Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.09-037 - Prosthetics Update #133
Current through Register Vol. 49, No. 9, September, 2024
242.191 Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult
Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age or modifier NU for beneficiaries age 21 and older. When a second modifier is listed, that modifier must be used in conjunction with either EP orNU.
Modifiers in this section are indicated by the headings Ml and M2. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a "Y" in the column; if not, an "N" is shown.
Other coding information found in the chart:
The purchase of this component for beneficiaries age 21 and older is limited to one per five-year period.
The purchase of this wheelchair component for beneficiaries under age 21 is limited to one per two-year period.
* The purchase of wheelchairs for beneficiaries age 21 and older is limited to one per five-year period.
** Bill only for beneficiaries under age 21.
' This procedure code is payable for beneficiaries ages 2 through 20. Prior authorization is required through Utilization Review.
**** Items listed require prior authorization (PA) when used in combination with other items listed and the total combined value exceeds the $1,000.00 Medicaid maximum allowable reimbursement limit.
* Prior authorization is not required when other insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount.
Note: W/C orw/c indicates wheelchair.
«%(...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description.
Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult (section 242.191)
|
Procedure Code |
Ml |
M2 |
Description |
PA |
Payment Method |
|
E0700 |
NU EP |
U1 U1 |
Safety equipment, e.g., belt, harness or vest |
K 1 **** |
Purchase |
|
E0700 |
NU EP |
U2 U2 |
***(Travel restraint auto safe harness, E-Z on vest, no known comparable product) Safety equipment, e.g., belt, harness or vest |
K 1 **** |
Purchase |
|
E0950 |
NU EP |
***(Tray for W/C) W/C accessory, tray, each |
Y |
Purchase |
|
E0950 |
NU EP |
U2 U2 |
A(ABS tray, 4-SM 5-LG) W/C accessory, tray, each |
Y |
Purchase |
|
E0950 |
NU EP |
U3 U3 |
A(W/C Tray, Custom) W/C accessory, tray, each |
Y |
Purchase |
|
E0950 |
NU EP |
U4 U4 |
A(Tray, customized) W/C accessory, tray, each |
N |
Purchase |
|
E0950 |
NU EP |
U5 U5 |
A(Clear upper Ex support system) W/C accessory, tray, each |
Y |
Purchase |
|
E0950 |
NU EP |
U6 U6 |
A(Lap Tray Switch Array) Wheelchair accessory, tray, each |
Y |
Purchase |
|
E0950 |
NU EP |
U7 U7 |
Wheelchair accessory, tray, each |
Y |
Purchase |
|
E0950 |
NU EP UE |
U7 U7 |
A(Removable Hinged Overlay for Tray) W/C accessory, tray, each |
Y**** |
Purchase |
|
E0950 |
NU EP |
U8 U8 |
A(Lap Tray for Switch Array) Wheelchair accessory, tray, each |
Y |
Purchase |
|
E0951 |
NU EP |
Heel loop/holder, with or without ankle strap, each |
N**** |
Purchase |
|
|
E0952 |
NU EP |
Toe loop/holder, each |
N**** |
Purchase |
|
|
E0955 |
NU EP |
Wheelchair accessory, headrest, cushioned, any type, including fixed mounting hardware, each |
N |
Purchase |
|
|
E0956 |
NU EP |
A(Trunk supports for any W/C, other than travel, with hardware) Wheelchair accessory, lateral trunk or hip support, any type, including fixed mounting hardware, each |
N**** |
Purchase |
|
|
E0956 |
NU EP |
U1 U1 |
A(Lateral trunk supports, swing away, each) Wheelchair accessory, lateral trunk or hip support, any type, including fixed mounting hardware, each |
N**** |
Purchase |
|
E0956 |
NU EP |
U2 U2 |
A(Med. Chest Panel Support) Wheelchair accessory, lateral trunk or hip support, any type, including fixed mounting hardware, each |
N**** |
Purchase |
|
E0956 |
NU EP |
U3 U3 |
A(Chest/Thoracic Supports) Wheelchair accessory, lateral trunk or hip support, any type, including fixed mounting hardware, each |
