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Minnesota Department of Human Services Provider Manual
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Mobility Devices

Revised: 06-20-2017

  • Overview
  • Eligible Providers
  • TPL and Medicare
  • Eligible Recipients
  • Criteria for all Covered Mobility Devices
  • Covered Services
  • Specific Mobility Devices, Options and Accessories
  • Manual Wheelchairs (E1031, E1037-E1039, E1161, E1229, E1231-E1238, K0001-K0007, K0009)
  • Power Operated Vehicles (K0800-K0802, K0806-K0808)
  • Power Wheelchairs (K0813-K0898)
  • Wheelchair Options and Accessories
  • Custom Molded and Prefabricated Custom Seating Systems
  • Wheelchairs in Long Term Care Facilities
  • Non-Covered Services
  • Authorizations
  • Required Authorization
  • Authorization Requests for Purchase/Rental
  • Repair/Modification Authorization Requests
  • Billing
  • Approved Purchase/Rental/Repair Billing for Devices Approved on a Multi-line Authorization
  • Use of modifiers KC and KE
  • Recipients with Third Party Coverage or Medicare
  • Overview

    Manual wheelchairs, power operated vehicles, and power wheelchairs help people with mobility-related disabilities to complete activities of daily living in their homes and communities.

    Eligible Providers

    Mobility device vendors must be enrolled as medical equipment providers. Providers must be able to provide support services such as:

  • • Emergency services
  • • Delivery and setup
  • • Repairs
  • • Warranty service (a copy of the warranty must be given to the recipient and a copy kept in the provider’s records)
  • • Education and ongoing assistance with the use of the wheelchair or scooter
  • Providers must have skilled and knowledgeable service personnel, with an adequate inventory of replacement parts to provide timely, on-site mobility device services and repairs.

    Providers must have loaner chairs available for the recipient whose chair requires repair. If the recipient’s chair is customized and unique to his or her specific needs, MHCP does not expect providers to have an equivalent chair on hand. If providers do not have an appropriate loaner chair available, they may provide a rental chair to accommodate the recipient’s needs while repairing the customized chair. MHCP will reimburse providers for one month’s rental. To bill, use code K0462 with modifier RR and include the HCPCS code of the item being repaired or the item dispensed as a rental if different and less costly in the claim notes field on the claim information tab in MN–ITS. If the item being repaired was originally billed using a HCPCS code that is no longer accepted for payment, include the HCPCS code of the item dispensed as a rental. If the rental is longer than one month, submit a request for authorization. Explain the additional circumstances and rental time needed. MHCP does not pay for repairs of rental or loaner chairs.

    TPL and Medicare

    Providers must meet any provider criteria, including accreditation, for third party insurance or for Medicare in order to assist recipients for whom MHCP is not the primary payer.

    Medicare requires providers dispensing Group 2 single power option wheelchairs or any multiple power option wheelchairs to employ a Rehabilitative Engineering and Assisted Technology Society of America (RESNA)-certified Assistive Technology Professional (ATP) specializing in wheelchairs who is directly involved in the wheelchair selection for the recipient. Providers assisting recipients who have both Medicare and MHCP (dual eligibles) must comply with this Medicare rule.

    Providers who do not meet Medicare requirements must refer and document the referral of dual eligible recipients to Medicare providers when Medicare is determined to be the appropriate payer for services and supplies and equipment.

    If Medicare downcodes a mobility device, MHCP must make payment based on the downcoded Medicare EOB, regardless of any MHCP prior authorization. Providers may choose to offer only Medicare-covered mobility devices to dual eligible recipients.

    Eligible Recipients

    Criteria For All Covered Mobility Devices

    Mobility devices are covered for eligible MHCP recipients with a mobility limitation that significantly impairs their ability to participate in one or more mobility-related activities of daily living and the mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker. Daily living refers to activities such as toileting, feeding, grooming, education, working or job training.

  • • The mobility device must enable the recipient to participate in mobility related activities of daily living and be appropriate to the recipient’s needs and abilities.
  • • A “back up” manual chair may be covered for recipients with powered mobility if needed to allow the recipient to access medical care or essential services in the community, or when the recipient’s power chair includes custom molded seating such that the recipient cannot be served with a loaner or rental chair during repairs.
  • • When a power wheelchair is purchased for a recipient who already has a manual wheelchair, MHCP will assume that the power wheelchair is replacing the manual wheelchair. Repairs to the manual wheelchair will not be covered unless documentation is submitted that the manual wheelchair meets criteria as a backup wheelchair.
  • • Documentation submitted with previous authorization requests will be considered when determining if criteria are met for a backup wheelchair.
  • • To be considered custom molded seating, the wheelchair must require significant customization to maintain the recipient in an appropriate position. The use of supports alone does not constitute customization.
  • • A basic manual wheelchair, transport chair or rollabout chair may be covered if needed to allow the recipient to access medical care in the community, even if not needed for other activities of daily living.
  • Covered Services

  • Specific Mobility Devices, Options and Accessories
  • Manual Wheelchairs
  • Power Operated Vehicles
  • Power Wheelchairs
  • Wheelchair Options and Accessories
  • Custom Molded and Prefabricated Seating System
  • Wheelchairs in Long Term Care Facilities
  • Specific Mobility Devices, Options and Accessories

    The criteria below are not all inclusive. Providers must be prepared to submit additional documentation of medical necessity, beyond what is typically required, when asked.

