Notification



Notification Issue Date:



Policy Attachment



Attachment to Policy # 05.00.67p


Attachment: A

Policy #:05.00.67p

Description:HCPCS Level II Codes For Wheelchair Options And Accessories

Title:Wheelchair Options and Accessories


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.



HCPCS LEVEL II CODES FOR WHEELCHAIR OPTIONS AND ACCESSORIES

TO REPORT ARM OF CHAIR, USE THE FOLLOWING CODES:

E0973 Wheelchair accessory, adjustable height, detachable armrest, complete assembly, each

E0994 Armrest, each

E1227 Special height arms for wheelchair

E2209 Arm trough, with or without hand support, each

E2626 Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable

E2627 Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable rancho type

E2628 Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, reclining

E2629 Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, friction arm support (friction dampening to proximal and distal joints)

E2630 Wheelchair accessory, shoulder elbow, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke type suspension support

E2631 Wheelchair accessory, addition to mobile arm support, elevating proximal arm

E2632 Wheelchair accessory, addition to mobile arm support, offset or lateral rocker arm with elastic balance control

E2633 Wheelchair accessory, addition to mobile arm support, supinator

K0015 Detachable, nonadjustable height armrest, each

K0017 Detachable, adjustable height armrest, base, replacement only, each

K0018 Detachable, adjustable height armrest, upper portion, replacement only, each

K0019 Arm pad, replacement only, each

K0020 Fixed, adjustable height armrest, pair


TO REPORT FOOT REST/LEG REST, USE THE FOLLOWING CODES:

E0951 Heel loop/holder, any type, with or without ankle strap, each

E0952 Toe loop/holder, any type, each

E0953 Wheelchair accessory, lateral thigh or knee support, any type including fixed mounting hardware, each

E0954 Wheelchair accessory, foot box, any type, includes attachment and mounting hardware, each foot

E0970 No. 2 footplates, except for elevating leg rest

E0990 Wheelchair accessory, elevating leg rest, complete assembly, each

E0995 Wheelchair accessory, calf rest/pad, replacement only, each

E1020 Residual limb support system for wheelchair, any type

K0037 High mount flip-up footrest, each

K0038 Leg strap, each

K0039 Leg strap, H style, each

K0040 Adjustable angle footplate, each

K0041 Large size footplate, each

K0042 Standard size footplate, replacement only, each

K0043 Footrest, lower extension tube, replacement only, each

K0044 Footrest, upper hanger bracket, replacement only, each

K0045 Footrest, complete assembly, replacement only, each

K0046 Elevating legrest, lower extension tube, replacement only, each

K0047 Elevating legrest, upper hanger bracket, replacement only, each

K0050 Ratchet assembly, replacement only

K0051 Cam release assembly, footrest or legrest, replacement only, each

K0052 Swingaway, detachable footrests, replacement only, each

K0053 Elevating footrests, articulating (telescoping), each

K0195 Elevating leg rest, pair (for use with capped rental wheelchair base)


TO REPORT NONSTANDARD SEAT FRAME DIMENSIONS, USE THE FOLLOWING CODES:

E1011 Modification to pediatric size wheelchair, width adjustment package (not to be dispensed with initial chair)

E1296 Special wheelchair seat height from floor

E1297 Special wheelchair seat depth, by upholstery

E1298 Special wheelchair seat depth and/or width, by construction

E2201 Manual wheelchair accessory, nonstandard seat frame, width greater than or equal to 20 inches and less than 24 inches

E2202 Manual wheelchair accessory, nonstandard seat frame width, 24-27 inches

E2203 Manual wheelchair accessory, nonstandard seat frame depth, 20 to less than 22 inches

E2204 Manual wheelchair accessory, nonstandard seat frame depth, 22-25 inches

E2295 Manual wheelchair accessory, for pediatric size wheelchair, dynamic seating frame, allows coordinated movement of multiple positioning features

E2340 Power wheelchair accessory, nonstandard seat frame width, 20-23 in.

E2341 Power wheelchair accessory, nonstandard seat frame width, 24-27 in.

E2342 Power wheelchair accessory, nonstandard seat frame depth, 20 or 21 in.

