Manual wheelchairs, power-operated vehicles, and power wheelchairs help people with mobility-related disabilities to complete activities of daily living (ADLs) 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 (providers must give a copy of the warranty to the member and keep a copy for their 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 member whose chair requires repair. If the member’s chair is customized and unique to his or her specific needs, MHCP does not expect providers to have an equivalent chair on hand.

TPL and Medicare
Providers must meet any provider criteria, including accreditation, for third party insurance or for Medicare to assist members for whom Minnesota Health Care Programs (MHCP) is not the primary payer.

MHCP quantity limits and thresholds apply to all members unless only Medicare coinsurance or deductible is requested. Authorization is not required for any item for which third party liability (TPL) has made payment that is equal to or greater than 60 percent of the MHCP maximum allowed amount for the item.

Refer to the Medicare and Other Insurance section of the MHCP Provider Manual for more information.

Eligible Members

Mobility devices are covered for eligible Medical Assistance and MinnesotaCare members with a mobility limitation that significantly impairs their ability to participate in one or more mobility-related activities of daily living (MRADLs) and the mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker. MRADLs include essential tasks that support self-maintenance and personal care, including but not limited to, ambulating, bathing, dressing, eating, education, grooming, toileting, transferring, and working.

· The mobility device must enable the member to participate in MRADLs and be appropriate to the member’s needs and abilities.

· When a power wheelchair is purchased for a member 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.

· The wheelchair must require significant customization to maintain the member in an appropriate position to be considered custom-molded. The use of supports does not constitute a custom-molded seating system or custom-molded back.

· Basic manual wheelchairs, transport chairs, or rollabout chairs may be covered if needed to allow the member to access medical care in the community, even if not needed for other ADLs.

Covered Services

· Specific Mobility Devices, Accessories, and Options

· Short-Term Rentals

· Backup Manual Wheelchairs

· Manual Wheelchairs

· Power-Operated Vehicles

· Power Wheelchairs

· Wheelchair Accessories and Options

· Batteries and Chargers

· Seating Systems and Seat Frames

· Long-Term Care (LTC) Facilities

Specific Mobility Devices, Accessories, and Options

The following criteria are not all inclusive. Documentation of medical necessity for all billed items must be made available to Minnesota Department of Human Services (DHS) or its authorized agent upon request.

Short-Term Rentals

Some members may require a mobility device because of a medical condition related to an accident or injury. It is the expectation by MHCP that providers dispense rentals for mobility device users who are expected to fully recover from the accident or injury and be able to perform MRADLs without a mobility device. It is at the discretion of the provider to determine the medical necessity of the device and if purchase or rental is more appropriate for the member.

Backup Manual Wheelchairs

Backup manual wheelchairs may be covered for members with a power mobility device. Authorization is required for backup manual wheelchairs, regardless of individual HCPCS code. Coverage determinations are based upon a review of submitted case-specific information. Clearly state that the request is for a backup chair when requesting authorization. Members must meet criteria for the specific device.

· Documentation submitted with previous authorization requests will be considered when determining if criteria are met for a backup wheelchair.

· A basic manual wheelchair, transport chair or rollabout chair may be covered if needed to allow the member to access medical care in the community, even if not needed for other ADLs.

· Documentation must clearly justify why other, less-costly manual wheelchairs, will not meet the member’s needs. The wheelchair must require significant customization to maintain the member in an appropriate position to be considered custom-molded. The use of supports does not constitute a custom-molded seating system or custom-molded back.

Accessories for backup manual wheelchairs do not require authorization, unless for excess quantities or if the individual item always requires authorization. Members must meet criteria for the specific accessory. Documentation must clearly explain medical necessity for the accessory or item for the backup manual wheelchair.

Manual Wheelchairs

Codes: E1031, E1037-E1039, E1161, E1229, E1231-E1239, K0001-K0009
Manual wheelchairs are covered for members who meet criteria for mobility devices as described under Eligible Members and the applicable criteria for the specific device. Authorization is required for ultralightweight (K0005), tilt-in-space (E1161), pediatric-size (E1229, E1231 to E1239), custom (K0008), and not otherwise specified (K0009) manual wheelchairs. Authorization is not required for other manual wheelchairs (E1031, E1037 to E1039, K0001 to K0004, K0006, K0007), unless requesting authorization for quantities over the MHCP quantity limit, as backup devices for users of power mobility devices, or for members who live in a nursing facility. MHCP covers one manual wheelchair per eligible member.

MHCP requires providers dispensing ultralightweight and tilt-in-space wheelchairs to employ an Assistive Technology Professional (ATP) certified by the Rehabilitative Engineering and Assistive Technology Society of America (RESNA). The ATP must be directly involved in the wheelchair selection and fitting for the member.

Standard options for manual wheelchairs include:

· A complete frame

· Armrests

· Brakes

· Casters

· Propulsion wheels

· Safety accessories

· Standard leg and footrests

· A sling seat, seat pan which can accommodate a wheelchair set cushion, or a seat frame structured in such a way as to be capable of accepting a seating system

· A sling back, other seat back support which can accommodate a wheelchair set cushion, or a back frame structured in such a way as to be capable of accepting a back system

Standard wheelchairs (K0001) are covered if the following criteria are met:

· The member meets criteria for a mobility device; and

· The member’s caregiver is willing and able to assist the member; or

· The member has sufficient upper extremity function to propel an optimally configured manual wheelchair to participate in MRADLs during a typical day.

Standard hemi wheelchairs (K0002) are covered if the following criteria are met:

· The member meets criteria for a mobility device; and

· The member requires a lower seat height (less than 19 inches) because of short stature; or

· The member requires a lower seat height (less than 19 inches) to propel the chair with their feet.

Lightweight wheelchairs (K0003) are covered if the following criteria are met:

· The member meets criteria for a mobility device; and

· The member primarily uses a manual wheelchair rather than a power wheelchair; and

· The member cannot self-propel in a standard wheelchair due to medical reasons; and

· The member can propel themselves in the requested chair.

High-strength, lightweight wheelchairs (K0004) are covered if the following criteria are met:

· The member meets criteria for a mobility device; and

· The member spends at least two hours per day in a mobility device; and

· The member primarily uses a manual wheelchair rather than a power wheelchair; or

· The member requires a seat width, depth, or height that cannot be accommodated by a standard, lightweight, or hemi wheelchair.

