Coverage Criteria and Medical Necessity for a Mobility Device

by  Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
February 23rd, 2016

General Coverage Criteria for a Mobility Device

According to CMS, all of the following basic criteria (A-C) must be met for a power mobility device (K0800-K0898) or a push-rim activated power assist device (E0986) to be covered. Additional coverage criteria for specific devices are listed below.

POWER OPERATED VEHICLES (K0800-K0808K0812):

A. POV is covered if all of the basic coverage criteria (A-C) have been met and if criteria D-I are also met.

     B. The beneficiary is able to:

  1. The beneficiary’s home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the POV that is provided. 

  2. The beneficiary’s weight is less than or equal to the weight capacity of the POV that is provided and greater than or equal to 95% of the weight capacity of the next lower weight class POV – i.e., a Heavy Duty POV is covered for a beneficiary weighing 285 – 450 pounds; a Very Heavy Duty POV is covered for a beneficiary weighing 428 – 600 pounds.

  3. Use of a POV will significantly improve the beneficiary’s ability to participate in MRADLs and the beneficiary will use it in the home.

  4. The beneficiary has not expressed an unwillingness to use a POV in the home.

If a POV will be used inside the home and coverage criteria A-I are not met, it will be denied as not reasonable and necessary. 

Group 2 POVs (K0806-K0808) have added capabilities that are not needed for use in the home. Therefore, if a Group 2 POV is provided it will be denied as not reasonable and necessary.

If a POV will only be used outside the home, see related Policy Article for information concerning noncoverage.

POWER WHEELCHAIRS (K0013K0813-K0891K0898):

A power wheelchair is covered if:

  1. All of the basic coverage criteria (A-C) are met; and
  2. The beneficiary does not meet coverage criterion D, E, or F for a POV; and
  3. Either criterion J or K is met; and
  4. Criteria L, M, N, and O are met; and
  5. Any coverage criteria pertaining to the specific wheelchair type (see below) are met.
  1. The beneficiary has the mental and physical capabilities to safely operate the power wheelchair that is provided; or

  2. If the beneficiary is unable to safely operate the power wheelchair, the beneficiary has a caregiver who is unable to adequately propel an optimally configured manual wheelchair, but is available, willing, and able to safely operate the power wheelchair that is provided; and

  3. The beneficiary’s weight is less than or equal to the weight capacity of the power wheelchair that is provided and greater than or equal to 95% of the weight capacity of the next lower weight class PWC – i.e., a Heavy Duty PWC is covered for a beneficiary weighing 285 – 450 pounds; a Very Heavy Duty PWC is covered for a beneficiary weighing 428 – 600 pounds; an Extra Heavy Duty PWC is covered for a beneficiary weighing 570 pounds or more.

  4. The beneficiary’s home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the power wheelchair that is provided.

  5. Use of a power wheelchair will significantly improve the beneficiary’s ability to participate in MRADLs and the beneficiary will use it in the home. For beneficiaries with severe cognitive and/or physical impairments, participation in MRADLs may require the assistance of a caregiver.

  6. The beneficiary has not expressed an unwillingness to use a power wheelchair in the home.

If a PWC will be used inside the home and if coverage criteria (a)-(e) are not met, it will be denied as not reasonable and necessary.

If a PWC will only be used outside the home, see related Policy Article for information concerning noncoverage. 

ADDITIONAL CRITERIA FOR SPECIFIC TYPES OF POWER WHEELCHAIRS:

  1. A Group 1 PWC (K0813-K0816) or a Group 2 PWC (K0820-K0829) is covered if all of the coverage criteria (a)-(e) for a PWC are met and the wheelchair is appropriate for the beneficiary’s weight.

  2. A Group 2 Single Power OptionPWC (K0835 – K0840) is covered if all of the coverage criteria (a)-(e)foraPWC are met and if:
    1. Criterion 1 or 2 is met; and
    2. Criteria 3 and 4 are met.
      1. The beneficiary requires a drive control interface other than a hand or chin-operated standard proportional joystick (examples include but are not limited to head control, sip and puff, switch control).
      2. The beneficiary meets coverage criteria for a power tilt or a power recline seating system (see Wheelchair Options and Accessories policy for coverage criteria) and the system is being used on the wheelchair.
      3. The beneficiary has had a specialty evaluation that was performed by a licensed/certified medical professional, 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 (see Documentation Requirements section). The PT, OT, or physician may have no financial relationship with the supplier.
      4. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the beneficiary.

    If a Group 2 Single Power Option PWC is provided and if criterion II(A) or II(B) is not met (including but not limited to situations in which it is only provided to accommodate a power seat elevation feature, a power standing feature, or power elevating legrests), it will be denied as not reasonable and necessary.

