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 (providers must give a copy of the warranty to the Minnesota Health Care Programs (MHCP) 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.

Eligible Members

Mobility devices are covered for eligible MHCP members 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. Activities of daily living refer to any activity a member must complete during a given day including (but not limited to): toileting, feeding, grooming, education, working or job training. The mobility device must enable the member to participate in mobility-related activities of daily living and be appropriate to the member’s needs and abilities.

· The mobility device must enable the member to participate in mobility-related activities of daily living 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.

· 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 activities of daily living.

Covered Services

· Specific Mobility Devices, Options and Accessories

· Backup Manual Wheelchairs

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

Backup Manual Wheelchairs

· A “backup” manual chair may be covered for members with a powered mobility device. Requests will be reviewed individually to determine medical necessity. Clearly state that the request is for a backup chair when requesting authorization.

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

· 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.

In addition to the general backup manual wheelchair criteria listed under Backup Manual Wheelchairs, the following specific criteria must be met when requesting one of the following backup manual wheelchairs:

· Hemi-wheelchairs (K0002). The member requires a lower seat height (less than 19 inches) because of short stature

· Light-weight wheelchairs (K0003). The member is unable to propel themselves in a standard wheelchair or their caregiver is unable to push a standard wheelchair

· High-strength, lightweight wheelchairs (K0004). The member requires a seat width, depth, or height that cannot be accommodated in a standard, lightweight or hemi-wheelchair

· Ultra-lightweight wheelchair (less than 30 lbs.) (K0005):

· 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 K0001 through K0004 manual wheelchair.

· If requesting additions to K0005 backup wheelchair, the member must have a specialty evaluation that was performed by a licensed or certified medical professional (LCMP), such as a physical therapist or occupational therapist 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.

· Heavy-duty or extra-heavy-duty wheelchairs (K0006-K0007), the member:

· Requires the chair because of weight; or

· Has a medical condition such as spasticity, which requires a heavy-duty chair for safety

· Tilt-in-Space manual wheelchairs (E1161) are covered if the member meets ONE of the following criteria:

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

· 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

· 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

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

Manual wheelchairs are covered if the member meets the criteria for a mobility device and meets ONE of the following criteria:

· A caregiver who is available, willing, and able to provide assistance; or

· 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)

· Footrests 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 or straps

· General-use seat and back cushions

· Positioning seat and back

· Skin protection seat and back cushions

The following codes are not allowed to be billed 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		K0195

K0195 is for capped rental manual wheelchairs and is not allowed to be billed with any manual wheelchair that is billed with modifier NU.

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

Hemi-wheelchairs (K0002) are covered if the member meets ONE of the following criteria:

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

· Requires a lower seat height (less than 19 inches) to propel the chair with their feet

Lightweight (34 – 36 lbs.) manual wheelchairs (K0003) are covered if the member meets ALL of the following criteria:

· Primarily uses a manual wheelchair rather than a power mobility device;

· Cannot self-propel in a standard wheelchair for various reasons; and

· Can propel themselves in the requested chair

High-strength, lightweight wheelchairs (K0004) are covered if the member primarily uses a manual wheelchair rather than a power mobility device if the member meets ONE of the following criteria:

· The member self-propels the wheelchair while engaging in frequent activities that cannot be performed in a standard or lightweight wheelchair; or

· The member requires a seat width, depth, or height that cannot be accommodated in a standard, lightweight or hemi-wheelchair, and spends at least two hours per day in the wheelchair.

Ultra-lightweight (less than 30 lbs.) manual wheelchairs (K0005) are covered if criteria (1) or (2) is met and criteria (3)

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

· The member must have a specialty evaluation that was performed by a licensed or certified medical professional (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.