E2343 Power wheelchair accessory, nonstandard seat frame depth, 22-25 in.

K0056 Seat height less than 17 in. or equal to or greater than 21 in. for a high strength, lightweight, or ultralightweight wheelchair


TO REPORT WHEELS/TIRES FOR MANUAL WHEELCHAIRS, USE THE FOLLOWING CODES:

E0961 Manual wheelchair accessory, wheel lock brake extension (handle), each

E0967 Manual wheelchair accessory, hand rim with projections, any type, replacement only, each

E2205 Manual wheelchair accessory, handrim without projections, any type, replacement only, each

E2206 Manual wheelchair accessory, wheel lock assembly, complete, replacement only, each

E2211 Manual wheelchair accessory, pneumatic propulsion tire, any size, each

E2212 Manual wheelchair accessory, tube for pneumatic propulsion tire, any size, each

E2213 Manual wheelchair accessory, insert for pneumatic propulsion tire (removable), any type, any size, each

E2214 Manual wheelchair accessory, pneumatic caster tire, any size, each

E2215 Manual wheelchair accessory, tube for pneumatic caster tire, any size, each

E2216 Manual wheelchair accessory, foam filled propulsion tire, any size, each

E2217 Manual wheelchair accessory, foam filled caster tire, any size, each

E2218 Manual wheelchair accessory, foam propulsion tire, any size, each

E2219 Manual wheelchair accessory, foam caster tire, any size, each

E2220 Manual wheelchair accessory, solid (rubber/plastic) propulsion tire, any size, replacement only, each

E2221 Manual wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, replacement only, each

E2222 Manual wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, replacement only, each

E2224 Manual wheelchair accessory, propulsion wheel excludes tire, any size, replacement only, each

E2225 Manual wheelchair accessory, caster wheel excludes tire, any size, replacement only, each

E2226 Manual wheelchair accessory, gear reduction drive wheel, each

E2227 Manual wheelchair accessory, wheel braking system and lock, complete, each

E2228 Manual wheelchair accessory, caster fork, any size, replacement only, each

K0065 Spoke protectors, each

K0069 Rear wheel assembly, complete, with solid tire, spokes or molded, replacement only, each

K0070 Rear wheel assembly, complete with pneumatic tire, spokes or molded, each

K0071 Front caster assembly, complete, with pneumatic tire, replacement only, each

K0072 Front caster assembly, complete, with semi-pneumatic tire, replacement only, each

K0073 Caster pin lock, each

K0077 Front caster assembly, complete, with solid tire, replacement only, each


TO REPORT OTHER MANUAL WHEELCHAIR OPTION, USE THE FOLLOWING CODE:

K0008 Custom Manual Wheelchair Base


TO REPORT BATTERIES/CHARGERS, USE THE FOLLOWING CODES:

E2359 Power wheelchair accessory, group 34 sealed lead acid battery, each (e.g. gel cell, absorbed glassmat)

E2361 Power wheelchair accessory, 22 NF sealed lead acid battery, each, (eg, gel cell, absorbed glassmat)

E2363 Power wheelchair accessory, group 24 sealed lead acid battery, each (eg, gel cell, absorbed glassmat)

E2365 Power wheelchair accessory, U-1 sealed lead acid battery, each (eg, gel cell, absorbed glassmat)

E2366 Power wheelchair accessory, battery charger, single mode, for use with only one battery type, sealed or nonsealed, each

E2371 Power wheelchair accessory, group 27 sealed lead acid battery, (eg, gel cell, absorbed glassmat), each

E2397 Power wheelchair accessory, lithium-based battery, each

K0733 Power wheelchair accessory, 12 to 24 AMP hour sealed lead acid battery, each (eg, gel cell, absorbed glassmat)


TO REPORT POWER SEATING SYSTEMS, USE THE FOLLOWING CODES:

E1002 Wheelchair accessory, power seating system, tilt only

E1003 Wheelchair accessory, power seating system, recline only, without shear reduction

E1004 Wheelchair accessory, power seating system, recline only, with mechanical shear reduction

E1005 Wheelchair accessory, power seating system, recline only, with power shear reduction

E1006 Wheelchair accessory, power seating system, combination tilt and recline, without shear reduction