Ultralightweight wheelchairs (K0005) are covered with authorization if the following criteria are met:

· The member meets criteria for a mobility device; and

· The member must be a full-time manual wheelchair user; or

· The member must require individualized fitting and adjustments for one or more features such as, but not limited to, axle configuration, wheel camber, or seat and back angles, and which cannot be accommodated by a manual wheelchair described by HCPCS codes K0001 through K0004; and

· The member must have a specialty evaluation that was performed by a licensed or certified medical professional (LCMP), such as a physical therapist (PT) or occupational therapist (OT), or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features. The LCMP may have no financial relationship with the supplier; and

· The wheelchair is provided by a Rehabilitative Technology Supplier (RTS) that employs a RESNA-certified ATP who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member.

Heavy-duty or extra-heavy-duty wheelchairs (K0006, K0007) are covered if the following criteria are met:

· The member meets criteria for a mobility device; and

· The member requires the wheelchair because of their size or weight; or

· The member has a medical condition such as spasticity, which requires a heavy-duty wheelchair for safety.

Tilt-in-space wheelchairs (E1161) are covered with authorization if the following criteria are met:

· The member meets criteria for a mobility device; and

· The member is at high risk for pressure ulcers and is unable to perform a functional weight shift; or

· The member has increased, or excess muscle tone or spasticity related to a medical condition that is anticipated to be unchanging for at least one year; or

· The member has decreased muscle tone related to a medical condition that inhibits their ability to sit up against gravity and requires tilt-in space for head and trunk control; and

· The member must have a specialty evaluation that was performed by a LCMP, such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features. The LCMP may have no financial relationship with the supplier; and

· The wheelchair is provided by a RTS provider that employs a RESNA-certified ATP who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the member.

Rollabout or transport chairs (E1031, E1037 to E1039) are covered if the following criteria are met:

· The member meets criteria for a mobility device; and

· The member is not expected to be able to self-propel a manual or power wheelchair in the next five years; and

· The member has needs that cannot be met by a less-costly manual wheelchair; and

· The proposed chair has casters of at least five inches in diameter and is specifically designed to meet durable medical equipment standards.

Pediatric-size wheelchairs (E1231 to E1238) are covered with authorization if the following criteria are met:

· The member meets criteria for a mobility device; and

· The member requires a pediatric-size wheelchair because of stature; and

· The wheelchair provides growth capability in width and length; and

· If requesting tilt-in-space system, the member meets criteria for tilt-in-space (E1231 to E1234).

Modifications to pediatric-size wheelchairs (E1011) are covered if the member requires an adjustment due to their growth in size. Authorization is required if submitted combined charges are $1,000 or more.

Pediatric-size manual (E1229) and power (E1239) wheelchairs that are not otherwise specified require authorization. HCPCS codes E1229 and E1239 should only be used when a pediatric-size wheelchair is not described by a more specific HCPCS code (E1231 to E1238). Documentation must clearly indicate member’s diagnosis, need for unspecified manual or power pediatric-size wheelchair, and consideration of less costly alternatives.

Custom (K0008) and not otherwise specified (K0009) manual wheelchairs require authorization. HCPCS codes K0008 and K0009 should only be used when a wheelchair is not described by a more specific HCPCS code (K0001 to K0007). Documentation must clearly indicate member’s diagnosis, need for custom or other manual wheelchair base, and consideration of less costly alternatives.

Power-Operated Vehicles

Codes: K0800-K0802, K0806-K0808
Power-operated vehicles are covered with authorization if the following criteria are met:

· The member meets criteria for a mobility device; and

· The member does not have sufficient upper extremity function to self-propel an optimally configured manual wheelchair to perform MRADLs; and

· The member is able to transfer to and from the power-operated vehicle safely; and

· The member has both the cognitive and physical ability to operate the tiller steering system; and

· The member is able to maintain postural stability and position while operating the power-operated vehicle; and

· The member is able to bring the power-operated vehicle into the home for use and storage, or if homeless, has demonstrated a plan to safely charge and store the device.

Standard options for power-operated vehicles include:

· Battery or batteries required for operation

· Battery charger, single mode

· Complete set of tires

· Nonexpandable controller with proportional response to input

· Tiller steering

· Weight appropriate upholstery and seating system

· All accessories needed for safe operation

Power Wheelchairs

Codes: K0813-K0816, K0820-K0831, K0835-K0843, K0848-K0864, K0868-K0871, K0877-K0880, K0884-K0886, K0890, K0891
A power wheelchair may be covered if the member has a specific medical need that cannot be met with a less costly alternative.

Power wheelchairs are covered with authorization if the following criteria are met:

· The member meets criteria for a mobility device; and

· The member does not have sufficient upper extremity function to self-propel an optimally configured manual wheelchair to perform ADLs; and

· The member is unable to safely operate a power-operated vehicle or maintain postural stability and position while operating the device; or

· The member is unable to fit or use a power-operated vehicle in all necessary areas of the home and is able to with a power wheelchair; and

· The member 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 device.

Power wheelchairs may also be covered if the member has a caregiver who cannot push a manual chair but can propel the power wheelchair using the attendant control.

Members under age 4 must be evaluated and found to be developmentally ready to begin to operate a power chair equipped with appropriate attendant control and safeguards.

MHCP requires providers dispensing Group 2 single-power-option wheelchairs or above to employ an ATP certified by the RESNA. The ATP must be directly involved in the wheelchair selection and fitting for the member. The member must have a specialty evaluation that was performed by an LCMP, such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features. The LCMP may have no financial relationship with the supplier.

Standard options for power wheelchairs include:

· Armrests (fixed, swingaway, or detachable)

· Battery charger, single mode

· Complete set of tires and casters, any type

· Controller and input device

· Footrests or foot platform

· Lap or safety belt

· Leg rests

· Any back width, except for Group 3 and Group 4 power wheelchairs with sling or solid back, the following are separately reimbursable:

· Standard-duty back width greater than 20 inches

· Heavy-duty back width greater than 22 inches

· Very heavy-duty back width greater than 24 inches

· Any seat width and depth, except for Group 3 and Group 4 power wheelchairs with sling or solid seat, the following are separately reimbursable:

· Standard-duty seat width or depth greater than 20 inches

· Heavy-duty seat width or depth greater than 22 inches

· Very heavy-duty seat width or depth greater than 24 inches

· Any weight specific components (bars, braces, brackets, gears, motors, upholstery)

Group 1 (K0813 to K0816) or Group 2 no-power option (K0820 to K0829) power wheelchairs are covered with authorization if the following criteria are met:

· The member meets criteria for a power wheelchair; and

· The member does not require a single or multiple-power option wheelchair; and

· The member does not require a drive-control interface other than a hand operated standard proportional joystick.

