Or. Admin. Code § 410-122-0325

Current through Register Vol. 63, No. 11, November 1, 2024

Section 410-122-0325 - Power Wheelchair Base

(1) Indications and limitations of coverage and medical appropriateness:

(a) The Division may cover a power wheelchair (PWC) when conditions of coverage in OAR 410-122-0080(1) and all of the following criteria are met:

(A) The client has a mobility limitation that significantly impairs their ability to participate in one or more mobility-related activities of daily living (MRADLs) in or out of the home. MRADLs include but are not limited to tasks such as toileting, feeding, dressing, grooming, and bathing. A mobility limitation is one that:

(i) Prevents the client from accomplishing an MRADL entirely; or

(ii) Places the client at reasonably determined heightened risk of morbidity or mortality secondary to attempts to perform an MRADL; or

(iii) Prevents the client from completing an MRADL within a reasonable time frame.

(B) An appropriately fitted cane or walker cannot sufficiently resolve the client's mobility limitation;

(C) The client does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair to perform MRADLs during a typical day:

(i) Assessment of upper extremity function shall consider limitations of strength, endurance, range of motion or coordination, presence of pain, and deformity or absence of one or both upper extremities;

(ii) An optimallyconfigured manual wheelchair is one with an appropriate wheelbase, device weight, seating options, and other appropriate non-powered accessories.

(D) If the client shall be using the PWC in the home, the home provides adequate maneuvering space, maneuvering surfaces, and access between rooms for the operation of the PWC that is being requested;

(E) Use of a PWC shall significantly improve the client's ability to participate in MRADLs. For clients with severe cognitive and physical impairments, participation in MRADLs may require the assistance of a caregiver;

(F) The presence of a caregiver does not preclude coverage of a PWC if the client is willing and able to safely operate the PWC;

(G) The client is willing to use the requested PWC on a regular basis;

(H) There is objective evidence that demonstrates that the client cannot use a power-operated vehicle (POV);

(I) The client has sufficient mental and physical capabilities to safely operate the PWC;

(J) If the client is unable to safely operate the PWC and has a caregiver, the Division may cover the PWC if the caregiver is unable to adequately propel an optimally-configured manual wheelchair and is available, willing, and able to safely operate the PWC being requested. The caregiver's need to use a PWC to assist the client with their MRADLs shall be considered in determining coverage;

(K) The client's weight is less than or equal to the weight capacity of the PWC requested.

(b) Only when conditions of coverage as specified in section (1) (a) of this rule are met may the Division authorize a PWC for any of the following situations:

(A) When the PWC can be reasonably expected to improve the client's ability to complete MRADLs by compensating for other limitations in addition to mobility deficits, and the client is compliant with treatment:

(i) Besides MRADLs deficits, when other limitations exist, and these limitations can be ameliorated or compensated sufficiently such that the additional provision of a PWC will be reasonably expected to significantly improve the client's ability to perform or obtain assistance to participate in MRADLs, a PWC may be considered for coverage;

(ii) If the amelioration or compensation requires the client's compliance with treatment, for example medications or therapy, substantive non-compliance, whether willing or involuntary, can be grounds for denial of PWC coverage if it results in the client continuing to have a significant limitation. It may be determined that partial compliance results in adequate amelioration or compensation for the appropriate use of a PWC.

(B) When a client's current wheelchair is no longer medically appropriate, or repair and modifications to the wheelchair exceed replacement costs;

(C) When a covered client-owned wheelchair is in need of repair, the Division may pay for one month's rental of a wheelchair.

(c) For a PWC to be covered, the treating practitioner must conduct a face-to-face examination of the client within six (6) months prior to writing the order, and the durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) provider must receive a written report of this examination within 45 days after the face-to-face examination and prior to delivery of the device:

(A) When this examination is performed during a hospital or nursing facility stay, the DMEPOS provider must receive the report of the examination within 45 days after date of discharge;

(B) The practitioner may refer the client to a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), to provide the assessment for the wheelchair. This individual may not be an employee of the DMEPOS provider or have any direct or indirect financial relationship, agreement, or contract with the DMEPOS provider. When the DMEPOS provider is owned by a hospital, a PT/OT working in the inpatient or outpatient hospital setting may perform part of the face-to-face examination:

(i) If the client was referred to the PT/OT before being seen by the practitioner, then once the practitioner has received and reviewed the written report of this examination, the practitioner must see the client and perform any additional examination that is needed. The practitioner's report of the visit shall state concurrence or any disagreement with the PT/OT examination. In this situation, the practitioner must provide the DMEPOS provider with a copy of both examinations within 45 days of the face-to-face examination with the practitioner;

(ii) If the practitioner examined the client before referring the client to a PT/OT, then again in person after receiving the report of the PT/OT examination, the 45-day period begins on the date of that second practitioner visit. However, it is also acceptable for the practitioner to review the written report of the PT/OT examination, to sign and date that report, and to state concurrence or any disagreement with that examination. In this situation, the practitioner must send a copy of the note from his initial visit to evaluate the client plus the annotated, signed, and dated copy of the PT/OT examination to the DMEPOS provider. The 45-day period begins when the practitioner signs and dates the PT/OT examination;

(iii) If the PWC is a replacement of a similar item that was previously covered by the Division or when only PWC accessories are being ordered and all other coverage criteria in this rule are met, a face-to-face examination is not required.