E1007 Wheelchair accessory, power seating system, combination tilt and recline, with mechanical shear reduction

E1008 Wheelchair accessory, power seating system, combination tilt and recline, with power shear reduction

E1009 Wheelchair accessory, addition to power seating system, mechanically linked leg elevation system, including pushrod and leg rest, each

E1010 Wheelchair accessory, addition to power seating system, power leg elevation system, including leg rest, pair

E1012 Wheelchair accessory, addition to power seating system, center mount power elevating leg rest/platform, complete system, any type, each

E2310 Power wheelchair accessory, electronic connection between wheelchair controller and one power seating system motor, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware

E2311 Power wheelchair accessory, electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware


TO REPORT POWER WHEELCHAIR DRIVE CONTROL SYSTEMS, USE THE FOLLOWING CODES:

E2312 Power wheelchair accessory, hand or chin control interface, mini-proportional remote joystick, proportional, including fixed mounting hardware

E2313 Power wheelchair accessory, harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware, each

E2321 Power wheelchair accessory, hand control interface, remote joystick, nonproportional, including all related electronics, mechanical stop switch, and fixed mounting hardware

E2322 Power wheelchair accessory, hand control interface, multiple mechanical switches, nonproportional, including all related electronics, mechanical stop switch, and fixed mounting hardware

E2323 Power wheelchair accessory, specialty joystick handle for hand control interface, prefabricated

E2324 Power wheelchair accessory, chin cup for chin control interface

E2325 Power wheelchair accessory, sip and puff interface, nonproportional, including all related electronics, mechanical stop switch, and manual swingaway mounting hardware

E2326 Power wheelchair accessory, breath tube kit for sip and puff interface

E2327 Power wheelchair accessory, head control interface, mechanical, proportional, including all related electronics, mechanical direction change switch, and fixed mounting hardware

E2328 Power wheelchair accessory, head control or extremity control interface, electronic, proportional, including all related electronics and fixed mounting hardware

E2329 Power wheelchair accessory, head control interface, contact switch mechanism, nonproportional, including all related electronics, mechanical stop switch, mechanical direction change switch, head array, and fixed mounting hardware

E2330 Power wheelchair accessory, head control interface, proximity switch mechanism, nonproportional, including all related electronics, mechanical stop switch, mechanical direction change switch, head array, and fixed mounting hardware

E2331 Power wheelchair accessory, attendant control, proportional, including all related electronics and fixed mounting hardware

E2373 Power wheelchair accessory, hand or chin control interface, compact remote joystick or touchpad, proportional, including fixed mounting hardware

E2374 Power wheelchair accessory, hand or chin control interface, standard remote joystick (not including controller), proportional, including all related electronics and fixed mounting hardware, replacement only

E2375 Power wheelchair accessory, nonexpandable controller, including all related electronics and mounting hardware, replacement only

E2376 Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, replacement only

E2377 Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue


TO REPORT WHEELS/TIRES FOR POWER WHEELCHAIRS, USE THE FOLLOWING CODES:

E2381 Power wheelchair accessory, pneumatic drive wheel tire, any size, replacement only, each

E2382 Power wheelchair accessory, tube for pneumatic drive wheel tire, any size, replacement only, each

E2383 Power wheelchair accessory, insert for pneumatic drive wheel tire (removable), any type, any size, replacement only, each

E2384 Power wheelchair accessory, pneumatic caster tire, any size, replacement only, each

E2385 Power wheelchair accessory, tube for pneumatic caster tire, any size, replacement only, each

E2386 Power wheelchair accessory, foam filled drive wheel tire, any size, replacement only, each

E2387 Power wheelchair accessory, foam filled caster tire, any size, replacement only, each

E2388 Power wheelchair accessory, foam drive wheel tire, any size, replacement only, each

E2389 Power wheelchair accessory, foam caster tire, any size, replacement only, each

E2390 Power wheelchair accessory, solid (rubber/plastic) drive wheel tire, any size, replacement only, each

E2391 Power wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, replacement only, each

E2392 Power wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, replacement only, each

E2394 Power wheelchair accessory, drive wheel excludes tire, any size, replacement only, each

