Manual Wheelchair

A manual wheelchair has fixed height removable arms and swing away detachable footrests. A standard wheelchair will generally accommodate patients’ 5’5” to 6” weighing between 110 lbs. to 200 lbs. Light weight wheelchairs are available for those who have trouble self propelling a standard weight wheelchair, and heavy duty and extra heavy duty wheelchairs are available for larger patients. A patient who qualifies for a wheelchair may also qualify for anti-tippers, a wheelchair cushion, and wheel lock extenders.

HCPCS Code:

K0001 – Standard Wheelchair
K0003 – Lightweight Wheelchair
K0006 – Heavy Duty Wheelchair
K0007 – Extra Heavy Duty

Category:

Capped Rental

Common Diagnosis:

(check for current coding)

343.9 Cerebral Palsy
359.1 Muscular Dystrophy (MD)
344.1 Paraplegia
340.0 Multiple Sclerosis (MS)
Any diagnosis that impairs the patient’s ability to ambulate within the home

Coverage Information

Requires a detailed written order

Covered if the following criteria are met:

K0001
The patient has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home AND

The patient’s mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker AND

The patient’s home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided AND

Use of a manual wheelchair will significantly improve the patient’s ability to participate in MRADLs and the patient will use it on a regular basis in the home AND

The patient has not expressed an unwillingness to use the manual wheelchair that is provided in the home AND

The patient has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair that is provided in the home during a typical day OR

The patient has a caregiver who is available, willing, and able to provide assistance with the wheelchair.

K0003
A light weight wheelchair (K0003) is covered if the patient meets the coverage criteria for a standard chair, AND medical documentation indicates they are not able to propel themselves in a standard weight wheelchair, but could self-propel in a light weight chair.

K0006
A heavy duty wheelchair (K0006) is covered if the patient meets the coverage criteria for a standard chair, AND medical documentation indicates patient weighs equal to or greater than 250 lbs (weighed within 30 days of providing chair, documentation in patient file).

K0007
An extra heavy duty wheelchair (K0007) is if the patient meets the coverage criteria for a standard chair, AND medical documentation indicates patient the weighs equal to or greater than 300 lbs (weighed within 30 days of providing device, documentation in patient file).

Accessories:
A reclining back (E1226) is covered on any wheelchair if: the patient suffers from quadriplegia, requires a fixed hip angle, or has a trunk cast or brace, or excessive extensor tone of the trunk muscles, or needs to rest in a recumbent position two or more times during the day.

Elevating Leg rests (pair = K0195 or each = E0990 – use LT or RT modifier) are covered when: the patient has a cast, brace or musculoskeletal condition which prevents 90 degree flexion of the knee, or has significant edema of the lower extremities that requires an elevating leg rest, or a reclining back is ordered.

A basic wheelchair cushion (E2601 or E2602) is covered when the chair is covered. Be aware that these codes require a written order prior to delivery (WOPD), and be sure to include them on the detailed written order for the wheelchair as well.

Note 1: You must use KX modifier to denote that patient meets the coverage criteria and that any required documentation is file.

Note 2: A patient is not covered for an ambulatory aide such as a cane or walker AND a wheelchair at the same time, UNLESS there is documentation in the medical record that the patient is in a gait retraining program via physical therapy. In that case, the wheelchair would be covered for a maximum of 6 months. Ensure that the patient is in physical therapy for gait retraining, and enter "Pt. in gait retraining w [name of rehab facility]" in box 19 of the narrative record.

Documentation Requirements: in addition to the basic Medicare documentation (proof of delivery, AOB, detailed written order, etc.)

Medicare requires that the ordering physician’s chart notes or other physician documentation support the coverage criteria listed above. Oftentimes the most recent history and physical (a common document in most medical records) will include information that supports the need described in the coverage criteria. You may choose to ask for this at the time you request the detailed written order, or you can obtain it only if requested during a routine or random audit by Medicare.

The detailed written order form must contain the patient’s name, the start date of the order, a description of the item, and a length of need if the product provided is a rental item or recurring supply.

A home mobility evaluation is required to be completed by the supplier and placed in the patient file that documents that the home will accommodate the wheelchair provided. This evaluation can be done at the patient’s home or through an interview with the patient/caregiver if the DME supplier does not deliver the product directly to the patient’s home.