(d) The Division does not reimburse for another chair if a client has a medically appropriate wheelchair, regardless of payer;

(e) If the client will be using the PWC in the home, the home must be able to accommodate and allow for the effective use of the requested PWC. The Division does not reimburse for adapting the living quarters;

(f) The equipment must be supplied by a DMEPOS provider that employs a Rehabilitation Engineering and Assistive Technology Society of North America (RESNA)-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the client;

(g) The ATP must be employed by the provider in a full-time, part-time, or contracted capacity as is acceptable by state law. The ATP, if part-time or contracted, must be under the direct control of the provider;

(h) Documentation must be complete and detailed enough so a third party would be able to understand the nature of the provider's ATP involvement, if any, in the licensed/certified medical professional (LCMP) specialty evaluation;

(i) The ATP may not conduct the provider evaluation at the time of delivery of the power mobility device to the client's residence;

(j) Reimbursement for wheelchair codes includes all labor charges involved in the assembly of the wheelchair and all covered additions or modifications. Reimbursement also includes support services such as emergency services, delivery, set-up, pick-up and delivery for repairs/modifications, education, and ongoing assistance with use of the wheelchair;

(k) The delivery of the PWC must be within 120 days following approval of the PA request by the Division;

(l) A PWC may not be ordered by a podiatrist;

(m) The following services are not considered medically necessary or medically appropriate:

(A) A PWC for functionally ambulatory clients;

(B) A PWC used to replace private or public transportation such as automobile, bus, or taxi;

(C) A PWC with a captain's chair for a client who needs a separate wheelchair seat and/or back cushion;

(D) Items or upgrades that primarily allow performance of leisure or recreational activities including but not limited to backup wheelchairs, backpacks, accessory bags, awnings, additional positioning equipment if wheelchair meets the same need, custom colors, wheelchair gloves, head lights, and tail lights;

(E) Power mobility devices, not coded by the Pricing, Data Analysis and Coding (PDAC) contractor or does not meet criteria;

(F) Power wheelchairs not otherwise classified (K0898).

(2) Coding Guidelines:

(a) Specific types of PWCs:

(A) A Group 1 PWC (K0813-K0816) or a Group 2 PWC (K0820-K0829) may be covered when all of the coverage criteria for a PWC are met and the wheelchair is appropriate for the client's weight and physical dimensions;

(B) A Group 2 Single Power Option PWC (K0835 - K0840) may be covered when the coverage criteria for a PWC are met; and:

(i) Criteria I or II is met and criteria III and IV are met; and

(I) The client 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); or

(II) The client meets the coverage criteria for a power tilt or recline seating system and the system is being used on the wheelchair; and

(III) The client has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, nurse practitioner, or practitioner who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical appropriateness for the wheelchair and its special features (see Documentation Requirements in section (3) of this rule). The PT, OT, nurse practitioner, or practitioner may have no financial relationship with the DMEPOS provider; and

(IV) 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 client;

(C) A Group 2 Multiple Power Option PWC (K0841, K0842, K0843) may be covered when the coverage criteria for a PWC are met, and:

(i) Criteria I or II is met and criteria III and IV are met;

(I) The client meets the coverage criteria for a power tilt or recline seating system and the system is being used on the wheelchair; or

(II) The client uses a ventilator that is mounted on the wheelchair; and

(III) The client has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT, OT, or practitioner who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical appropriateness for the wheelchair and its special features (see Documentation Requirements section). The PT, OT, or practitioner may have no financial relationship with the DMEPOS provider; and

(IV) 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 client;

(D) A Group 3 PWC with no power options (K0848-K0855) may be covered when:

(i) The coverage criteria for a PWC are met; and

(ii) The client's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal deformity; and

(iii) The client has had a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, or practitioner 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 practitioner may have no financial relationship with the DMEPOS provider;

(E) A Group 3 PWC with Single Power Option (K0856-K0860) or with Multiple Power Options (K0861-K0864) may be covered when:

(i) The Group 3 criteria in section (2)(a)(D) (i-ii) are met; and

(ii) The Group 2 Single Power Option in section (2)(a)(B) or Multiple Power Options section (2)(a)(C) (respectively) are met.