Group 2 single-power option power wheelchairs (K0835 to K0840) are covered with authorization if the following criteria are met:

· The member meets criteria for a power wheelchair; and

· The member meets criteria for power tilt or recline seating system; or

· The member requires a drive-control interface other than a hand-operated standard proportional joystick.

Group 2 multiple-power option power wheelchairs (K0841 to K0843) are covered with authorization if the following criteria are met:

· The member meets criteria for a power wheelchair; and

· The member meets criteria for power tilt or recline seating system; or

· The member requires a drive-control interface other than a hand-operated standard proportional joystick; or

· The member uses a ventilator mounted on the device.

Group 3 no-power option power wheelchairs (K0848 to K0855) are covered with authorization if the following criteria are met:

· The member meets criteria for a power wheelchair; and

· The member has mobility limitations due to a neurological condition, myopathy, or congenital skeletal deformity; or

· The member 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 to K0860) are covered with authorization if the following criteria are met:

· The member meets criteria for a power wheelchair; and

· The member has mobility limitations due to a neurological condition, myopathy, or congenital skeletal deformity; or

· The member 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; and

· The member meets criteria for Group 2 single-power option.

Group 3 multiple-power option power wheelchairs (K0861 to K0864) are covered with authorization if the following criteria are met:

· The member meets criteria for a power wheelchair; and

· The member has mobility limitations due to a neurological condition, myopathy, or congenital skeletal deformity; or

· The member meets criteria for Group 2 multiple-power option.

Group 4 no-power option power wheelchairs (K0868 to K0871) are covered with authorization if the following criteria are met:

· The member meets criteria for a power wheelchair; and

· The member cannot safely use an equivalent Group 3 power wheelchair without significant modifications to the member’s living environment; and

· The member 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 4 single-power option power wheelchairs (K0877 to K0880) are covered with authorization if the following criteria are met:

· The member meets criteria for a power wheelchair; and

· The member has mobility limitations due to a neurological condition, myopathy, or congenital skeletal deformity; or

· The member cannot safely use an equivalent Group 3 power wheelchair without significant modifications to the member’s living environment; and

· The member meets criteria for Group 2 single-power option.

Group 4 multiple-power option power wheelchairs (K0884 to K0886) are covered with authorization if the following criteria are met:

· The member meets criteria for a power wheelchair; and

· The member has mobility limitations due to a neurological condition, myopathy, or congenital skeletal deformity; or

· The member cannot safely use an equivalent Group 3 power wheelchair without significant modifications to the member’s living environment; and

· The member meets criteria for Group 2 multiple-power option.

Group 5 power wheelchairs (K0890 to K0891) are covered with authorization if the following criteria are met:

· The member meets criteria for a power wheelchair; and

· The member meets criteria for a single or multiple-power option; and

· The member is expected to grow in height, or their size necessitates a Group 5 power wheelchair.

Wheelchair Accessories and Options

Wheelchair accessories are covered if they are medically necessary and address a specific medical need of the member. The following is not an exhaustive list of options; many additional accessories and options may be covered if medically necessary. Do not bill for standard accessories and options provided at time of initial issue of a wheelchair. Standard options are listed in the applicable section under Covered Services. Document in the medical record which accessories and options are included with the member’s mobility device. Refer to the Billing section for information on which HCPCS codes are included at time of initial issue. Refer to the Medical Supply Coverage Guide (PDF) for information on MHCP authorization requirements and quantity limits by HCPCS code.

Trays (E0950), heel loop/holders (E0951), toe loop/holders (E0952), antitipping devices (E0971), antirollback devices (E0974), solid seat inserts (E0992), and armrests (E0994) are covered for members who use wheelchairs.

Headrests (E0955), headrest extensions (E0966), foot boxes (E0954), adjustable height armrests (E0973, K0020), positioning belts (E0978), lateral thigh or knee support (E0953), lateral trunk or hip support (E0956), medial thigh support (E0957), shoulder harnesses or straps (E0960), wheel lock brake extensions (E0961), safety vests (E0980), and other positioning accessories are covered for members who use wheelchairs and require accessories for positioning or safety.

One-arm drive attachments (E0958) are covered with authorization if the following criteria are met:

· The member meets criteria for a manual wheelchair but is unable to use both upper extremities or at least one lower extremity to safely propel the wheelchair; and

· A trial demonstrates the member has the cognitive and physical ability to propel the wheelchair using the one-arm attachment.

Narrowing devices (E0969) are covered for members who use wheelchairs and require their device be made temporarily narrower to navigate their surroundings.

Seat lift mechanisms (E0985) are covered for members who use wheelchairs and can safely transfer independently with a seat lift mechanism to increase the device’s seat height or go from sitting to standing position.

Power assist systems (E0986) are covered with authorization if the following criteria are met:

· The member meets criteria for a manual wheelchair and has expressed an unwillingness to operate a power wheelchair; and

· The member no longer has sufficient upper extremity function to self-propel a manual wheelchair; or

· The member has repetitive motion stress or weakness in their arms or shoulders.

Documentation must include:

· An assessment of the distance the member is expected to need to operate the manual wheelchair; and

· A trial demonstrates the member is able to operate the manual wheelchair for that distance; and

· An estimate indicating how long the push-activated power-assisted manual wheelchair is expected to meet the member’s mobility needs.

HCPCS code E0986 is all-inclusive of components required for manual wheelchair conversions.

There is no separate payment for components including, but not limited to, batteries, chargers, controls, drive wheels, and mounting hardware.

Elevating leg rests (E0990, K0053, K0195) are covered for members who use wheelchairs and require elevating leg rests for positioning, edema, or other medical condition. HCPCS code K0195 should only be billed when dispensing a wheelchair under a capped rental period.

Power tilt seating systems (E1002) are covered with authorization if the following criteria are met:

· The member meets criteria for a mobility device; and

· The member is at risk for pressure ulcers and is unable to perform a functional weight shift; or

· The member has a fixed-hip angle; or

· The member has increased, or excess muscle tone or spasticity related to a medical condition which impairs their ability to tolerate the fully upright sitting position for significant periods of time.