N**** |
Purchase |
|
E0957 |
NU EP |
Wheelchair accessory, medial thigh support, (*Vflip-up) any type, including fixed mounting hardware, each |
N |
Purchase |
|
|
E0958 |
NU EP |
Manual W/C accessory, one-arm drive attachment, each |
N**** |
Purchase |
|
|
E0959 |
NU EP |
A(Amputee adapters for conventional chair, ea.) Manual W/C accessory, adapter for amputee, each |
N**** |
Purchase |
|
|
E0959 |
NU EP |
A(Amputee axle plate for high performance manual W/C, ea.) Manual wheelchair accessory, adapter for amputee, each |
N**** |
Purchase |
|
|
E0959 |
NU EP |
U1 U1 |
Manual W/C accessory, adapter for amputee, each |
N |
Purchase |
|
E0960 |
NU EP |
W/C accessory, shoulder harness/straps or chest strap including any type mounting hardware |
N |
Purchase |
|
|
E0961 |
NU EP |
Manual W/C accessory, wheel lock brake extension (handle), each |
N**** |
Purchase |
|
|
E0966 |
NU EP |
Manual wheelchair accessory, headrest extension, each |
N**** |
Purchase |
|
|
E0967 |
NU EP |
A(Hand rim, any type) Manual W/C accessory, hand rim w/projections, any type, replacement only, each |
N**** |
Purchase |
|
|
E0967 |
NU EP |
U1 U1 |
A(Hand rim, any type) Manual W/C accessory, hand rim w/projections, any type, replacement only, each |
N**** |
Purchase |
|
E0967 |
NU EP |
U2 U2 |
A(Hand rim, any type) Manual W/C accessory, hand rim w/projections, any type, replacement only, each |
N**** |
Purchase |
|
E0967 |
NU EP |
U3 U3 |
A(Hand rim, any type) Manual W/C accessory, hand rim w/projections, any type, replacement only, each |
N**** |
Purchase |
|
E0967 |
NU EP |
U4 U4 |
A(Hand rim, any type) Manual W/C accessory, hand rim w/projections, any type, replacement only, each |
N**** |
Purchase |
|
E0970 |
NU EP |
No. 2 footplates, except for elevating legrest` |
N**** |
Purchase |
|
|
E0971 |
NU EP |
Anti-tipping device W/C |
N**** |
Purchase |
|
|
E0973 |
NU EP |
W/C accessory, adjustable height, detachable armrest, complete assembly, each |
N**** |
Purchase |
|
|
E0973 |
NU EP |
U1 U1 |
A(Height Adj. Arms, replacement) W/C accessory, adjustable height, detachable armrest, complete assembly, each |
N**** |
Purchase |
|
E0974 |
NU EP |
Manual wheelchair accessory, anti-rollback device (Agrade aids), each |
N**** |
Purchase |
|
|
E0978 |
NU EP |
Wheelchair accessory, positioning belt/safety belt/pelvic strap, each |
N**** |
Purchase |
|
|
E0978 |
NU EP |
U1 U1 |
A(Belt, safety or chest, w/pad) Wheelchair accessory, positioning belt/safety belt/ pelvic strap, each |
N**** N |
Purchase |
|
E0978 |
NU EP |
U2 U2 |
Wheelchair accessory, positioning belt/safety belt/pelvic strap, each |
N**** |
Purchase |
|
E0980 |
NU EP |
A(Chest panel, 21-SM 22-LG) Safety vest, wheelchair |
N**** |
Purchase |
|
|
E0980 |
NU EP |
U1 U1 |
A(Shoulder retractors) Safety vest, W/C |
N**** |
Purchase |
|
E0981 |
NU EP |
W/C accessory, seat upholstery, replacement only, each |
N |
Purchase |
|
|
E0982 |
NU EP |
W/C accessory, back upholstery, replacement only, each |
N**** |
Purchase |
|
|
E0982 |
NU EP |
U1 U1 |
A(Standard back upholstery replacement) W/C accessory, back upholstery, replacement only, each |
N**** |
Purchase |
|
E0990 |
NU EP |
A(Elevating foot, leg rest) W/C accessory, elevating leg rest, complete assembly, each |
N**** |
Purchase |
|
|
E0990 |
NU EP |
U1 U1 |
A(Elevating Leg Rest 90 Degree, 12" -16" Wdth) W/C accessory, elevating leg rest, complete assembly, each |
N**** |
Purchase |
|
E0992 |
NU EP |
A(Manual wheelchair accessory, solid seat) |
N**** |
Purchase |
|
E0992 |
NU EP |
U1 U1 |
AManual w/c accessory, solid seat insert (Large adjustable solid seat w/hardware) |
N**** |
Purchase |
|
E0992 |
NU EP |
U2 U2 |
A(Foam and Plywood Flat Side Manual wheelchair accessory, solid seat) |
N**** |
Purchase |
|
E0992 |