    Manual Wheelchairs (E1031, E1037-E1039, E1161, E1229, E1231-E1238, K0001-K0007, K0009)

    Manual wheelchairs are covered if the recipient meets the criteria for a mobility device and has one of the following:

  • • A caregiver who is available, willing and able to provide assistance
  • • Sufficient upper extremity function to propel an optimally configured manual wheelchair to participate in mobility-related activities of daily living during a typical day
  • Standard options and accessories for manual wheelchairs include:

  • • Calf rests or pads
  • • Fixed height arm rests (fixed, swing-away or detachable)
  • • Foot rests and footplates (fixed, swing-away or detachable)
  • • Hand rims with or without projections
  • • Wheel lock assemblies
  • Nonstandard options and accessories for manual wheelchairs may include:

  • • Adjustable height arm rests
  • • Anti-rollback device
  • • Elevating leg rests
  • • Head rest extensions
  • • Nonstandard seat frames (standard is 15” – 19” width and depth)
  • • One-arm drive attachments
  • • Positioning accessories
  • • Push activated power assist
  • • Safety belts/straps
  • • General use seat and back cushions
  • • Skin protection seat and back cushions
  • Do not bill the following codes within 30 days of initial issue of a manual wheelchair:

    Manual Wheelchair Accessory Codes

    E0967

    E2210

    E2225

    K0043

    K0052

    E0981

    E2220

    E2226

    K0044

    K0069

    E0982

    E2221

    K0015

    K0045

    K0070

    E0995

    E2222

    K0017

    K0046

    K0071

    E1011

    E2223

    K0018

    K0047

    K0072

    E2205

    E2224

    K0019

    K0050

    K0077

    E2206

    K0042


    Do not bill K0195 with any manual wheelchair that is billed with modifier NU.

    Options and accessories provided at the time of initial issue of a transport chair or rollabout chair are not separately billable.

    Hemi-wheelchairs (K0002) are covered if the recipient has one of the following needs:

  • • Requires a lower seat height (less than 19 inches) because of short stature
  • • To propel the chair with their feet
  • Lightweight (34 – 36 lbs.) or ultra-lightweight (less than 30 lbs.) manual wheelchairs (K0003 and K0005) are covered if the recipient:

  • • Primarily uses a manual wheelchair rather than a power mobility device
  • • Can propel themselves in the requested chair
  • • May be at risk for shoulder pain or injury related to propelling the wheelchair.
  • High strength, lightweight wheelchairs (K0004) are covered if the recipient primarily uses a manual wheelchair rather than a power mobility device and:

  • • Can propel themselves in the requested chair or
  • • Needs a high strength wheelchair to be safe because of medical conditions such as spasticity or seizures
  • Heavy duty or extra heavy duty wheelchairs (K0006-K0007) are covered if the recipient has one of the following needs:

  • • Requires the chair because of weight
  • • Has a medical condition such as spasticity, which requires a heavier duty chair for safety
  • Tilt in Space manual wheelchairs (E1161) are covered if the recipient has one of the following needs:

  • • Is at high risk for pressure ulcers and is unable to perform a functional weight shift
  • • Has increased or excess muscle tone or spasticity related to a medical condition that is anticipated to be unchanging for at least one year
  • Rollabout or Transport chairs (E1031, E1037-E1039) are covered if:

  • • The recipient is not expected to be able to self-propel a manual or power wheelchair in the next five years,
  • • The recipient has needs that cannot be met by a less costly manual wheelchair, and
  • • The proposed chair has casters of at least 5 inches in diameter and is specifically designed to meet the needs of ill, injured or otherwise impaired individuals
  • Power Operated Vehicles (K0800-K0802, K0806-K0808)

    Power operated vehicles are covered if the recipient:

  • • Meets the criteria for a mobility device
  • • Does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair to perform mobility-related activities of daily living
  • • Is able to safely transfer to and from the POV
  • • Has both the physical and cognitive ability to operate the tiller steering system
  • • Is able to maintain postural stability and position while operating the POV
  • • Is able to bring the POV into the home for use and storage or if homeless, has demonstrated a plan to safely charge and store the POV.
  • Standard equipment for a POV includes:

  • Battery or batteries required for operation
  • Single mode battery charger
  • Weight appropriate upholstery and seating system
  • Tiller steering
  • Non-expandable controller with proportional response to input
  • Complete set of tires
  • • All accessories needed for safe operation
  • Options and accessories provided at the time of initial issue of a power operated vehicle are not separately billable
  • Power Wheelchairs (K0813-K0898)

    A power wheelchair may be covered if the recipient has a specific medical need that cannot be met with a less costly alternative.