Power recline seating systems (E1003 to E1005) are covered with authorization if the following criteria are met:

· The member meets criteria for a mobility device; and

· The member is unable to tolerate a fully upright position related to a medical condition which impairs their ability to tolerate the fully upright sitting position for significant periods of time; or

· The member uses intermittent catheterization; or

· The member has edema and is physically unable to periodically transfer from their mobility device to elevate the legs.

Manual or power elevating leg rests must be requested if a reclining seating system is approved because a member has edema.

Power tilt and recline seating systems (E1006 to E1008) are covered with authorization if the following criteria are met:

· The member meets criteria for a power wheelchair; and

· The member meets criteria for both power tilt and power recline.

Manual or power-elevating leg rests must be requested if a reclining seating system is approved because a member has edema.

Mechanical leg elevation systems (E1009) are covered with authorization if the following criteria are met:

· The member meets criteria for a mobility device; and

· The member has a medical condition which prevents 90 degrees of knee flexion; or

· The member is in a treatment program to decrease flexion contractures of the knee; or

· The member has leg edema which cannot be treated by an edema control wrap, a recline feature as part of the device, and is physically unable to periodically transfer from their mobility device to elevate the legs.

Power leg elevation systems (E1010, E1012) are covered with authorization if the following criteria are met:

· The member meets criteria for a mobility device; and

· The member has a medical condition which prevents 90 degrees of knee flexion; or

· The member is in a treatment program to decrease flexion contractures of the knee; or

Manual, fully or semi-reclining backs (E1014, E1225, E1226) are covered with authorization if the following criteria are met:

· The member meets criteria for a mobility device; and

· The member is at high risk for pressure ulcers and is unable to perform a function weight shift; or

· The member uses intermittent catheterization and is unable to independently transfer from the wheelchair; or

· The member is unable to tolerate a fully upright position related to a medical condition.

Shock absorbers (E1015 to E1018) are covered for members who use wheelchairs to minimize jarring.

Residual limb support systems (E1020) and adapters (E0959) are covered for members who use wheelchairs and are amputees.

Wheelchair transportation or transit securement systems (E1022, E1023) are covered with authorization if the following criteria are met:

· The member meets criteria for a mobility device; and

· The member is at risk for unsafe transfers in private vehicles or public transportation; and

· The member needs public or private transportation to perform MRADLs; and

· The member is dependent for transfers and transitions in transportation.

Medicare does not cover transportation or transit systems, including restraints, tiedowns, transport brackets, or similar accessories. Bill MHCP directly using HCPCS codes E1022 and E1023.

Retractable or removable mounting hardware (E1028, E1032 to E1034) is covered if the member needs accessories to be manually moved or removed from the wheelchair mount.

Ventilator trays (E1029, E1030) are covered for members who use wheelchairs and ventilators. Authorization is required for gimbaled ventilator trays (E1030). Documentation must clearly indicate member’s diagnosis and need for gimbaled feature.

Multi-positional patient transfer systems (E1035, E1036) are covered with authorization if the following criteria are met:

· The member meets criteria for a mobility device; and

· The member requires a lift for transfers between bed and a mobility device because without the lift they would be bed confined; and

· The member requires supine positioning for transfers; and

· The member’s caregiver is willing and able to operate the device and assist the member.

Crutch and cane holders (E2207) and cylinder tank carriers (E2208) are covered for members who use wheelchairs and canes, crutches, or oxygen tanks.

Arm troughs (E2209) are covered if the member has quadriplegia, hemiplegia, or uncontrolled arm movements.

Gear-reduction drive wheels (E2227) are covered with authorization if the following criteria are met:

· The member meets criteria for a manual wheelchair; and

· The member is at risk for repetitive motion stress or weakness in their arms or shoulders.

Wheel braking systems (E2228) are covered with authorization if the following criteria are met:

· The member meets criteria for a manual wheelchair; and

· The member requires their mobility device be locked in place during transfers.

Dynamic seating frames and hardware (E2295, E2398) are covered with authorization if the following criteria are met:

· The member meets criteria for a manual wheelchair; and

· The requested dynamic seating frame is made by the same manufacturer as the requested wheelchair; and

· The requested wheelchair independently meets all criteria for medical necessity and least-costly appropriate equipment; and

· The member does not require tilt-in-space or reclining back; and

· The member is able to engage in some hip or knee extension.

Power seat elevation systems (E2298) are covered with authorization if the following criteria are met:

· The member meets criteria for a manual wheelchair; and

· The member must routinely transfer between uneven surfaces and the surfaces cannot be adjusted and the seat elevation feature allows them to independently transfer; or

· The member cannot be safely transferred using a patient lift or standing transfer but can safely transfer with the seat elevation feature; or

· The seat elevation system has been demonstrated to allow the member to independently access areas in the home necessary for completion of MRADLs.

Documentation must specify where uneven transfers will be needed in the member’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 member to socialize with peers.

If a seat elevation feature is approved for a member, the provider must obtain documentation from the member or the member’s authorized representative acknowledging that member 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.

Manual (E2230) and power (E2301) standing systems are covered with authorization if the following criteria are met:

· The member meets criteria for a mobility device; and

· The member meets criteria for a stander; and

· MHCP has not purchased a stander for the member in the previous three years; and

· The standing function has been demonstrated to allow the member to independently access areas in the home necessary for completion of MRADLs.

A standing feature is not covered when requested solely to allow the member to socialize at eye level with peers.

If a standing feature is approved for a member, the provider must obtain documentation from the member or the member’s authorized representative acknowledging that the member 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.

Electronic components for motors controlled by interfaces (E2310, E2311), harnesses (E2313), and expandable controllers (E2377) are covered with authorization for members who are approved for interface devices or powered accessories, including wheelchair drives, power tilt, power recline, power shear reduction, power leg elevation, seat elevation, and standing systems. Expandable controllers and harnesses are allowed when interface devices or three or more power seating system actuators, functions, or motors are authorized. HCPCS code E2313 is all-inclusive of components required for operation of HCPCS code E2377. There is no separate payment for components including, but not limited to, circuits, connectors, fasteners, fuse boxes, mounting hardware, switches, and wires. There is no separate payment for electronics if a nonexpandable controller and standard proportional joystick are provided.