NU EP |
U3 U3 |
A(Foam & Plywood Seat, MPI Like Manual wheelchair accessory, solid seat) |
N**** |
Purchase |
|
E0992 |
NU EP |
U4 U4 |
A(Adjustable solid standard seat with hardware Manual wheelchair accessory, solid seat) |
N**** |
Purchase |
|
E0994 |
NU EP |
Armrest, each |
N**** |
Purchase |
|
|
E1002 |
NU EP |
W/C accessory power seating system, tilt only |
Y* |
Purchase |
|
|
E1004 |
NU EP |
W/C accessory, power seating system, recline only, with mechanical shear reduction |
Y* |
Purchase |
|
|
E1006 |
NU EP |
W/C accessory, power seating system, combination tilt and recline, w/o shear reduction |
Y |
Purchase |
|
|
E1007 |
NU EP |
Wheelchair accessory, power seating system, combination tilt and recline, with mechanical shear reduction |
Y |
Purchase |
|
|
E1010 |
NU EP |
W/C accessory, addition to power seating system, power leg elevation system, including leg rest, each |
Y |
Purchase |
|
|
E1020 |
NU EP |
A(Adjustable Contour Lateral Thigh Support) Residual limb support system for W/C |
N**** |
Purchase |
|
|
E1029 |
NU EP |
A(Ventilator Tray With Battery Tray) Wheelchair accessory, ventilator tray, fixed |
Y |
Purchase |
|
|
E1030 |
NU EP |
Wheelchair accessory, ventilator tray, gimbaled |
Y |
Purchase |
|
|
E1050* |
NU EP |
Full reclining W/C, fixed full-length arms, swing-away, detachable elevating legrests |
N**** |
Purchase |
|
|
E1060* |
NU EP |
Full reclining W/C, detachable arms, desk or full-length, swing-away detachable, elevating legrests |
Y* |
Purchase |
|
E1070# |
EP |
A(A maximum use of three months only) Fully-reclining wheelchair, detachable arms, (desk or full-length) swing-away, detachable footrest/elevated legrest |
Y |
Rental only |
|
|
E1084* |
NU EP |
Hemi-W/C; detachable arms, desk or full-length, swing-away, detachable, elevating leg rests |
N**** |
Purchase |
|
|
E1086* |
NU EP |
Hemi W/C; detachable arms, desk or full-length, swing-away, detachable footrests |
N**** |
Purchase |
|
|
E1086* |
NU EP |
U1 U1 |
Hemi W/C, detachable arms, desk or full-length, swing-away detachable footrests |
Y |
Purchase |
|
E1088* |
NU EP |
High strength lightweight W/C; detachable arms, desk or full-length, swing-away, detachable, elevating legrests |
Y* |
Purchase |
|
|
E1090 |
NU EP |
High-strength lightweight W/C; detachable arms, desk or full-length, swing-away, detachable footrests |
N**** |
Purchase |
|
|
E1092* |
NU EP |
Wide, heavy-duty W/C; detachable arms, desk or full-length, swing-away, detachable, elevating legrests |
Y* |
Purchase |
|
|
E1093* |
NU EP |
Wide, heavy-duty W/C; detachable arms, desk or full-length arms, swing-away, detachable footrests |
Y* |
Purchase |
|
|
E1110* |
NU EP |
Semi-reclining W/C; detachable arms, desk or full-length, elevating legrest |
Y* |
Purchase |
|
|
E1161 |
NU EP |
Manual adult size W/C, includes tilt in space |
Y* |
Purchase |
|
|
E1170* |
NU EP |
Amputee W/C; fixed full-length arms, swing-away, detachable, elevating legrests |
N**** |
Purchase |
|
|
E1172* |
NU EP |
Amputee W/C; detachable arms, desk or full-length, without footrests or legrests |
Y* |
Purchase |
|
|
E1180* |
NU EP |
Amputee W/C; detachable arms, desk or full-length, swing-away, detachable footrests |
Y* |
Purchase |
|
|
E1200* |
NU EP |
Amputee W/C; fixed full-length arms, swing-away, detachable footrests |
N**** |
Purchase |
|
E1220* |
NU EP |
W/C, specially sized or constructed (indicate brand name, model number, if any, and justification) |
Y |
Manually Priced |
|
|
E1225 |
NU EP |
***(Folding Backrest, 8 Degree Bend, Low, 15" - 16") Manual W/C accessory, semi-reclining back, (recline greater than 15 degrees, but less than 80 degrees), each |
N**** |
Purchase |
|
|
E1228 |
NU EP |
***(Folding Backrest, Tall, 19" - 20") Special back height for W/C |
N**** |
Purchase |
|
|
E1228 |