    Power wheelchairs are covered if the recipient:

  • • Meets the criteria for a mobility device
  • • Does not have sufficient upper extremity function to self-propel an optimally configured manual wheelchair to perform mobility-related activities of daily living
  • • Is not able to safely operate a POV or maintain postural stability and position while operating a POV
  • • Has a caregiver who cannot push a manual chair, but can propel the power chair using an attendant control
  • • For a recipient under age 4, has been evaluated and found to be developmentally ready to begin to operate a power chair equipped with appropriate attendant control and safeguards
  • • Is able to bring the power wheelchair into the home for use and storage or if homeless, has demonstrated a plan to safely charge and store the power wheelchair.
  • Standard equipment includes:

  • • All types of tires and wheels
  • • Any back width
  • • Any seat width and depth
  • • Weight-specific components required by the patient-weight capacity of the wheelchair
  • • Battery charger
  • • Fixed swing-away or detachable footrests or foot platform, including angle adjustable footrests for group 1 or 2 power wheelchairs
  • • Fixed swing-away or detachable non-adjustable armrests with arm pad
  • • Fixed swing-away or detachable non-elevating leg rests with or without calf pad
  • • Lap belt or safety belt
  • • Non expandable controller
  • • Standard integrated or remote proportional joystick
  • • All labor charges involved in the assembly of the wheelchair.
  • Nonstandard options or accessories may include:

  • • Adjustable height arm rests
  • • Elevating leg rests
  • • Angle adjustable footrests for group 3, 4 or 5 power wheelchairs
  • • Manual fully reclining back option
  • • Power tilt
  • • Power recline
  • • Seat elevator
  • • Shoulder harness or straps or chest straps or vest
  • • Skin protection seat cushions, position accessories
  • • Standing feature
  • • Expandable controller
  • • Nonstandard joystick or alternative control device
  • Do not bill the following codes within 30 days of initial issue of a power wheelchair:

    Power Wheelchair Accessory Codes

    E0971

    E2369

    E2386

    E2395

    K0042

    E0978

    E2370

    E2387

    E2396

    K0043

    E0981

    E2374

    E2388

    K0015

    K0044

    E0982

    E2375

    E2389

    K0017

    K0045

    E0995

    E2376

    E2390

    K0018

    K0046

    E1225

    E2381

    E2391

    K0019

    K0047

    E2366

    E2382

    E2392

    K0020

    K0051

    E2367

    E2384

    E2393

    K0037

    K0052

    E2368

    E2385

    E2394

    K0041

    K0098


    Do not bill E2377 when used with a Group 1 or Group 2 no power option power wheelchair and do not bill K0040 when used with a Group 1 or Group 2 power wheelchair.

    Group 1 (K0813-K0816) or Group 2 no power option (K0820-K0829) power wheelchairs are covered if the recipient:

  • • Meets the criteria for a power wheelchair
  • • Does not require a single or multiple power option wheelchair
  • • Does not require a drive control interface other than a hand operated standard proportional joystick
  • Group 2 single power option power wheelchairs (K0835-K0840) are covered if the recipient has one of the following:

  • • Meets coverage criteria for a power tilt or power recline seating system
  • • Requires a drive control interface other than a hand operated standard proportional joystick (examples include but are not limited to chin control, head control, sip and puff, switch control)
  • Group 2 multiple power option power wheelchairs (K0841-K0843) are covered if the recipient has one of the following:

  • • Meets coverage criteria for power tilt and recline seating system
  • • Requires a drive control interface other than a hand operated standard proportional joystick and meets criteria for a power tilt or power recline seating system
  • • Uses a ventilator mounted on the wheelchair
  • Group 3 no power option power wheelchairs (K0848-K0855) are covered if the recipient:

  • • Has mobility limitations due to a neurological condition, myopathy, congenital skeletal deformity or the recipient has a significant medical condition which requires the use of seating, positioning or other accessories that cannot be adequately accommodated by a Group 1 or Group 2 power wheelchair
  • Group 3 single power option power wheelchairs (K0856-K0860) are covered if the recipient:

  • • Has mobility limitations due to a neurological condition, myopathy, congenital skeletal deformity or the recipient has a significant medical condition which require the use of seating, positioning or other accessories that cannot be adequately accommodated by a Group 1 or Group 2 power wheelchair
  • • The Group 2 single power option criteria are met
  • Group 3 multiple power option power wheelchairs (K0861-K0864) are covered if the recipient:

  • • Has mobility limitations due to a neurological condition, myopathy, congenital skeletal deformity or the recipient has a significant medical condition which require the use of seating, positioning or other accessories that cannot be accommodated by a Group 1 or Group 2 power wheelchair
  • • The Group 2 multiple power option criteria are met
  • Group 4 no power option power wheelchairs (K0868-K0871) are covered if the recipient:

  • • Cannot safely use an equivalent Group 3 power wheelchair without significant modifications to the recipient’s living environment
  • • Has mobility limitations requiring the use of seating and positioning items that cannot be accommodated by a Group 1 or Group 2 power wheelchair
  • • Meets the criteria for a power wheelchair
  • Group 4 single power option power wheelchairs (K0877-K0880) are covered if the recipient:

  • • Has mobility limitations due to a neurological condition, myopathy, congenital skeletal deformity or the recipient has a significant medical condition which require the use of seating, positioning or other accessories that cannot be accommodated by a Group 1 or Group 2 power wheelchair
  • • Cannot safely use an equivalent Group 3 power wheelchair without significant modifications to the recipient’s living environment or meets criteria for accessories that are not available on a Group 3 power wheelchair
  • • Meets the Group 2 single power wheelchair criteria
  • Group 4 multiple power option power wheelchairs (K0884-K0886) are covered if the recipient:

  • • Has mobility limitations due to a neurological condition, myopathy, congenital skeletal deformity or the recipient has a significant medical condition which require the use of seating, positioning or other accessories that cannot be accommodated by a Group 1 or Group 2 power wheelchair
  • • Cannot safely use an equivalent Group 3 power wheelchair without significant modifications to the recipient’s living environment or meets criteria for accessories that are not available on a Group 3 power wheelchair
  • • Meets the Group 2 multiple power options criteria
  • Group 5 power wheelchairs (K0890-K0891) are covered if the recipient:

  • • Meets the criteria for a power wheelchair
  • • Meets the criteria for a single or multiple power option
  • • Is expected to grow in height or whose size is best served by a Group 5 power wheelchair
  • Wheelchair Options and Accessories

    Wheelchair options and accessories are covered if they are medically necessary and address a specific medical need of the recipient. The following list of options and accessories is not all-inclusive; many additional options and accessories may be covered if medically necessary.

    One arm drive attachments (E0958) are covered if:

  • The recipient meets the criteria for a manual wheelchair, but is unable to use both arms or at least one lower extremity to safely propel the manual wheelchair, and
  • A trial demonstrated the recipient has the strength, stamina and cognitive ability to propel the wheelchair using the one arm drive attachment
  • The Authorization Medical Review Agent does not separately review for medical necessity when part of a new wheelchair.

    Push activated power assist (E0986) is covered if the recipient:

  • • Has expressed an unwillingness to operate a power wheelchair
  • • Was self-propelling in a manual wheelchair but no longer has sufficient upper extremity function to self-propel a manual wheelchair or has weakness or repetitive motion stress to the shoulders or upper arms
  • Documentation must include:

  • • An assessment of the distance the recipient is expected to need to operate the manual wheelchair
  • • A trial sufficient to demonstrate the recipient is able to operate the manual wheelchair for that distance
  • • An estimate indicating how long the push activated power assisted manual wheelchair is expected to meet the recipient’s mobility needs
  • The Authorization Medical Review Agent will review for medical necessity.

    Power tilt (E1002) is covered if the recipient:

  • • Meets criteria for a power wheelchair
  • • Has one of the following needs:
  • • Is at risk for pressure ulcers and is unable to perform a functional weight shift
  • • Has a fixed hip angle
  • • Has increased or excess muscle tone or spasticity related to a medical diagnosis which impairs their ability to tolerate the fully upright sitting position for significant periods of time
  • • Is able to independently operate the power tilt system
  • The Authorization Medical Review Agent will review for medical necessity.

    Power recline (E1003-E1005) is covered if the recipient:

  • • Meets criteria for a power wheelchair
  • • Is able to independently operate the power recline system
  • • Has one of the following:
  • • Is unable to tolerate a full upright position due to a medical condition which impairs their ability to tolerate the fully upright sitting position for significant periods of time
  • • Uses intermittent catheterization
  • • Has edema and is unable, for physical or other reasons, to periodically transfer from the wheelchair to elevate the legs
  • If a reclining seating system is approved because a recipient has edema, manual or power elevating leg rests must be requested.

    The Authorization Medical Review Agent will review for medical necessity.

    Power tilt and recline seating systems, with or without power elevating legs rests (E1006-E1008) are covered if the recipient:

  • • Meets criteria for a power wheelchair
  • • Is able to independently operate the power tilt and recline system
  • • Meets criteria for both power tilt and power recline
  • If a reclining seating system is approved because a recipient has edema, manual or power elevating leg rests must be requested.

    The Authorization Medical Review Agent will review for medical necessity.

    Mechanical leg elevation systems (E1009) are covered if the recipient:

  • • Meets criteria for a wheelchair
  • • Has one of the following:
  • • Has a medical condition which prevents 90 degrees of knee flexion
  • • A treatment program to decrease flexion contractures of the knee
  • • Leg edema which cannot be treated by an edema control wrap, a recline feature as part of the wheelchair and is unable, for physical or other reasons, to periodically independently transfer from the wheelchair to elevate legs
  • The Authorization Medical Review Agent does not separately review for medical necessity when part of a new wheelchair.

    Power leg elevation systems (E1010, E1012) are covered if the recipient:

  • • The recipient meets criteria for a power wheelchair
  • • Is able to independently operate the power leg elevation system
  • • Has one of the following:
  • • A medical condition which prevents 90 degree of knee flexion
  • • A treatment program to decrease flexion contractures of the knee
  • • Leg edema which cannot be treated by an edema control wrap, a recline feature as part of the wheelchair and is unable for physical or other reasons, to periodically independently transfer from the wheelchair to elevate the legs
  • The Authorization Medical Review Agent will review for medical necessity.