Alternative interface devices (E2312, E2321 to E2330, E2373, E2399) are covered with authorization if the following criteria are met:

· The member meets criteria for a power wheelchair; and

· The member cannot safely operate the wheelchair using a hand or chin-operated standard proportional joystick but can safely operate the wheelchair using the alternative device.

Power wheelchair attendant control (E2331) is covered with authorization if the following criteria are met:

· The member meets criteria for a mobility device but is unable to operate a manual or power wheelchair; and

· The member requires a power wheelchair or lacks a caregiver able to propel a manual chair; and

· The member has a caregiver willing and able to operate the power wheelchair and assist the member.

Mobile arm supports and additions (E2626 to E2633) are covered with authorization if the following criteria are met:

· The member meets criteria for a mobility device; and

· The member has a medical condition that only allows them to use their upper extremities to move through partial range of motion against gravity, as evident by manual muscle testing; and

· If requesting for positioning needs, include documentation explaining why less costly positioning equipment is not appropriate for the member’s medical needs; or

· If requesting for assistance in performing MRADLs, include documentation illustrating how the device will allow the member to be independent in one or more MRADLs; and

· A trial demonstrates the member is able to operate the equipment.

Wheelchair components or accessories (K0108) that are not otherwise specified are covered if medically necessary or if required for the functioning of other covered items. HCPCS code K0108 should only be used when there is not a more specific HCPCS code. Authorization is required, regardless of submitted charge.

Batteries and Chargers

Codes: E2358-E2367, E2371-E2372, E2397
Batteries (E2358 to E2365, E2397, E2371 to E2372) and chargers (E2366, E2367) are covered for member-owned power mobility devices when the original item no longer functions. MHCP pays for two batteries and one charger annually. Document in the medical record that the original item is no longer functional. Batteries and chargers are not separately reimbursable within 30 days of initial issue of a power mobility device.

Seating Systems and Seat Frames

Prefabricated seating systems and seat frames
Codes: E2201-E2204, E2340-E2343, E2601-E2608, E2610-E2616, E2619-E2625
Prefabricated systems and nonstandard frames do not require authorization, unless requesting quantities over the MHCP quantity limit.

General use seat and back cushions (E2601, E2602, E2611, E2612) are covered for members who use wheelchairs.

Skin protection seat and back cushions (E2603, E2604, E2622, E2623) are covered for members who use wheelchairs and are vulnerable to skin breakdown. Document in the medical record the member’s diagnosis and need for skin protection seat and back cushions to mitigate skin breakdown.

Positioning seat and back cushions (E2605, E2606, E2613 to E2616, E2620, E2621) are covered for members who use wheelchairs and require positioning assistance. Document in the medical record the member’s diagnosis and need for seat and back cushions for positioning support.

Skin protection and positioning seat and back cushions (E2607, E2608, E2624, E2625) are covered for members who use wheelchairs, are vulnerable to skin breakdown, and require positioning assistance. Document in the medical record the member’s diagnosis and need for both skin protection and positioning seat and back cushions.

Nonstandard seat frame dimensions (E2201 to E2204, E2340 to E2343) are covered if the member’s dimensions necessitate a seat width or depth of 20 inches or more for manual or power wheelchairs.

Seat or back replacement cushions (E2619) and replacement upholstery (E0981, E0982) are covered when the original item no longer functions. MHCP allows up to two units annually. Document in the medical record that the original item is no longer functional. Replacement cushions and upholstery are not separately reimbursable within 30 days of initial issue of a wheelchair.

Powered seat cushions (E2610) require authorization. Powered cushions are prefabricated, battery-powered, and provide sequential inflation and deflation of air or a low interface pressure. Documentation must clearly indicate member’s diagnosis and clinical history, consideration of less costly alternatives, and need for powered feature to mitigate pressure sores or provide positioning support. MHCP will only consider requests for powered cushions when all other seating systems have been contraindicated, including custom fabricated seating systems.

Custom fabricated seating systems
Codes: E2609, E2617
Custom fabricated seating systems (E2609, E2617) provide positioning or pressure relief that cannot be met with a standard, mass-produced cushion or seating system. They are fabricated from an impression or digital image of the member using created-for- or molded-to-patient techniques. Authorization is required for custom fabricated seating systems.

Custom fabricated 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 or E2617 by the Centers for Medicare & Medicaid Services’ (CMS) Pricing, Data Analysis and Coding (PDAC) to be considered custom fabricated seating.

Bill labor and material costs associated with fabricating an individually made seating system to MHCP using one of the following HCPCS codes:

· E2609: Custom fabricated wheelchair seat cushion, any size.

· E2617: Custom fabricated wheelchair back cushion, any size, including any type mounting hardware.

· 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.

When billing for custom fabricated seating and backs that have been purchased from the manufacturer, submit the invoice from the manufacturer as an attachment to show cost.

When billing for custom fabricated seating, backs, or customized wheelchair equipment that has been created by the provider, submit an invoice from the provider showing the provider’s cost for parts and labor.

When dispensing custom fabricated seating that has been molded or created as one piece, allocate the cost between E2609 and E2617 and attach pricing documentation.

Long-Term Care (LTC) Facilities

Wheelchairs in LTC facilities

ICF/DD coverage

· Wheelchair purchases and rentals are not included in the intermediate care facility for people who are developmentally disabled (ICF/DD) per diem.

SNF per diem coverage

· Standard wheelchairs (K0001) are included in the skilled nursing facility (SNF) per diem.

· All other wheelchairs are billable outside of the per diem if they are necessary for the continuous care and exclusive use by a member. Members must meet criteria for the specific device. Other covered services for devices that are used for the continuous care and exclusive use by a member in a nursing facility include medically necessary repairs, accessories, and options. Authorization is required for members who live in a nursing facility.

Noncovered Services

MHCP does not cover the following:

· Mobility devices for members that do not meet medical necessity criteria for the specific device.

· Mobility devices that are not used by the member.

· 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 manual wheelchairs if requested in case of equipment malfunction, unless the member’s power chair has custom molded seating such that the member cannot be served by a loaner or rental chair.

· Backup power wheelchairs.

· Power mobility devices if requested solely for the purpose of community outings such as attending social activities.

· Power-operated vehicles and power wheelchairs that are not otherwise specified (K0812, K0898).

· Power mobility devices that are not coded by DME PDAC or do not meet criteria (K0899). Use the Durable Medical Equipment Coding System (DMECS) Product Classification List to determine the correct HCPCS code.