Heavy-duty or extra-heavy-duty wheelchairs (K0006-K0007) are covered if the member meets ONE of the following criteria:

· Requires the chair because of weight; or

· Has a medical condition such as spasticity, which requires a heavy-duty chair for safety

Tilt-in-Space manual wheelchairs (E1161) are covered if the member meets ONE of the following criteria:

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

· 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

· 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

Rollabout or Transport chairs (E1031, E1037-E1039) are covered if the member meets ALL of the following criteria:

· 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

Power-Operated Vehicles (POV) (K0800-K0802, K0806-K0808)

Power-operated vehicles are covered if the member meets ALL of the following criteria:

· Meets the criteria for a mobility device; and

· Does not have sufficient upper extremity function to self-propel an optimally configured manual wheelchair to perform mobility-related activities of daily living; and

· Is able to safely transfer to and from the POV; and

· Has both the physical and cognitive ability to operate the tiller steering system; and

· Is able to maintain postural stability and position while operating the POV; and

· 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

· Nonexpandable 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 member has a specific medical need that cannot be met with a less-costly alternative.

Power wheelchairs are covered if the member meets ALL of the following criteria:

· Meets the criteria for a mobility device; and

· Does not have sufficient upper extremity function to self-propel an optimally configured manual wheelchair to perform mobility-related activities of daily living; and

· Is not able to safely operate a POV or maintain postural stability and position while operating a POV; and

· 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

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

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 nonadjustable armrests with arm pad

· Fixed swing-away or detachable nonelevating leg rests with or without calf pad

· Lap belt or safety belt

· Nonexpandable 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

The following codes are not allowed to be billed 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 member meets ALL of the following criteria:

· Meets the criteria for a power wheelchair; and

· Does not require a single or multiple-power option wheelchair; and

· 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 member meets ONE of the following criteria:

· 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 member meets ONE of the following criteria:

· 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 member meets ONE of the following criteria:

· Has mobility limitations due to a neurological condition, myopathy, congenital skeletal deformity

· 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-K0860) are covered if the member meets ALL of the following criteria:

· Has mobility limitations due to a neurological condition, myopathy, congenital skeletal deformity or the member 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

AND

· The Group 2 single-power option criteria are met

Group 3 multiple-power option power wheelchairs (K0861-K0864) are covered if the member meets ALL of the following criteria:

· Has mobility limitations due to a neurological condition, myopathy, congenital skeletal deformity or the member 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

AND

· The Group 2 multiple-power option criteria are met

Group 4 no-power option power wheelchairs (K0868-K0871) are covered if the member meets ALL of the following criteria:

· Cannot safely use an equivalent Group 3 power wheelchair without significant modifications to the member’s living environment

AND

· Has mobility limitations requiring the use of seating and positioning items that cannot be accommodated by a Group 1 or Group 2 power wheelchair

AND

· Meets the criteria for a power wheelchair

Group 4 single-power option power wheelchairs (K0877-K0880) are covered if the member meets ALL of the following criteria:

· Has mobility limitations due to a neurological condition, myopathy, congenital skeletal deformity or the member 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

AND

· Cannot safely use an equivalent Group 3 power wheelchair without significant modifications to the member’s living environment or meets criteria for accessories that are not available on a Group 3 power wheelchair

AND

· Meets the Group 2 single-power wheelchair criteria

Group 4 multiple-power option power wheelchairs (K0884-K0886) are covered if the member meets ALL of the following criteria:

· Has mobility limitations due to a neurological condition, myopathy, congenital skeletal deformity or the member 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

AND

· Meets the Group 2 multiple power options criteria

Group 5 power wheelchairs (K0890-K0891) are covered if the member meets ALL of the following criteria:

· Meets the criteria for a power wheelchair

AND

· Meets the criteria for a single or multiple-power option

AND

· 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 member. The following is not an all-inclusive list of options and accessories; many additional options and accessories may be covered if medically necessary.

One-arm drive attachments (E0958) are covered when the member meets BOTH of the following:

· The member 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 member has the strength, stamina and cognitive ability to propel the wheelchair using the one-arm drive attachment

Push-activated power assist (E0986) is covered if the member meets both of the following criteria:

· Has expressed an unwillingness to operate a power wheelchair, and

· 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 member is expected to need to operate the manual wheelchair

· A trial sufficient to demonstrate the member 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 member’s mobility needs

Power tilt (E1002) is covered if the member meets the criteria for a wheelchair and meets ONE of the following criteria:

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

· Has a fixed-hip angle; or

· 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

Power recline (E1003-E1005) is covered if the member meets the criteria for a power wheelchair and meets ONE of the following criteria:

· 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; or

· Uses intermittent catheterization; or

· Has edema and is unable, for physical or other reasons, to periodically transfer from the wheelchair 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, with or without power-elevating legs rests (E1006-E1008) are covered if the member meets BOTH of the following criteria:

· Meets criteria for a power wheelchair; and

· 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 if the member meets the criteria for a wheelchair AND meets ONE of the following criteria:

· Has a medical condition which prevents 90 degrees of knee flexion; or

· A treatment program to decrease flexion contractures of the knee; or

· 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

Power leg elevation systems (E1010, E1012) are covered if the member meets the criteria for a power wheelchair AND meets ONE of the following criteria:

· A medical condition which prevents knee flexion of 90 degrees; or

· A treatment program to decrease flexion contractures of the knee; or

· A 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

Manual, fully or semi-reclining backs (E1014, E1225, E1226) are covered if the member meets ONE of the following criteria:

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

· Uses intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair; or

· Is unable to tolerate a full upright position due to a medical condition

Gear-reduction drive wheels (E2227) are covered if the member meets BOTH the following criteria:

· Meets criteria for a manual wheelchair; and

· Is at risk for weakness or repetitive motion injury to the arms or shoulders

Dynamic seating frame/hardware (E2295, E2398) are covered if the member meets ALL of the following criteria:

· 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 system (E2298) is covered if the member meets ONE of the following criteria:

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

· 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 activities of daily living (ADLs) (cupboards, closets, and the like)

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 Minnesota Department of Human Services (DHS) or its authorized agent upon request.

Standing feature (manual: E2230; power: E2301) is covered if a member meets ALL of the following criteria:

· The member meets the Minnesota Health Care Programs (MHCP) 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 ADLs (cupboards, closets, and the like)

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.

Alternative Interface Devices (E2312, E2321-E2330, E2373, E2399) are covered if a member meets the 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.

Power wheelchair attendant control (E2331) is covered if the member meets ALL of the following criteria:

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

· Requires a power wheelchair or lacks a caregiver able to propel a manual chair; and

· Has a caregiver willing and able to operate the power wheelchair and assist the member

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.

Prior authorization is required from the Authorization Medical Review Agent if the submitted charge for an individual item is $400 or more.

Custom molded and pre-fabricated seating systems

Custom molded seating systems
Custom fabricated seating systems 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.

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 Medicare’s Pricing, Data Analysis and Coding to be considered custom fabricated seating.

Custom fabricated seating systems (E2609 or E2617) requires authorization when the submitted charge is over $1,200.

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 requesting authorization or 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 requesting authorization or 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 as previously described.

Other covered services

Wheelchairs in long-term care 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 (HCPCS code: K0001) are included in the nursing facility per diem.

· All other wheelchairs (including tilt-in-space) are billable outside of the nursing facility per diem if they are necessary for the continuous care and exclusive use by a member. The member must also meet any of the policy criteria for their requested chair.

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 member’s power chair has custom-molded seating such that the member cannot be served by a loaner or rental chair

· Mobility devices designed for sports or recreational purposes

· Wheelchairs with stair climbing ability

· Unbundling is not allowed for titanium, carbon fiber, and so on. Manual wheelchair bases (K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0008, and K0009) include construction of any type 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, K0002, K0003, K0004, K0005, K0006, K0007, K0008, and K0009) for 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.

· 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. Access the Durable Medical Equipment Coding System (DMECS) Product Classification List to determine the correct HCPCS code for a power mobility device.

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.

Authorizations

· Required Authorization

· Authorization Requests for Purchase or Rental

· Repairs or Modification Authorization Requests

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

Authorization is required in 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 $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 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

· Any part which alone costs $400 or more

· Professional services associated with custom-molded seating systems

· Custom-molded seating systems when the submitted charge is over $1,200

· All mobility device purchases, rentals and repairs when the member 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 percent of the MHCP maximum allowed amount for the item.

Authorization Requests for Purchase or Rental must include

· Letter of medical necessity or Mobility Devices Authorization Form (DHS-4315) (PDF). Either documentation must address all the applicable requested information from this policy.

· Order from the doctor that is signed and dated

· Any pertinent clinical documentation that speaks to medical necessity

· List all standard and nonstandard accessories and 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 nonstandard items

· 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, and the specific medical justification for each option or accessory on the request, although only the major accessories will be reviewed for medical necessity.