NU EP |
***(Folding Straight Backrest, Low, (15" -16") Special back height for W/C |
N**** |
Purchase |
|
|
E1228 |
NU EP |
***(Folding Straight Backrest, Tall, 19" -20") Special back height for W/C |
N**** |
Purchase |
|
|
E1228 |
NU EP |
U1 U1 |
***(High back contour seat) Special back height for W/C |
N**** |
Purchase |
|
E1228 |
NU EP |
U2 U2 |
***(Positioning tall back) Special back height for W/C |
N**** |
Purchase |
|
E1230* |
NU EP |
Power operated vehicle (three- or four-wheel nonhighway), specify brand name and model number |
Y* |
Purchase |
|
|
E1230 |
EP NU |
U1 U1 |
Power operated vehicle (three- or four-wheel nonhighway), specify brand name and model number |
Y* |
Purchase |
|
E1232* |
EP |
W/C, pediatric size, tilt-in-space, folding, adjustable, with seating system |
Y* |
Purchase |
|
|
E1233* |
EP |
W/C, pediatric size, tilt-in-space, rigid, adjustable, without seating system |
Y* |
Purchase |
|
|
E1234* |
EP |
W/C, pediatric size, tilt-in-space, folding, adjustable, without seating system |
Y* |
Purchase |
|
|
E1235* |
NU EP |
Wheelchair, pediatric size, rigid, adjustable, with seating system |
Y* |
Purchase |
|
|
E12352 |
EP |
U1 |
A(Rigid W/C Frame) W/C, pediatric size, rigid, adjustable with seating system |
Y |
Purchase |
|
E1236 |
EP |
Wheelchair, pediatric size, folding, adjustable, with seating system |
Y |
Purchase |
|
|
E1237* |
EP |
W/C, pediatric size, rigid, adjustable, without seating system |
Y* |
Purchase |
|
E1238* |
EP |
W/C, pediatric size, folding, adjustable, without seating system |
Y* |
Purchase |
|
|
E1240* |
NU EP |
Lightweight W/C; detachable arms, desk or full-length, swing-away, detachable, elevating legrest |
Y* |
Purchase |
|
|
E1260* |
NU EP |
Lightweight W/C; detachable arms, desk or full-length, swing-away, detachable footrests |
N**** |
Purchase |
|
|
E1280* |
NU EP |
Heavy-duty W/C; detachable arms, desk or full-length, elevating legrests |
Y* |
Purchase |
|
|
E1290* |
NU EP |
Heavy-duty W/C; detachable arms, swing-away, detachable footrests |
Y* |
Purchase |
|
|
E1340 |
NU EP |
U1 U1 |
A(Labor Only; a maximum of twenty [20] units [20 units = 5 hours of labor] per date of service is allowable.) Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes |
Y |
Purchase |
|
E1340 |
NU EP |
U3 U3 |
A(Unlisted Repairs/Parts Only Wheelchairs; applicable pages from the manufacturer's catalog must be attached to the claim form.)Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes |
N**** |
Manually Priced |
|
E2201 |
NU EP |
A(Seat Width 20") Manual w/c accessory, nonstandard seat frame width [GREATER THAN] than or equal to 20 inches and [LESS THAN] 24 inches |
N**** |
Purchase |
|
|
E2201 |
NU EP |
U1 U1 |
A(Frame Wdth 14"-15") Manual w/c accessory, nonstandard seat frame width[GREATER THAN]than or equal to 20 inches and [LESS THAN]24 inches |
N**** |
Purchase |
|
E2201 |
NU EP |
U2 U2 |
A(Frame Wdth 19"-20") Manual w/c accessory, nonstandard seat frame width[GREATER THAN]than or equal to 20 inches and [LESS THAN]24 inches |
N**** |
Purchase |
|
E2201 |
NU EP |
U3 U3 |
Manual w/c accessory, nonstandard seat frame width [GREATER THAN] than or equal to 20 inches and [LESS THAN]24 inches |
N**** |
Manually Priced |
|
E2203 |
NU EP |
A(Seat Depth 15") Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches |
N**** |
Purchase |
|
|
E2203 |
NU EP |
U1 U1 |
A(Seat Depth 17" - 18") Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches |
N**** |
Purchase |
|
E2203 |
NU EP |
U2 U2 |
A(Frame, Long; 16", 17"3, 18", 19"3, 20" Depth) Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches |
N**** |
Purchase |
|
E2203 |
NU EP |
U3 U3 |
A(Seat Depth 19" - 20") Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches |
N**** |
Purchase |
|
E2203 |
NU EP |
U4 U4 |
Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches |
N |
Manually Priced |
|
E2206 |
NU EP |
Manual wheelchair accessory, wheel lock assembly, complete, each |
N |
Purchase |
|
|
E2207 |
NU EP |
Wheelchair accessory, crutch and cane holder, each |
N**** |
Purchase |
|
|
E2208 |
NU EP |
Wheelchair accessory, cylinder tank carrier, each |
N |
Purchase |
|
|
E2209 |
NU EP |
Wheelchair accessory, arm trough, each |
N |
Purchase |
|
|
E2210 |
NU EP |
Wheelchair accessory, bearings, any type, replacement only, each |
N |
Purchase |
|
|
E2211 |
NU EP |
Manual wheelchair accessory, pneumatic propulsion tire, any size, each |
N |
Purchase |
|
|
E2212 |
NU EP |
Manual wheelchair accessory, tube for pneumatic propulsion tire, any size, each |
N |
Purchase |
|
|
E2213 |
NU EP |
Manual wheelchair accessory, insert for pneumatic propulsion tire (removable), any type, any size, each |
N |
Purchase |
|
|
E2214 |
NU EP |
Manual wheelchair accessory, pneumatic caster tire, any size, each |
N |
Purchase |
|
E2215 |
NU EP |
Manual wheelchair accessory, tube for pneumatic caster tire, any size, each |
N |
Purchase |
|
E2220 |
NU EP |
Manual wheelchair accessory, solid (rubber/plastic) propulsion tire, any size, each |
N |
Purchase |
|
E2221 |
NU EP |
Manual wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, each |
N |
Purchase |
|
E2226 |
NU EP |
Manual wheelchair accessory, caster fork, any size, replacement only, each |
N |
Purchase |
|
E2291 |
EP |
Back, planar, for pediatric-size wheelchair, including fixed attaching hardware |
N |
Manually Priced |
|
E2292 |
EP |
Seat, planar, for pediatric-size wheelchair, including fixed attaching hardware |
N |
Manually Priced |
|
E2293 |
EP |
Back, contoured, for pediatric-size wheelchair, including fixed attaching hardware |
N |
Manually Priced |
|
E2294 |
EP |
Seat, contoured, for pediatric-size wheelchair, including fixed attaching hardware |
N |
Manually Priced |
|
E2310 |
NU EP |
Power w/c 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 |
Y |
Purchase |
|
E2311 |
NU EP |
Power w/c 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 |
Y |
Purchase |
|
E2322 |
NU EP |
Power w/c accessory, hand control interface, multiple mechanical switches, nonproportional, including all related electronics, mechanical stop switch, and fixed mounting hardware |
Y |
Purchase |
|
E2323 |
NU EP |
Power w/c accessory, specialty joystick handle for hand control interface, prefabricated |
Y |
Purchase |
|
|
E2324 |
NU EP |
Power w/c accessory, chin cup for chin control interface |
Y |
Purchase |
|
|
E2325 |
NU EP |
Power w/c accessory, sip & puff interface nonproportional, including all related electronics, mechanical stop switch, and manual swingaway mounting hardware |
Y |
Purchase |
|
|
E2326 |
NU EP |
Power wheelchair accessory, breath tube kit for sip and puff interface A (replacement only) |
Y |
Purchase |
|
|
E2327 |
NU EP |
Power w/c accessory, head control interface, mechanical, proportional, including all related electronics, mechanical direction change switch, and fixed mounting hardware |
Y |
Purchase |
|
|
E2360 |
NU EP |
Power w/c accessory, 22 NF non-sealed lead acid battery, each |
N |
Purchase |
|
|
E2361 |
NU EP |
Power w/c accessory, 22 NF sealed lead acid battery, each, (e.g., gel cell, absorbed glassmat) |
N |
Purchase |
|
|
E2363 |
NU EP |
Power w/c accessory, group 24 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat) |
N |
Purchase |
|
|
E2363 |
NU EP |
U1 U1 |
Power w/c accessory, group 24 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat) |
N |
Purchase |
|
E2365 |
NU EP |
A(U-1 gel cell battery, each) Power wheelchair accessory, U-1 sealed lead acid battery, each, (e.g., gel cell, absorbed glassmat) |
N |
Purchase |
|
|
E2365 |
NU EP |
U1 U1 |