(F) Requests for Group 4 PWCs shall be reviewed on a case-by-case basis. Client specific clinical documentation must be submitted that supports the medical need for this level of PWC and demonstrates that there is no equally effective, less costly PWC that meets the client's medical needs.

(G) A push-rim activated power assist device (E0986) for a manual wheelchair may be covered if all of the following criteria are met:

(i) The client meets criteria for a power wheelchair but does not require a fully-powered wheelchair; and

(ii) The client has demonstrated ability to self-propelling in a manual wheelchair or a history of self-propelling for at least one year; and

(iii) The client has had a specialty evaluation that was performed by a licensed/certified medical professional, such as physical therapist (PT) or occupational therapist (OT), or practitioner who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical need for the device; and

(iv) 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 client;(v) E0986 is all-inclusive. All components, e.g., drive wheels, batteries, chargers, controls, mounting hardware, etc, for a manual wheelchair conversion are included in this code.

(b) PWC Basic Equipment Package: Each PWC code is required to include the following items on initial issue (i.e., no separate billing/payment at the time of initial issue, unless otherwise noted):

(A) Lap belt or safety belt;

(B) Battery charger, single mode;

(C) Complete set of tires and casters, any type;

(D) Legrests. There is no separate billingor payment if fixed, swingaway, or detachable non-elevating legrests withor without calf pad are provided. Elevating legrests may be billed separately;

(E) Footrests/foot platform. There is no separate billing or payment if fixed, swingaway or detachable footrests or a foot platform without angle adjustment are provided. There is no separate billing for angle adjustable footplates with Group 1 or 2 power wheelchairs. Angle adjustable footplates may be billed separately with Group 3, 4 or 5 power wheelchairs;

(F) K0040 may be billed separately with K0848 through K0864;

(G) Armrests. There is no separate billing or payment if fixed, swingaway, or detachable non-adjustable armrests with arm pad are provided. Adjustable height armrests may be billed separately;

(H) Upholstery for seat and back of proper strength and type for patient weight capacity of the power wheelchair;

(I) Weight specific components (braces, bars, upholstery, brackets, motors, gears) as required by patient weight capacity;

(J) Controller and Input Device. There is no separate billing or payment if a non-expandable controller and a standard proportional joystick (integrated or remote) is provided. An expandable controller, a non-standard joystick (i.e., non-proportional or mini, compact or short throw proportional), or other alternative control device may be billed separately.

(c) If a client needs a seat and/or back cushion but does not meet coverage criteria for a skin protection and/or positioning cushion, it may be appropriate to request a captain's chair seat rather than a sling/solid seat/back and a separate general use seat and/or back cushion;

(d) A PWC with a seat width or depth of 14" or less is considered a pediatric PWC base and is coded E1239, PWC, pediatric size, not otherwise specified (see OAR 410-122-0720 Pediatric Wheelchairs);

(e) Contact the Medicare Pricing, Data Analysis and Coding (PDAC) contractor regarding correct coding. See 410-122-0180 Healthcare Common Procedure Coding System (HCPCS) Level II Coding for more information.

(3) Documentation Requirements: Submit all of the following documentation with the prior authorization (PA) request:

(a) A copy of the written report of the face-to-face examination of the client by the practitioner:

(A) This report must include information related to the following:

(i) This client's mobility limitation and how it interferes with the performance of activities of daily living;

(ii) Why a cane or walker cannot sufficiently resolve the client's mobility limitation;

(iii) Why a manual wheelchair cannot sufficiently resolve the client's mobility limitation;

(iv) Why a POV/scooter cannot sufficiently resolve the client's mobility limitation;

(v) The client's physical and mental abilities to operate a PWC safely:

(I) Besides a mobility limitation, if other conditions exist that limit a client's ability to participate in activities of daily living (ADLs), how these conditions shall be ameliorated or compensated by use of the wheelchair;

(II) How these other conditions shall be ameliorated or compensated sufficiently such that the provision of a PWC shall be reasonably expected to significantly improve the client's ability to perform or obtain assistance to participate in MRADLs.

(B) The face-to-face examination shall provide pertinent information about the following elements. Only relevant elements need to be addressed:

(i) Symptoms;

(ii) Related diagnoses;

(iii) History:

(I) How long the condition has been present;

(II) Clinical progression;

(III) Interventions that have been tried and the results;

(IV) Past use of walker, manual wheelchair, POV, or PWC and the results.

(iv) Physical exam:

(I) Weight;

(II) Impairment of strength, range of motion, sensation, or coordination of arms and legs;

(III) Presence of abnormal tone or deformity of arms, legs, or trunk;

(IV) Neck, trunk, and pelvic posture and flexibility;

(V) Sitting and standing balance.