    Manual, fully or semi-reclining backs (E1014, E1225, E1226) are covered if the recipient has one of the following:

  • • At high risk for pressure ulcers and is unable to perform a function weight shift
  • Uses intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair
  • Is unable to tolerate a full upright position due to a medical condition
  • The Authorization Medical Review Agent will review for medical necessity.

    Gear reduction drive wheels (E2227) are covered if the recipient:

  • Meets criteria for a manual wheelchair
  • Is at risk for weakness or repetitive motion injury to the arms or shoulders
  • The Authorization Medical Review Agent does not separately review for medical necessity when part of a new wheelchair

    Dynamic seating frame (E2295) is covered when:

  • • The requested dynamic seating frame is made by the same manufacturer as the requested pediatric wheelchair
  • • The requested pediatric wheelchair independently meets all criteria for medical necessity and least costly appropriate equipment
  • • The recipient does not require tilt-in-space or reclining back
  • • The recipient is able to engage in some hip or knee extension.
  • The Authorization Medical Review Agent will review for medical necessity.
  • Seat elevation feature (E2300) is covered if the recipient has one of the following:

  • • Must routinely transfer between uneven surfaces and the surfaces cannot be adjusted and the seat elevation feature allows them to independently transfer
  • • Cannot be safely transferred using a patient lift or standing transfer but can safely transfer with the seat elevation feature
  • • The seat elevation feature has been demonstrated to allow the recipient to independently access areas in the home necessary for completion of activities of daily living (ADLs) (cupboards, closets, etc.)
  • Documentation must specify where uneven transfers will be needed in the recipient’s home, or where in the home safe transfers cannot be made using a patient lift or standing transfer.

    A seat elevation feature is not covered when requested solely to allow the recipient to socialize with peers.

    If a seat elevation feature is approved for a recipient, the provider must obtain documentation from the recipient or the recipient’s authorized representative acknowledging that he or she understands that the seat elevation function may affect future requests for PCA or home care services before dispensing and billing for this item. This documentation must be made available to DHS or its authorized agent upon request.

    The Authorization Medical Review Agent will review for medical necessity.

    Standing feature (manual: E2230; power: E2301) is covered if:

  • • The recipient meets the Minnesota Health Care Programs (MHCP) criteria for a stander
  • • MHCP has not purchased a stander for the recipient in the previous three years
  • • The standing function has been demonstrated to allow the recipient to independently access areas in the home necessary for completion of ADLs (cupboards, closets, etc.)
  • A standing feature is not covered when requested solely to allow the recipient to socialize at eye level with peers.

    If a standing feature is approved for a recipient, the provider must obtain documentation from the recipient or the recipient’s authorized representative acknowledging that he or she understands MHCP will not pay for future repairs to a stander and that the standing function may affect future requests for PCA or home care services before dispensing and billing for this item. This documentation must be made available to DHS or its authorized agent upon request.

    The Authorization Medical Review Agent will review for medical necessity.

    Alternative Interface Devices (E2312, E2321-E2330, E2373, E2399)
    Alternative interface devices are covered if a recipient meets criteria for a power wheelchair and cannot safely operate the wheelchair using a hand or chin-operated standard proportional joystick, but can safely operate the wheelchair using the alternative device.

    The Authorization Medical Review Agent does not separately review for medical necessity when part of a new wheelchair.

    Power wheelchair attendant control (E2331) is covered if the recipient:

  • Meets criteria for a mobility device but is unable to operate a manual or power wheelchair
  • Requires a power wheelchair or lacks a caregiver able to propel a manual chair
  • Has a caregiver willing and able to operate the power wheelchair and assist the recipient
  • The Authorization Medical Review Agent will review for medical necessity.

    Wheelchair component or accessory, not otherwise specified (K0108)
    Miscellaneous items are covered if medically necessary or if required for the functioning of other covered items. For example, if a high mount footrest is needed because the chair has a power or manual tilt, the high mount bracket is covered.

    The Authorization Medical Review Agent will review for medical necessity only if the submitted charge for an individual item is $400.00 or more.

    Custom Molded and Prefabricated Custom Seating Systems

    Custom molded seating systems
    Custom molded seating systems provide positioning or pressure relief that cannot be met with a prefabricated cushion. They are fabricated from an impression or digital image of the recipient using molded-to-patient techniques.

    Custom molded seating systems may be entirely created by the provider or may be purchased from the manufacturer. Seating systems that are purchased from the manufacturer must have been coded E2609 / E2617 by the PDAC to be considered custom molded seating.

    Authorization is always required for professional services associated with custom molded seating systems. Include a statement and certification number to verify the provider is certified by the American Board for Certification of Orthotics or by the RESNA with the authorization request.

    Professional services associated with custom molded seating systems include evaluating the recipient’s seating needs, taking impressions or creating digital images, and making any necessary adjustments to the seating system.

    Custom molded seating systems (E2609/E2617) require authorization when the submitted charge is over $1200.