· Mobility devices, including adaptive tricycles, for sports or recreational purposes, which are coded as HCPCS code A9270.

· The following power wheelchair features, which are coded as HCPCS code A9270:

· Stair climbing

· Electronic balance

· Ability to elevate the seat by balancing on two wheels

· Home modifications.

· Items of convenience, including but not limited to the following, which are coded as HCPCS code A9270:

· Bags

· Baskets

· Canopies

· Clothing guards

· Cup or bottle holders

· Identification devices or license plates

· Lighting systems

· Pouches

· Snow tires

· Speed conversion kits

· Options and accessories to convert a manual chair to a power chair (E0983, E0984).

· Lever-activated wheel drive accessories (E0988).

· Unbundling is not allowed for titanium, carbon fiber, and so on. Manual wheelchair bases (K0001 to K0009) include construction of any type of material, including, but not limited to, titanium, carbon, or any other lightweight high-strength material. Suppliers must not bill a wheelchair component or accessory, not otherwise specified (K0108) in addition to the wheelchair base (K0001 to K0009) construction materials or for a “heavy-duty package” reflecting the type of material used to construct the manual wheelchair base. Billing for construction material is incorrect coding.

Refer to information under the Noncovered Services heading in the Billing the Member (Recipient) section of the MHCP Provider Manual to review the conditions required to bill the member.

Typically Noncovered Services
Typically noncovered services may be requested for members with unique medical conditions. Typically noncovered items are items that in absence of the member’s diagnosis would otherwise be categorized as an item of convenience or other category of equipment under Noncovered Services. Coverage determinations are based upon a review of submitted case-specific information. Use HCPCS code K0108 for medically necessary items. Authorization is required, regardless of submitted charge. Documentation must clearly indicate the member’s diagnosis and the medical necessity for each item. Providers should only submit requests for HCPCS code K0108. Use HCPCS code A9270 for noncovered indications.

Authorizations

· Required Authorization

· Requests for Purchase or Rental

· Requests for Repairs or Modification

· Replacement Components

· Loaner Wheelchairs

Submit authorization requests and required documentation to the Medical Review Agent.

Required Authorization

Authorization is required for the following:

· All purchases and rentals of the following devices:

· Ultralightweight manual wheelchairs (K0005)

· Tilt-in-space manual wheelchairs (E1161)

· Power-operated vehicles (K0800 to K0802, K0806 to K0808)

· Power wheelchairs (K0813 to K0891)

· Pediatric-size wheelchairs (E1229, E1231 to E1239)

· Custom or other manual wheelchair bases (K0008, K0009)

· All purchases and rentals of the following items:

· One-arm drive attachments (E0958)

· Push-rim activated power assist systems (E0986)

· Power tilt seating systems (E1002)

· Power recline seating systems (E1003 to E1005)

· Power tilt and recline seating systems (E1006 to E1008)

· Mechanical leg elevation systems (E1009)

· Power leg elevation systems (E1010, E1012)

· Wheelchair transportation and transit securement systems (E1022, E1023)

· Gimbaled ventilator trays (E1030)

· Multi-positional transfer systems (E1035, E1036)

· Gear reduction drive wheelchairs (E2227)

· Wheel braking systems (E2228)

· Manual standing systems (E2230)

· Power seat elevation systems (E2298)

· Power standing systems (E2301)

· Electronic components for motors controlled by interfaces (E2310, E2311)

· Alternative interface devices (E2312, E2321 to E2331, E2373, E2399)

· Harness for expandable controller (E2313)

· Expandable controller for power wheelchair (E2377)

· Custom fabricated seating systems (E2609, E2617)

· Powered seat cushions (E2610)

· Mobile arm supports and additions (E2626 to E2633)

· Miscellaneous parts billed with HCPCS code K0108.

· All mobility device and accessory purchases, rentals, and repairs when the member lives in a nursing facility.

· Backup manual wheelchairs, regardless of HCPCS code.

· Quantities over MHCP quantity limits.

· Modifications to an existing wheelchair, including HCPCS code E1011, if the submitted combined charges for parts and labor are $1,000 or more.

· Repairs or replacement of parts or accessories if the submitted combined charges for parts and labor are $1,000 or more.

· Repairs or replacement of parts or accessories that are less than one year old.

· Professional services associated with custom fabricated seating systems.

Authorization is not required for any item for which a third-party payer has made payment that is equal to or greater than 60 percent of the MHCP maximum allowed amount for the item.

Requests for Purchase or Rental

Authorization requests for purchase or rental must include:

· Member’s diagnosis and clinical history.

· Letter of medical necessity or Mobility Devices Authorization Form (DHS-4315) (PDF). Documentation must address all requested policy information.

· Order.

· Any pertinent clinical documentation that speaks to medical necessity.

· List accessories that require authorization on separate lines on the authorization request. Do not include items that do not require authorization, unless requesting quantities over the MHCP quantity limit. List each item by HCPCS code, appropriate modifier, quantity, charged amount, and medical necessity information.

· Documentation must address the member’s medical need, and how the mobility device and each option or accessory meets that need. List all options and accessories in the medical record, and the specific medical justification for the mobility device and each option or accessory. Only include devices and accessories that require authorization always or for excess quantities on the request. These items will be reviewed for medical necessity. Documentation of medical necessity for all components must be made available to DHS or its authorized agent upon request.

· Documentation of the member’s current device, if applicable. If possible, have the member’s current device with them during the evaluation to assess and document why it is no longer appropriate for the authorization request. If the device cannot be present, you must discuss why it is no longer suitable for the member’s needs.

· An in-home trial must demonstrate that the mobility device fits and can be used in all necessary areas of the home.

· Documentation must address what types of transportation will be used for the mobility device and how it will be transported.

· Manual wheelchairs without seating or propulsion options may use same and similar equipment for home and transportation trials, but for all other mobility devices the trial must be performed with equipment that has the same specifications as to measurement and maneuverability and power options.

· If the member 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 member.

Review the following categories of mobility devices for information on specific documentation required for each type of mobility device.

Manual wheelchairs, power-operated vehicles, and Group 1 or Group 2 no-power option wheelchairs
Documentation must include:

· An assessment by an LCMP; and

· The assessment must include consideration of the member’s medical condition on the member’s ability to use the requested mobility device and an estimate indicating how long the requested mobility device is expected to meet the member’s mobility needs; and

· The assessment must be completed by a PT, OT, or physician with training in rehabilitation wheelchair evaluations.