(v) Functional assessment indicating any problems with performing the following activities including the need to use a cane, walker, or the assistance of another person:

(I) Transferring between a bed, chair, and power mobility device;

(II) Walking around their home or community including information on distance walked, speed, and balance.

(C) The examination must clearly distinguish the client's abilities and needs within the home and community.

(b) The practitioner's written order received by the DMEPOS provider within 45 days (date stamp or equivalent must be used to document receipt date) after the practitioner's face-to-face examination. The order must include all of the following elements:

(A) Client's name;

(B) Description of the item that is ordered. This may be general (e.g., "power wheelchair" or "power mobility device") or may be more specific:

(i) If this order does not identify the specific type of PWC that is being requested, the DMEPOS provider must clarify this by obtaining another written order that lists the specific PWC that is being ordered and any options and accessories requested;

(ii) The items on this clarifying order may be entered by the DMEPOS provider. This subsequent order must be signed and dated by the treating practitioner, received by the DMEPOS provider, and submitted to the authorizing authority, but does not have to be received within 45 days following the face-to-face examination.

(C) Date of the face-to-face examination;

(D) Pertinent diagnoses/conditions and diagnosis codes that relate specifically to the need for the PWC;

(E) Length of need;

(F) Practitioner's signature;

(G) Date of practitioner's signature.

(c) For all requested equipment and accessories, the manufacturer's name, product name, model number, standard features, specifications, dimensions, and options;

(d) Detailed information about client-owned equipment (including serial numbers) as well as any other equipment being used or available to meet the client's medical needs, including how long it has been used by the client and why it cannot be grown (expanded) or modified, if applicable;

(e) If the client shall be using the PWC in the home, the DMEPOS provider or practitioner must perform an on-site, written evaluation of the client's living quarters, prior to delivery of the PWC. This assessment must support that the client's home can accommodate and allow for the effective use of a PWC. Assessment must include but is not limited to evaluation of physical layout, doorway widths, doorway thresholds, surfaces, counter or table height, accessibility (e.g., ramps), electrical service, etc.;

(f) A written document (termed a detailed product description) prepared by the DMEPOS provider and signed and dated by the practitioner that includes:

(i) The specific base (HCPCS code and manufacturer name/model) and all options and accessories (including HCPCS codes), whether PA is required or not, that shall be billed separately;

(ii) The DMEPOS provider's charge and the Division fee schedule allowance for each separately billed item;

(iii) If there is no Division fee schedule allowance, the DMEPOS provider must enter "not applicable";

(iv) The DMEPOS provider must receive the signed and dated detailed product description from the practitioner prior to delivery of the PWC;

(v) A date stamp or equivalent must be used to document receipt date of the detailed product description.

(g) Any additional documentation that supports indications of coverage are met as specified in this rule;

(h) The DMEPOS provider must keep the above documentation on file;

(i) Documentation that the coverage criteria have been met must be present in the client's medical records and made available to the Division upon request.

(4) Prior Authorization:

(a) All codes in this rule require PA and may be purchased, rented, and repaired;

(b) Codes specified in this rule are not covered for clients residing in nursing facilities;

(c) Reimbursement on standard Group 1 and Group 2 wheelchairs without power option (K0813-K0816, K0820-K0829) shall only be made on a monthly rental basis;

(d) Rented equipment is considered purchased when the Division fee schedule allowable for purchase is met or the actual charge from the provider is met, whichever is the lowest.

(5) Table 122-0325.

Or. Admin. Code § 410-122-0325

OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP 47-2002, f. & cert. ef. 10-1-02; OMAP 44-2004, f. & cert. ef. 7-1-04; OMAP 44-2005, f. 9-9-05, cert. ef. 10-1-05; OMAP 25-2006, f. 6-14-06, cert. ef. 7-1-06; OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07; DMAP 15-2007, f. 12-5-07, cert. ef. 1-1-08; DMAP 17-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 15-2009 f. 6-12-09, cert. ef. 7-1-09; DMAP 13-2010, f. 6-10-10, cert. ef. 7-1-10; DMAP 31-2012(Temp), f. 6-29-12, cert. ef. 7-1-12 thru 12-27-12; DMAP 57-2012, f. & cert. ef 12-27-12; DMAP 36-2017(Temp), f. 9-14-17, cert. ef. 9-15-17 thru 3-13-18; DMAP 12-2018, amend filed 03/07/2018, effective 3/8/2018; DMAP 101-2023, amend filed 12/29/2023, effective 1/1/2024; DMAP 9-2024, minor correction filed 01/04/2024, effective 1/4/2024

To view attachments referenced in rule text, click here to view rule.

Statutory/Other Authority: ORS 413.042 & 414.065

Statutes/Other Implemented: ORS 414.065