    Bill labor and material costs associated with fabricating an individually made sitting support spinal orthosis to MHCP using one of the following HCPCS codes:

  • K0108 with modifier UD: professional services associated with the evaluation, molding and fitting of custom molded seating systems
  • E2609: Seat module molded to fit a recipient, custom fabricated for attachment to wheelchair base
  • E2609, E2617: Seat and back sections molded as one piece, custom fabricated for attachment to wheelchair base
  • • E2609, E2617 for repairs: Repair to custom seating systems. Detail the cost of material. Use modifier RB.
  • K0739: repairs to seating systems, per 15 minutes labor. Clearly state in the documentation that the repairs are for a seating system and not for the wheelchair
  • Wheelchairs in long-term care facilities
    Wheelchair purchases and rentals are not included in the ICF/DD per diem.

    Standard wheelchairs for recipients in a nursing facility are included in the nursing facility per diem. Wheelchairs for recipients in a nursing facility may be approved if one of the following criteria is met:

  • • The recipient needs a wheelchair that must be modified. Wheelchairs manufactured in various widths and sizes are not considered modified. Modified means one of the following:
  • • The addition of an item to the wheelchair that cannot be removed without damaging the wheelchair
  • • It permanently alters the wheelchair so it is no longer usable by other residents of the facility
  • • The wheelchair is necessary for the continuous care and exclusive use by the recipient to meet their unusual medical need. Please note:
  • • Exclusive use alone does not justify approval of a wheelchair for a recipient if the chair required is a standard chair.
  • • Medical conditions common or expected in nursing facility populations are not “unusual” just because they are rare in one specific facility. For example, Alzheimer’s disease, osteoporosis and vulnerability to pressure ulcers are common in nursing facilities.
  • • The resident is being discharged to the community. Document the resident’s planned discharge date. If the recipient is being discharged, a standard wheelchair may be approved if it meets the recipient’s needs.
  • Facilities must exhaust other options for meeting a recipient’s needs, such as non-permanent positioning items, before requesting authorization for a wheelchair.

    Authorization for a power wheelchair will be considered only if it allows the recipient to complete most activities of daily living independently. All other coverage criteria must be met.

    Authorization is required for the purchase of wheelchair seating devices, headrests, and additions or modifications to the seating system regardless of the amount billed.

    Wheelchair cushions for prevention and treatment of skin pressure areas, including cushions used on patient owned wheelchairs, are not covered. These items are included in the facility per diem.

    When a wheelchair is approved for a recipient, all medically necessary parts and accessories of the wheelchair are covered except skin protection cushions.

    For recipient-owned wheelchairs in nursing facilities, repairs are covered if the chair would be approved outside the facility per diem. All repairs to wheelchairs in nursing facilities require authorization.

    Replacement of worn batteries, battery chargers, wheels, tires or arm pads is not considered a repair.
    Follow authorization request guidelines for repairs, and include the following information:

  • • State “patient owned wheelchair, living in LTC” in the Notes field or on an attachment
  • • The original wheelchair authorization number if available
  • • If MHCP did not authorize the original purchase of the wheelchair/if the wheelchair was purchased prior to admission to the nursing facility, include documentation to support medical necessity
  • • Bill using place of service 31 and modifier U3.
  • Medicare does not cover the rental, purchase or repair of mobility devices when the recipient is living in a long term care facility. Providers must follow MHCP authorization and billing procedures. It is not necessary to bill Medicare before billing MHCP.

    Noncovered Services

    Mobility devices are not covered in the following circumstances:

  • • Power mobility devices if requested solely for the purpose of community outings such as attending social activities
  • • Mobility devices requested to meet behavioral needs rather than mobility needs
  • • Mobility devices requested solely for use in a public school if the device can be covered through an individualized education program (IEP)
  • • Backup devices if requested in case of equipment malfunction, unless the recipient’s power chair has custom molded seating such that the recipient cannot be served by a loaner or rental chair
  • • Mobility devices designed for sports or recreational purposes
  • • Wheelchairs with stair climbing ability
  • • Options and accessories to convert a manual chair to a power chair (E0983-E0984)
  • • Adult power mobility devices (power wheelchairs or power operated vehicles) not reviewed by Medicare’s Pricing, Data Analysis and Coding (PDAC) contractor or reviewed by the PDAC contractor and found not to meet the definition of a specific power mobility device. To determine the correct HCPCS code for a power mobility device, access the Durable Medical Equipment Coding System (DMECS) Product Classification List.
  • Authorizations

  • Required Authorization
  • Authorization Requests for Purchase/Rental
  • Repair/Modification Authorization Requests
  • Submit authorization requests and required documentation the Authorization Medical Review Agent.

    Required Authorization

    Authorization is always required under the following circumstances:

  • • All mobility device purchases
  • • K0001-K0005 rentals after six months
  • • All other mobility device rentals after three months
  • • Modifications to an existing wheelchair if the submitted combined charges for parts and labor are $1000 or more
  • • Repairs or replacement of parts or accessories if the submitted combined charges for parts and labor are $1000 or more
  • • Repairs or replacement of parts or accessories that are less than 365 days old
  • • Miscellaneous parts billed with HCPCS code K0108 when the submitted charge for the part is $400 or more, regardless of the submitted combined charges for repairs or modifications
  • • Professional services associated with custom molded seating systems
  • • Custom molded seating systems when the submitted charge is over $1,200.
  • • All mobility devices purchases, rentals and repairs when the recipient lives in a nursing facility
  • Exception: Authorization is not required for any item for which a third party payer has made payment that is equal to or greater than 60% of the MHCP maximum allowed amount for the item.