Most manual wheelchairs do not require authorization. If requesting a backup manual wheelchair, for excess quantities, or for members who live in a nursing facility, clearly state this in the request.

Group 2, Group 3, Group 4, or Group 5 single or multiple-power options power wheelchairs
Documentation must include:

· An assessment by an LCMP; and

· The assessment must be completed by a PT, OT, or physician with training in rehabilitation wheelchair evaluations; and

· Consideration of less costly alternatives.

Mobility devices for members younger than age 21
Documentation must include:

· An assessment by an LCMP; and

· The assessment must be completed by a PT, OT, or physician with training in rehabilitation wheelchair evaluations; and

· The assessment must address the member’s current and expected future mobility needs; and

· The original cost of the device, cost of modifications to accommodate growth, and cost of a new device when requesting a new device or modification to an existing device; and

· Consideration of less costly alternatives.

Mobility devices for members with recent brain or spinal cord injuries
Documentation must include:

· An assessment by an LCMP; and

· The assessment must be completed by a PT, OT, or physician with training in rehabilitation wheelchair evaluations; and

· Therapy notes detailing the member’s progress toward goals, the expected outcome of therapy, and the expected time until maximum benefit from therapy is achieved.

Power mobility devices for members under age 4
Documentation must include:

· An assessment by an LCMP; and

· The assessment must be completed by a PT, OT, or physician with training in rehabilitation wheelchair evaluations; and

· Documentation must detail that the member is cognitively and physically able to operate the device; and

· Documentation must demonstrate the device will be used as a primary means of mobility for several years and include consideration of age-appropriate MRADLs the member wishes to perform; and

· The assessment must address the member’s current and expected future mobility needs; and

· The original cost of the device, cost of modifications to accommodate growth, and cost of a new device when requesting a new device or modification to an existing device; and

· Documentation must detail that the member’s caregiver is willing and able to assist the member and has acknowledged the benefits and risks of a power mobility device for the member; and

· Consideration of less costly alternatives.

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

Submit authorization requests and required documentation to the Medical Review Agent. Providers must include required documentation, physician’s orders, all policy information, and the signature of the provider recommending and fitting the mobility device, including their credentials.

· Submit the mobility device base and all options and accessories that require authorization when requesting an authorization, including HCPCS code, appropriate modifiers, and quantities. List the recommended mobility device by name and model number.

· List all options and accessories in the medical record, and the specific medical justification for the mobility device and each option or accessory. Only include devices and accessories that require authorization always or for excess quantities on the submitted authorization request. These items will be reviewed for medical necessity.

· When requesting multiple items that are different but require the miscellaneous code K0108, list each item on a separate line of the authorization request, with modifier 76 on the second 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.

· All accessories that require authorization will be listed on the authorization letter by HCPCS code, and whether approved or denied.

· All coverage determinations are based on the least costly, most effective and medically necessary mobility device for the individual member.

Requests for Repairs or Modifications

Authorizations requests for modifications or repairs must include:

· Documentation must detail the age of the chair being repaired, expected lifespan after repair, cost of repairs, and cost of a new chair, if applicable.

· Consideration of less costly alternatives during the span of the next five years of the device.

· 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 modifiers as determined by date of service.

· Documentation must include the estimated labor time on the authorization request with K0739, as appropriate.

· Documentation must include the original mobility device authorization number or the approximate purchase date of service, if available.

· If adding accessories to an existing mobility device, include documentation detailing the medical necessity for each item.

· If repairs are needed because of damage to the device, include documentation detailing the cause of the damage.

· 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 each accessory or option to be repaired or replaced.

· All items that require authorization will be listed on the authorization letter by HCPCS code, and whether approved or denied.

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; or

· The frequency or extent of repairs requested indicates the member lacks the ability to safely and appropriately operate the device. It may be necessary to consider a different mobility device for the member; or

· The repairs or modifications are requested for a device that does not currently meet MHCP criteria for coverage.

Use the following when billing for modifications or repairs:

· Modifier RB for items being repaired

· Modifier NU for items being installed as a modification

· Modifier RA for items being installed as a replacement

· Usual and customary charges

Replacement Components
MHCP pays for replacement parts when the original item no longer functions. Replacement of certain worn components of mobility devices is not considered repair. Authorization is not required for these replacement parts, regardless of submitted charge, unless requesting quantities over the MHCP quantity limit, or if the part would require authorization when dispensed as part of a new mobility device. Document in the medical record that the original item is no longer functional. The following codes are covered as replacement components except within 30 days of initial issue of a wheelchair:

E0967	E2369	E2388	K0043
E0981	E2370	E2389	K0044
E0982	E2374	E2390	K0045
E0995	E2375	E2391	K0046
E2205	E2376	E2392	K0047
E2206	E2377	E2394	K0050
E2210	E2378	E2395	K0051
E2220	E2381	E2396	K0052
E2221	E2382	E2619	K0069
E2222	E2383	K0015	K0070
E2224	E2384	K0017	K0071
E2225	E2385	K0018	K0072
E2226	E2386	K0019	K0077
E2368	E2387	K0042	K0098

Replacement of other components billed using modifier RA is considered a repair and subject to the $1,000 limit for authorization.

Replacement components are purchase-only items, except for certain power wheelchair accessories (E2374 to E2378, K0070), which may be purchased or capped rentals.

Refer to the Medical Supply Coverage Guide for information on MHCP authorization requirements and quantity limits by HCPCS code.

Loaner Wheelchairs
If providers do not have an appropriate loaner chair available, they may provide a rental chair to accommodate the member’s needs while repairing the customized chair. MHCP will reimburse providers for one month’s rental. Bill using HCPCS code K0462 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 note field.

Billing

Providers are responsible to coordinate services. Review MHCP Billing Policy Overview for general requirements and guidance when submitting claims.

Bill mobility device services using MN–ITS 837P. Refer to the Billing for Durable Medical Equipment, Medical Supplies, Prosthetics and Orthotics, and Augmentative Devices MN–ITS user guide for claim instructions. Refer to the Equipment and Supplies Resources webpage to review modifier price lists.

· Bill HCPCS codes on two claims, one for HCPCS codes that do not require authorization, and one for HCPCS codes that do require authorization.

· Use modifier NU for purchases.

· Use modifier RR for rentals.

