Manual Wheelchairs

REMINDER:

• Each lower level item must be ruled out.
• Medicare pays for the least costly alternative - Notes must indicate why a cane or a walker won't meet the client's needs.
• Medicare will not cover a wheelchair if the need is only for outside the home.

Medicare Qualifications

• STANDARD WHEELCHAIRS (K0001)– MEDICAL RECORDS DOCUMENT ALL OF THE FOLLOWING ARE MET:
  • The patient has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADL) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home; AND
  • The patient’s mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker; AND
  • The patient’s home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided; AND
  • Use of a manual wheelchair will significantly improve the beneficiary’s ability to participate in their MRADLs and will get used in the home on a regular basis; AND
  • The patient has not expressed an unwillingness to use the wheelchair in the home; AND
  • The patient has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair that is provided in the home during a typical day.  (Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function.) OR The patient has a caregiver who is available, willing, and able to provide assistance with the wheelchair. 
• HEMI WHEELCHAIRS (K0002) meets criteria for a standard wheelchair AND
  • The patient needs a lower seat to floor height for transfers; OR
  • The patient needs to place his/her feet on the ground to assist with propelling
• LIGHTWEIGHT WHEELCHAIR (K0003) meets criteria for a standard wheelchair AND
  • The patient cannot self-propel in a standard wheelchair in the home; AND
  • The patient can and does self-propel in a lightweight wheelchair.
• HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR (K0004) meets criteria for a standard wheelchair AND
  • The patient self-propels the wheelchair while engaging in frequent activities in the home that cannot be performed in a standard or lightweight chair; OR
  • The patient requires a seat width, depth, or height that cannot be accomplished in a standard, lightweight, or hemi-wheelchair, and spends at least two hours per day in a wheelchair.
• HEAVY DUTY WHEELCHAIR (K0006) meets criteria for a standard wheelchair AND
  • The beneficiary's weight is greater than 250 pounds; OR
  • The beneficiary has severe spasticity.
• EXTRA HEAVY DUTY WHEELCHAIR (K0007) meets criteria for a standard wheelchair AND
  • The beneficiary's weight is greater than 300 pounds.

Documentation Required for Medicare

1. Prescription – Must be signed and dated by treating physician.
2. Detailed Written Order – Signed and dated by the treating physician (prior to delivery).
3. Chart Notes – Including information stating why a standard wheelchair is medically necessary (must comply with Qualifications listed above).
4. Face to Face Evaluation – Completed Face to Face evaluation from physician.

If you are in need of more detailed information please click the link below to access the LCD.

 Manual Wheelchair LCD 

Ultra Lightweight – K0005

As of March 1, 2013 it is required that ATP and PT/OT evaluation as well as face-to-face exam by physician and must have past history of use of same type base and activity both inside and outside the home.

Medicare Qualifications

ULTRA LIGHTWEIGHT WHEELCHAIR (K0005) meets criteria for a standard wheelchair AND

• The beneficiary must be a full-time manual wheelchair user; OR
• The beneficiary 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.

AND both of the following:

• The beneficiary must have a specialty evaluation that was performed by a licensed/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 (see Documentation Requiremetns section).  The LCMP may have no financial relationship with the supplier; AND
• The wheelchair is provided by a Rehabilitation Technology Supplier (RTS) 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 patient.

Documentation Required for Medicare

1. Prescription – Must be signed and dated by treating physician.
2. Detailed Written Order – Signed and dated by the treating physician (prior to delivery).
3. Chart Notes – Including information stating why an ultra lightweight is medically necessary (must comply with Qualifications listed above).
4. Face to Face Evaluation – Completed Face to Face evaluation from physician.
5. ATP and PT/OT Evaluation

If you are in need of more detailed information please click the link below to access the LCD.

Ultra Lightweight Manual Wheelchair LCD