    Authorization Requests for Purchase or Rental

    Manual wheelchairs, power operated vehicles and Group 1 or Group 2 No Power Option wheelchairs
    Authorization requests for recipients with progressive diseases or conditions must include an assessment by a licensed/certified medical professional of the effects of the disease’s progress on the recipient’s ability to use the requested mobility device and an estimate indicating how long the requested mobility device is expected to meet the recipient’s mobility needs. Medical professional includes physical therapist, occupational therapist, or physician with training in rehabilitation wheelchair evaluations.

    Group 2, 3, 4 or 5 Single or Multiple Power Option power wheelchairs
    Authorization requests must include a functional assessment by a licensed or certified medical professional (physical therapist, occupational therapist, or physician with training in rehabilitation wheelchair evaluations).

    Mobility devices for recipients under age 21
    Authorization requests must include an assessment by a licensed or certified medical professional (physical therapist, occupational therapist, or physician with training in rehabilitation wheelchair evaluations). The assessment must address both the recipient’s current and expected future mobility needs.

    Mobility devices for recipients with recent spinal cord or brain injuries
    Authorization requests must include therapy notes detailing the recipient’s progress toward goals, the expected outcome of therapy for the recipient, and the expected time until maximum benefit from therapy is achieved.

    Power mobility devices for recipients under age 4
    Power mobility devices will not be considered for recipients under age 18 months.

    Authorization requests for power mobility devices for children under age 4 must include:

  • • Documentation, including any relevant assessments, that the child is developmentally and cognitively ready to begin to operate a power wheelchair
  • • Documentation that the child is expected to use a powered mobility device as a primary means of mobility for several years. It is not necessary that there is no expectation or hope of functional walking in the future.
  • • Documentation of the age-appropriate ADLs for which the child is expected to use the power mobility device
  • • Documentation that the caregivers have carefully considered the risks and benefits of independent power mobility for very small children
  • • Due to the expense of mobility devices for very small children, it is particularly important that issues of transportation be addressed to eliminate the need for multiple mobility devices.
  • Documentation of Recipient Ability to Use In-home and Transportation Trials
    All authorization requests must include a trial in the home which demonstrates the mobility device fits in all necessary areas of the home and the recipient is able to use the mobility device in all necessary areas of the home:

  • • During the trial also address transportation of the mobility device in the recipient’s vehicle if appropriate. If the recipient does not have a vehicle, address the recipient’s primary transportation method.
  • • For manual wheelchairs without seating or propulsion options, the trial may be performed with the same or similar equipment.
  • • For other mobility devices, the trial must be performed with equipment with the same specifications as to measurement and maneuverability and power options.
  • • If the recipient is homeless, there must be a plan for charging power mobility devices and for safe storage of the device.
  • In all cases, the trial must demonstrate the proposed device is medically necessary and appropriate for the recipient.

    Mobility device authorization requests must include the physician’s order for the device. The physician must sign and date the order.

    To request authorization:

  • • Complete the MN–ITS Authorization Request 278 transaction (or paper Authorization Form (DHS-4695) (PDF))
  • • Complete the Mobility Devices Authorization Form (DHS-4315) (PDF) (signed by the person recommending and fitting the mobility device, including the credentials (MD, PT, OT, ATP) of each person signing the form
  • Fax required documentation with the form(s) to the Authorization Medical Review Agent.

  • • Submit the mobility device base HCPCS code for an authorization number when requesting an authorization. List the recommended device by name and model number
  • • List all standard and non-standard accessories/options on separate lines on the authorization request, even if the individual item does not require authorization. List each item by HCPCS code, appropriate modifier, quantity, with the charge and medical necessity documentation for non-standard items
  • • When multiple items that are different but require the miscellaneous code K0108 are requested, list each item on a separate line of the authorization request, with modifier 76 on the 2nd and subsequent lines. Enter a unique description (model number or narrative description up to 20 characters) of each item into the model number field for each line
  • • Documentation must address the recipient’s medical need, and how the mobility device and each option or accessory meets that need. List all options and accessories, and the specific medical justification for each option or accessory on the request, although only the major accessories will be reviewed for medical necessity
  • • Standard items included in the initial issue of the device will not be reviewed for medical necessity, but will be listed on the authorization letter as an approved item
  • • All major accessories will be listed on the authorization letter by procedure code, whether approved or denied, with the allowed dollar amount if approved
  • • All coverage determinations are based on the least costly, most effective and medically necessary mobility device for the individual recipient
  • Repair or Modification Authorization Requests

    When requesting authorization for repairs or modifications to a mobility device not originally authorized by MHCP, include documentation of medical necessity for the device, and the accessories to be repaired/replaced.

    Replacement of worn batteries, battery chargers, wheels, tires or arm pads
    Replacement of worn batteries, battery chargers, wheels, tires or arm pads is not considered a repair. Authorization is not required, regardless of submitted charge, unless the part being replaced is less than one year old. Replacement of other components is considered a repair and subject to the $1,000 limit.