· Use modifiers KH, KI, KJ, and RR as appropriate for capped rentals.

· When billing for modifications, repairs, or replacements:

· Use modifier NU for items being installed as a modification.

· Use modifier RB for items being repaired.

· Use modifier RA for items being installed as a replacement.

· Use usual and customary charges

· Do not bill repairs over a date span.

· Do not bill for repairs or replacements for items that are under warranty.

· Do not bill for standard accessories and options provided at time of initial issue of a wheelchair.

· Do not bill for construction material. Unbundling is not allowed for wheelchair bases.

· Do not bill HCPCS code E2377 when used with a Group 1 or Group 2 no-power option power wheelchair.

· Do not bill HCPCS code K0040 when used with a Group 1 or Group 2 power wheelchair.

· Only bill HCPCS code K0195 when used with a wheelchair during capped rental periods.

· 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. Authorization is required if the submitted combined charges for parts and labor are $1,000 or more.

· When billing for labor costs under HCPCS code K0739, MHCP will deny additional claims for K0739 billed by the same provider on the same date of service.

· Bill items that require manual pricing using MN–ITS 837P with the manufacturer’s invoice or price list as an attachment as described in the Billing Policy Overview section.

· If you are billing for parts or accessories for two medically necessary member-owned devices, clearly indicate this in the notes field including the authorization number or serial number that refers to the appropriate wheelchair in the claim note field.

· When billing for a loaner wheelchair under HCPCS code K0462, include the HCPCS code of the item being repaired or the item dispensed as a rental if different and less costly in the claim note field. 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.

· Medicare does not cover transportation or transit systems, including restraints, tiedowns, transport brackets, or similar accessories. Bill MHCP directly using HCPCS codes E1022, E1023, or K0108. When billing K0108, providers must clearly state “wheelchair transportation accessory not covered by Medicare” in the claim note field.

· The KE modifier can be billed for wheelchair accessory codes listed in Attachment A of the CMS Manual System Change Request 11784 (PDF) when provided in connection with mobility device codes described by HCPCS codes E1161, E1229, E1231 through E1239, K0005, K0009, and K0898.

· The KU modifier can be billed for wheelchair accessories and seat and back cushion codes listed in Attachment A of the CMS Manual System Change Request 12345 (PDF) and Attachment A of the CMS Manual System Change Request 12453 (PDF) when provided in connection with mobility device codes described by HCPCS codes E1161, E1231 through E1238, K0005, K0008, and K0848 through K0864.

· MHCP policy only allows one pricing modifier per HCPCS accessory code.

· Follow Medicare billing rules when billing repairs to equipment owned by Medicare members. Medicare guidelines include 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 1 must follow Medicare billing rules. On line 2, bill K0739 using modifier GZ (item or service expected to be denied as not reasonable and necessary) and the number of units that exceed Medicare’s allowance.

Billing for Accessories and Components
Standard options for mobility devices are listed in each section under Covered Services. Standard options are not separately reimbursable at the time of initial issue of a device. Batteries, chargers, and replacement components are not covered within 30 days of initial issue of a mobility device. Certain replacement components are not separately reimbursable in addition to other parts. Refer to the Medical Supply Coverage Guide for information on which HCPCS codes are considered included in payment for other HCPCS codes.

Payment for HCPCS codes listed in column 2 are included in payment for any of those in column 1:

Column 1	Column 2
E1161, E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0009	E0967, E0981, E0982, E0995, E2205, E2206, E2210, E2220, E2221, E2222, E2224, E2225, E2226, K0015, K0017, K0018, K0019, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0052, K0069, K0070, K0071, K0072, K0077
K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843	E0971, E0978, E0981, E0982, E0995, E1225, E2366, E2367, E2368, E2369, E2370, E2374, E2375, E2376, E2378, E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2394, E2395, E2396, K0015, K0017, K0018, K0019, K0037, K0040, K0041, K0042, K0043, K0044, K0045, K0046, K0047, K0051, K0052, K0077, K0098
K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856 K0857, K0858, K0859, K0860, K0861 K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886, K0890, K0891	E0971, E0978, E0981, E0982, E0995, E1225, E2366, E2367, E2368, E2369, E2370, E2374, E2375, E2376, E2378, E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2394, E2395, E2396, K0015, K0017, K0018, K0019, K0037, K0041, K0042, K0043, K0044, K0045, K0046, K0047, K0051, K0052, K0077, K0098
E0973	K0017, K0018, K0019
E0950, E0954, E1020	E1028
E0990	E0995, K0042, K0043, K0044, K0045, K0046, K0047
E1002, E1003, E1004, E1005, E1006, E1007, E1008	E0973, K0015, K0017, K0018, K0019, K0020, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052
E1009, E1010, E1012	E0990, E0995, K0042, K0043, K0044, K0045, K0046, K0047, K0052, K0053, K0195
E2325	E1032
K0039	K0038
K0045	K0043, K0044
K0046	K0043
K0047	K0044
K0053	E0990, E0995, K0042, K0043, K0044, K0045, K0046, K0047
K0069	E2220, E2224
K0070	E2211, E2212, E2224
K0071	E2214, E2215, E2225, E2226
K0072	E2219, E2225, E2226
K0077	E2221, E2222, E2225, E2226
K0195	E0995, K0042, K0043, K0044, K0045, K0046, K0047

Definitions

Activities of daily living (ADLs): Personal care activities that members perform regularly to take care of themselves and maintain wellbeing.

Assistive Technology Professional (ATP): Professional provider that analyzes the technological needs of members with disabilities and assists members in selecting and using adaptive devices.

Licensed or certified medical professional (LCMP): Licensed physician, physician assistant, or registered nurse who is acting within the scope of their issued license.

Mobility-related activities of daily living (MRADLs): Personal care activities that involve members moving themselves from one place to another.

Occupational therapist (OT): Health care specialist who evaluates and assists members to overcome emotional, physical, and social challenges to perform ADLs.

Physical therapist (PT): Health care specialist who evaluates and treats disorders affecting movement of the body.

Rehabilitative Engineering and Assistive Technology Society of America (RESNA): Professional organization that promotes the health and wellbeing of people with disabilities through technological solutions. ATPs are certified by RESNA.

Rehabilitative Technology Supplier (RTS): Professional provider that provides enabling technology in area of mobility.

Legal References

Minnesota Statutes, 256B.0625, subdivision 31

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