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.