    Authorization may be denied if:

  • • The repairs or modifications are not cost effective because the age or condition of the device indicates replacement is more appropriate.
  • • The frequency or extent of repairs requested indicates the recipient lacks the ability to safely and appropriately operate the device. It may be necessary to consider a different mobility device for the recipient.
  • • The repairs or modifications are requested for a device that does not currently meet MHCP criteria for coverage
  • When submitting authorization requests:

  • • List all accessories or options to be replaced or repaired on separate lines on the authorization request. List each item by HCPCS code, quantity, and the usual and customary charge. Use appropriate modifier(s) as determined by date of service.
  • • When multiple items that are different but require the miscellaneous code K0108 are requested, each item must be listed on a separate line of the authorization request with modifier 76 on 2nd and subsequent lines. A unique description of each item must be entered into the model number field for each line. The unique description may be a model number or narrative description up to 20 characters.
  • • Include the estimated labor time on the authorization request with K0739 as appropriate
  • • If adding accessories to an existing wheelchair, include medical necessity documentation for each accessory.
  • • Include the original mobility device prior authorization number if available, or the approximate purchase date of service.
  • • If repairs are needed because of damage to the device, specify the cause of the damage.
  • • All approved items will be listed on the authorization, with the approved payment amount.
  • Requesting authorization for repairs or modifications to a mobility device

    For all parts and accessories to be repaired or replaced use:

  • • Modifier RB for items being repaired
  • • Modifier NU for items being installed as a modification
  • • Modifier RA for items being installed as a replacement for the same accessory
  • • Usual and customary charge(s)
  • Billing

  • • Submit the usual and customary charge for the mobility device and part or accessories, not the approved amount from the authorization letter. Payment will be the balance of the lesser of the billed amount or the approved amount, after any primary or secondary payers have made payment.
  • • If billing for parts or accessories for two approved wheelchairs, clearly indicate this in the notes field. Include the authorization number that refers to the appropriate wheelchair in the notes field.
  • • Do not bill repairs over a span of dates.
  • • When a provider sends a part or accessory to a manufacturer for repair, bill using the appropriate HCPCS code for the part and RB modifier. Submit the invoice from the manufacturer as an attachment to show cost. Bill K0739 for the provider's labor for removal or reinstallation of the part or accessory. Follow usual MHCP policies in determining if a PA is necessary.
  • • Bill items that require manual pricing using the X12 Batch or MN–ITS Interactive 837P Professional electronic claim with the manufacturer’s invoice or price list as an attachment as described in the Billing Policy section. Items included in an approved authorization do not require manual pricing.
  • • If billing for parts or accessories for two medically necessary recipient owned wheelchairs, clearly indicate this in the notes field including the authorization number or serial number that refers to the appropriate in the notes field
  • • If you bill K0739, MHCP will deny additional claims billed by the same provider for the same date of service
  • • Repairs to equipment owned by Medicare recipients: Medicare has Unit of Service Allowances for repairs to some commonly repaired items. When the actual repair time exceeds Medicare’s allowance, bill the labor on two lines. Line one must follow Medicare billing rules. On line two, bill K0739 use modifier GZ (item or service expected to be denied as not reasonable and necessary) and the number of units that exceed Medicare’s allowance
  • Approved Purchase, Rental or Repair Billing for Devices Approved on a Multi-line Authorization

    Submit one claim for the approved power-operated vehicle or wheelchair base (for purchase or rental) and all approved parts or accessories (for all claims); make sure the HCPCS codes, modifiers and the description on the claim match the same information on the prior authorization.

    Enter the authorization number in the authorization field in the authorization field for each line.

    Use of modifiers KC and KE

    Follow Medicare guidelines for use of modifiers KC (replacement of special power wheelchair interface) and KE (items bid under round one of the Medicare DMEPOS competitive bidding program for use with noncompetitive bid base equipment). DHS will apply the appropriate Medicare rate to lines billed with KC and KE modifiers.

    Recipients with Third Party Coverage or Medicare

    When MHCP is not the primary payer, other insurance must be exhausted before submitting a claim for payment to MHCP.

  • • MHCP will not consider a request for authorization unless the provider has made a good faith effort to receive authorization or payment from the primary payer(s).
  • • The Authorization Medical Review Agent must approve an authorization before MHCP can make a payment unless the primary payer has paid 60% or more of the MHCP maximum allowed amount for that item.
  • • The Authorization Medical Review Agent will review an authorization request after the fact. Refer to the mobility device authorization section for instructions.
  • • If authorization is required, the mobility device must meet all MHCP medical necessity requirements, and documentation included in the request must identify the mobility device in detail.
  • • Include the amount the primary payer will reimburse for the mobility device in the authorization request.
  • • Recipients and providers must comply with policies and procedures of the primary insurance.
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    © 2017 Minnesota Department of Human Services Updated: 7/18/17 2:54 PM | Accessibility | Terms/Policy | Contact DHS | Top of Page | Updated: 7/18/17 2:54 PM