. Three measurements are taken on each subject on each cushion separated by a complete unloading of the cushion for at least 60 seconds.

The standard reference cushion must be an uncovered 75 mm (± 5mm) thick high resiliency foam with a rated 25% indentation force deflection (IFD) equal to 45 pounds (density range of 2.6-2.9 pounds/cubic ft and IFD range of 40-49 pounds).

There must be a report of the tests which includes:
1) The name and address of the facility performing the tests and the date(s) of the tests; and
2) The manufacturer and brand name/number of the test cushion; and
3) Information about the interface pressure measurement device utilized:
a) Manufacturer and brand name
b) Date of most recent calibration
c) Percent error of measurement at 50 and 100 mm Hg pressure; and
4) Actual 25% IFD and density of the reference cushion (obtained from the foam manufacturer or supplier) and actual thickness of the reference cushion; and
5) Information on each subject (coding subjects to preserve confidentiality) including:
a) Age
b) Height
c) Weight
d) Disability
e) Buttocks sensation status; and
6) Interface pressure measurements for each subject on the test cushion and on the reference cushion:
a) If the transducer covers the entire seating area, the entire map showing the pressure in each cell must be submitted. The anatomical locations (as determined by palpation) of the right and left ischial tuberosities and the sacrum/coccyx must be identified on each map. (Data can be submitted as a hard copy map or utilizing the device software.) or,
b) If the transducer only covers a portion of the seat surface, measurements must be taken at the following three locations (as determined by palpation): right and left ischial tuberosities and sacrum/coccyx. The report must identify the anatomical location of each set of measurements. The report must list the pressure in each cell at each specified location. The values for the three locations are considered a single test; and
7) The Peak Pressure Index (PPI) for each subject on the test cushion and on the reference cushion. The PPI is determined as follows:
a) For each test, identify the cell in the sacro-ischial zone with the highest pressure;
b) Determine the greatest sum of pressures in the identified cell and the adjacent cells in a 9-10 square centimeter area. If there are multiple cells with the same “highest pressure”, consider all of them in the determination of the “greatest sum”. [Note: A 3 cm by 3 cm square or a 3.5 cm diameter circular area are examples of a 9-10 sq cm area. For example, if using an interface pressure sensing array with a cell size of 1 sq cm, 9 cells (a 3 by 3 array) are used and if using a sensing array with a cell size of 2.5 sq cm, 4 cells (a 2 by 2 array) are used.];
c) For each test, calculate the average of the cells with the greatest sum of pressures;
d) Calculate the average of the results obtained in step (c) for the 3 tests on the test cushion and the 3 tests on the reference cushion. These values are the PPIs for the subject on each cushion; and
8) A statement attesting that the testing methodology described in this policy was followed; and
9)The printed name and signature of the person performing or supervising the tests and the signature date.

To determine if the minimum performance characteristics specified in the Definitions section for a particular type of cushion have been met, calculate the average PPI for the 10 subjects on the test cushion and the average PPI for the 10 subjects on the reference cushion. Divide the average PPI on the test cushion by the average PPI on the reference cushion and multiply the value by 100 to give the percentage comparison of Peak Pressure Indexes. If the comparative pressures are less than the specified values (125% or 85% depending on the cushion), then the minimum performance characteristics with respect to pressure have been met.

Coverage Topic

Durable Medical Equipment
Wheelchairs
 

CPT/HCPCS Codes

There is no Coding Table Information for this policy.

Other Comments

REVISION HISTORY

Revision Effective Date: 10/01/2004
CODING GUIDELINES:
Revised the description of a solid seat insert and solid support base.

Revision Effective Date: 07/25/04

HCPCS CODES:

CMS corrected a non-substantive typographical error in code K0650.

Revision Effective Date: 07/01/2004
CODING GUIDELINES:
Added description of E0966 and E0955
Added K0660 and K0661 (General use back cushions) to the list of codes requiring Coding Verification Review by the SADMERC.
Added E1025-E1027, K0115, and K0116 to the list of codes that are invalid for claim submission to the DMERCS.
HCPCS CODES:
Added: E0966

Related Documents

LCD(s)
L15809 - Wheelchair Seating