E2395 Power wheelchair accessory, caster wheel excludes tire, any size, replacement only, each


TO REPORT OTHER POWER WHEELCHAIR ACCESSORIES, USE THE FOLLOWING CODES:

E1016 Shock absorber for power wheelchair, each

E1018 Heavy duty shock absorber for heavy duty or extra heavy duty power wheelchair, each

E2351 Power wheelchair accessory, electronic interface to operate speech generating device using power wheelchair control interface

E2368 Power wheelchair component, drive wheel motor, replacement only

E2369 Power wheelchair component, drive wheel gear box, replacement only

E2370 Power wheelchair component, integrated drive wheel motor and gear box combination, replacement only

E2396 Power wheelchair accessory, caster fork, any size, replacement only, each

K0098 Drive belt for power wheelchair, replacement only


TO REPORT OTHER POWER WHEELCHAIR OPTIONS, USE THE FOLLOWING CODE:

K0013 Custom Motorized/Power Wheelchair Base


TO REPORT MISCELLANEOUS ACCESSORIES, USE THE FOLLOWING CODES:

E0705 Transfer device, any type, each

E0950 Wheelchair accessory, tray, each

E0958 Manual wheelchair accessory, one-arm drive attachment, each

E0959 Manual wheelchair accessory, adapter for amputee, each

E0968 Commode seat, wheelchair

E0969 Narrowing device, wheelchair

E0971 Manual wheelchair accessory, anti-tipping device, each

E0974 Manual wheelchair accessory, anti-rollback device, each

E0978 Wheelchair accessory, positioning belt/safety belt/pelvic strap, each

E0980 Safety vest, wheelchair

E0981 Wheelchair accessory, seat upholstery, replacement only, each

E0982 Wheelchair accessory, back upholstery, replacement only, each

E0985 Wheelchair accessory, seat lift mechanism

E0988 Manual wheelchair accessory, lever-activated, wheel drive, pair

E1014 Reclining back, addition to pediatric size wheelchair

E1015 Shock absorber for manual wheelchair, each

E1017 Heavy duty shock absorber for heavy duty or extra heavy duty manual wheelchair, each

E1028 Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for joystick, other control interface or positioning accessory

E1029 Wheelchair accessory, ventilator tray, fixed

E1030 Wheelchair accessory, ventilator tray, gimbaled

E1225 Wheelchair accessory, manual semi-reclining back, (recline greater than 15 degrees, but less than 80 degrees), each

E1226 Wheelchair accessory, manual fully reclining back, (recline greater than 80 degrees), each

E1228 Special back height for wheelchair

E2207 Wheelchair accessory, crutch and cane holder, each

E2208 Wheelchair accessory, cylinder tank carrier, each

E2210 Wheelchair accessory, bearings, any type, replacement only, each

E2378 Power wheelchair component, actuator, replacement only

E2398 Wheelchair accessory, dynamic positioning hardware for back

K0105 IV hanger, each

K0108 Wheelchair component or accessory, not otherwise specified


NOT MEDICALLY NECESSARY

E2358 Power wheelchair accessory, group 34 non-sealed lead acid battery, each

E2360 Power wheelchair accessory, 22 NF nonsealed lead acid battery, each

E2362 Power wheelchair accessory, group 24 nonsealed lead acid battery, each

E2364 Power wheelchair accessory, U-1 nonsealed lead acid battery, each

E2367 Power wheelchair accessory, battery charger, dual mode, for use with either battery type, sealed or nonsealed, each

E2372 Power wheelchair accessory, group 27 nonsealed lead acid battery, each


NOT PRIMARILY MEDICAL IN NATURE (BENEFIT EXCLUSION)

E2230 Manual wheelchair accessory, manual standing system

E2300 Wheelchair accessory, power seat elevation system, any type

E2301 Wheelchair accessory, power standing system, any type


NONCOVERED

A9270 Noncovered item or service


NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT

A9900 Miscellaneous DME supply, accessory, and/or service component of another HCPCS code



Version Effective Date: 01/01/2020
Version Issued Date: 12/30/2019
Version Reissued Date: n/a



2017 AmeriHealth.