· Documentation of the member’s current wheelchair (if applicable) and, if possible, have the member’s current wheelchair with them during the evaluation to assess (and document) why it is no longer appropriate for the authorization request. If the chair 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

Authorization requests for manual wheelchairs, power-operated vehicles and Group 1 or Group 2 No-Power Option wheelchairs must include ALL the following:

· An assessment by a licensed or certified medical professional.

AND

· The assessment must include the effects of the disease’s progress 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

· Medical professionals can be one of the following: physical therapist, occupational therapist or physician with training in rehabilitation wheelchair evaluations.

Authorization requests for Group 2, 3, 4 or 5 Single or Multiple-Power Option power wheelchairs must include the following:

· A functional assessment by a licensed or certified medical professional (physical therapist, occupational therapist or physician with training in rehabilitation wheelchair evaluations).

Authorization requests for mobility devices for members under age 21 must include ALL the following:

· An assessment by a licensed or certified medical professional (physical therapist, occupational therapist or physician with training in rehabilitation wheelchair evaluations).

AND

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

AND

· The original cost of the current chair, cost of the modifications to accommodate growth, and cost of the new chair when requesting a new wheelchair or a modification to an existing wheelchair. Clearly state what is the most appropriate (considering further growth) and cost-effective option for the member.

Authorization requests for mobility devices for members with recent spinal cord or brain injuries must include ALL the following:

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

Authorization requests for power mobility devices for members under age 4 must include ALL the following:

· Documentation, including any relevant assessments, that the child is developmentally and cognitively ready to begin to operate a power wheelchair

AND

· 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

AND

· Documentation of the age-appropriate ADLs for which the child is expected to use the power mobility device

AND

· Documentation that the caregivers have carefully considered the risks and benefits of independent power mobility for very small children

AND

· 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

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

To request authorization:

· Complete the MN–ITS Authorization Request 278 transaction or paper Authorization Form (DHS-4695) (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 or forms 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

· 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 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

· 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 member

Repairs or Modifications

Loaner Chairs

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.

Authorizations for repairs or modifications

Authorizations must include all the following applicable information:

· Submitted documentation must include the age of the chair being repaired (and expected lifespan after repair), cost of repairs and if applicable cost of a new chair

· Least costly alternative during the span of the next five years of the device must be considered (factoring in longevity 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.

· 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 second 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.

· 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 or replaced.

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 member lacks the ability to safely and appropriately operate the device. It may be necessary to consider a different mobility device for the member

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

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 charges

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.

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.

· 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 you are 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 date span.

· 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 MN–ITS 837P electronic claim with the manufacturer’s invoice or price list as an attachment as described in the Billing Policy section.

· If you are billing for parts or accessories for two medically necessary member-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.

· The KU modifier can be billed for wheelchair accessories and seat and back cushion codes listed in Attachment A of the Centers for Medicare & Medicaid Services (CMS) Manual System Change Request 12345 (PDF) and Attachment A of the CMS Manual System Change Request 12453 (PDF) when provided in connection with Group 3 power wheelchairs, complex rehabilitative manual wheelchairs, and certain other manual wheelchairs described by HCPCS codes E1161, E1231 through E1238, K0005, K0008, and K0848 through K0864.

· 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.

· To bill for a loaner chair, use 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 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.

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.

Members 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 payers.

· The Authorization Medical Review Agent must approve an authorization before MHCP can make a payment unless the primary payer has paid 60 percent 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.

· Members and providers must comply with policies and procedures of the primary insurance.

Providers must meet any provider criteria, including accreditation, for third-party insurance or for Medicare to assist members 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 member. Providers assisting members who have both Medicare and MHCP (dual-eligible members) must comply with this Medicare rule.

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

Medicare does not cover wheelchair transit systems including: tie downs, transport brackets or similar wheelchair accessories. Providers may bill MHCP directly for these accessories that are part of a covered wheelchair. When billing, clearly state “wheelchair transportation accessory not covered by Medicare” in the claim note field in MN–ITS. MHCP does not cover accessories that are modifications to a vehicle.

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