  3. A Group 2 Multiple Power OptionPWC (K0841-K0843) is covered if all of the coverage criteria (a)-(e)foraPWC are met and if:
    1. Criterion 1 or 2 is met; and
    2. Criteria 3 and 4 are met.
      1. The beneficiary meets coverage criteria for a power tilt and recline seating system (see Wheelchair Options and Accessories policy) and the system is being used on the wheelchair.
      2. The beneficiary uses a ventilator which is mounted on the wheelchair.
      3. The beneficiary has had a specialty evaluation that was performed by a licensed/certified medical professional, 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 (see Documentation Requirements section). The PT, OT, or physician may have no financial relationship with the supplier.
      4. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the beneficiary.

    If a Group 2 Multiple Power Option PWC is provided and if criterion III(A) or III(B) is not met, it will be denied as not reasonable and necessary.

  4. A Group 3PWC with no power options (K0848-K0855) is covered if:
    1. All of the coverage criteria (a)-(e) for a PWC are met; and
    2. The beneficiary's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity; and
    3. The beneficiary has had a specialty evaluation that was performed by a licensed/certified medical professional, 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 (see Documentation Requirements section). The PT, OT, or physician may have no financial relationship with the supplier; and
    4. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the beneficiary.

    If a Group 3 PWC is provided and if criteria (IV)(A) – (IV)(D) are not met, it will be denied as not reasonable and necessary.

  5. A Group 3PWC with Single Power Option (K0856-K0860) or with Multiple Power Options (K0861-K0864) is covered if:
    1. The Group 3 criteria IV(A) and IV(B) are met; and
    2. The Group 2 Single Power Option (criteria II[A] and II[B]) or Multiple Power Options (criteria III[A] and III[B]) (respectively) are met.

    If a Group 3 Single Power Option or Multiple Power Options PWC is provided and if criterion V(A) or (V)(B) is not met, it will be denied as not reasonable and necessary.

  6. Group 4 PWCs (K0868-K0886) have added capabilities that are not needed for use in the home. Therefore, if these wheelchairs are provided they will be denied as not reasonable and necessary.

  7. A Group 5 (Pediatric)PWC with Single Power Option (K0890) or with Multiple Power Options (K0891) is covered if:
    1. All the coverage criteria (a)-(e) for a PWC are met; and
    2. The beneficiary is expected to grow in height; and
    3. The Group 2 Single Power Option (criteria II[A] and II[B]) or Multiple Power Options (criteria III[A] and III[B]) (respectively) are met.

    If a Group 5 PWC is provided and if criteria (VII)(A) – (VII)(C) are not met, it will be denied as not reasonable and necessary.

  8. A push-rim activated power assist device (E0986) for a manual wheelchair is covered if all of the following criteria are met:
    1. All of the criteria for a power mobility device listed in the Basic Coverage Criteria section are met; and
    2. The beneficiary has been self-propelling in a manual wheelchair for at least one year; and
    3. The beneficiary has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the need for the device in the beneficiary’s home. The PT, OT, or physician may have no financial relationship with the supplier; and
    4. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the beneficiary.

    If all of the coverage criteria are not met, it will be denied as not reasonable and necessary.

A custom motorized/power wheelchair base (K0013) will be covered if:

If coverage criterion 1 for K0013 is not met, the claim will be denied as not reasonable and necessary.

If coverage criterion 2 for K0013 is not met, the claim will be denied for incorrect coding (see related Policy Article for additional information).

A custom motorized/power wheelchair base is not reasonable and necessary if the expected duration of need for the chair is less than three months (e.g., post-operative recovery).

If the PWC base is not covered, then related accessories will be denied.

Read the entire CMS coverage Policy

Coverage Criteria and Medical Necessity for a Mobility Device. (2016, February 23). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/coverage-criteria-and-medical-necessity-31616.html

© InnoviHealth Systems Inc

Article Tags  (click on a tag to see related articles)


Publish this Article on your Website, Blog or Newsletter

This article is available for publishing on websites, blogs, and newsletters. The article must be published in its entirety - all links must be active. If you would like to publish this article, please contact us and let us know where you will be publishing it. The easiest way to get the text of the article is to highlight and copy. Or use your browser's "View Source" option to capture the HTML formatted code.

If you would like a specific article written on a medical coding and billing topic, please Contact Us.


contact

innoviHealth Systems, Inc.
62 East 300 North
Spanish Fork, UT 84660
Phone: 801-770-4203 (9-5 Mountain)
Email:
free demo
request yours today
pricing
for any budget
sign IN
welcome back!

Thank you for choosing Find-A-Code, please Sign In to remove ads.