Power w/c accessory, U-1 sealed lead acid battery, each, gel cell |
N |
Purchase |
|
E2366 |
NU EP |
A(24-Volt Battery Charger - Standard, Replacement) Power w/c accessory, battery charger, single mode, for use with only one battery type, sealed or non-sealed, each |
N |
Purchase |
|
E2367 |
NU EP |
A(24-Volt Battery Charger - Dual Mode, Replacement) Power w/c accessory, battery charger, dual mode, sealed or non-sealed, each |
N |
Purchase |
|
E2368 |
NU EP |
Power wheelchair component, motor, replacement only |
N |
Purchase |
|
E2369 |
NU EP |
Power wheelchair component, gear box, replacement only |
N |
Purchase |
|
E2370 |
NU EP |
Power wheelchair component, motor and gear box combination, replacement only |
Y |
Purchase |
|
E2372 |
NU EP |
Power wheelchair accessory, group 27 non-sealed lead acid battery, each |
Y |
Purchase |
|
E2373 |
NU EP |
Power wheelchair accessory, hand or chin control interface, mini-proportional, compact, or short throw remote joystick or touchpad, proportional, including all related electronics and fixing mounting hardware. |
Y |
Purchase |
|
E2375 |
NU EP |
Power wheelchair accessory, nonexpandable controller, including all related electronics and mounting hardware, replacement only |
Y |
Purchase |
|
E2376 |
NU EP |
Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, replacement only |
Y |
Purchase |
|
E2377 |
NU EP |
Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue |
Y |
Purchase |
|
E2381 |
NU EP |
Power wheelchair accessory, pneumatic drive wheel tire, any size, replacement only, each |
Y |
Purchase |
|
E2382 |
NU EP |
Power wheelchair accessory, tube for pneumatic drive wheel tire, any size, replacement only, each |
Y |
Purchase |
|
E2383 |
NU EP |
Power wheelchair accessory, insert for pneumatic drive wheel tire (removable), any type, any size, replacement only, each |
Y |
Purchase |
|
E2384 |
NU EP |
Power wheelchair accessory, pneumatic caster tire, any size, replacement only, each |
Y |
Purchase |
|
|
E2385 |
NU EP |
Power wheelchair accessory, tube for pneumatic caster tire, any size, replacement only, each |
Y |
Purchase |
|
|
E2386 |
NU EP |
Power wheelchair accessory, foam filled drive wheel tire, any size, replacement only, each |
Y |
Purchase |
|
|
E2387 |
NU EP |
Power wheelchair accessory, foam caster tire, any size, replacement only, each |
Y |
Purchase |
|
|
E2601 |
NU EP UE |
General use wheelchair seat cushion, width less than 22 in., any depth |
N |
Purchase |
|
|
E2602 |
NU EP UE |
General use wheelchair seat cushion, width 22 in. or greater, any depth |
N |
Purchase |
|
|
E2611 |
NU EP UE |
General use wheelchair back cushion, width less than 22 in., any height, including any type mounting hardware |
N |
Purchase |
|
|
E2612 |
NU EP UE |
General use wheelchair back cushion, width 22 in. or greater, any height, including any type mounting hardware |
N |
Purchase |
|
|
E2619 |
NU EP |
Replacement cover for wheelchair seat cushion or back cushion, each |
N |
Purchase |
|
|
K0004 |
NU EP |
High-strength lightweight wheelchair |
Y**** |
Purchase |
|
|
K0005* |
NU EP |
A(High-performance manual W/C-adult) Ultralightweight W/C |
Y* |
Purchase |
|
|
K0005* |
NU EP |
U1 U1 |
A(High-performance manual W/C with growth adjustability-child) Ultralightweight W/C |
Y* |
Purchase |
|
K0010 |
NU EP |
A(Motorized, standard frame, DA, swing away footrests) Standard weight frame motorized/power W/C |
Y* |
Purchase |
|
|
K0010 |
NU EP |
U1 U1 |
A(Motorized, standard frame, DA, swing away ELR) Standard weight frame motorized/power W/C |
Y* |
Purchase |
|
K0011 |
NU EP |
A(Motorized, power base or convention frame w/c DA/swing away footrests, programmable electronics and custom options) Standard-weight frame motorized/power, W/C with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking |
al Y* |
Purchase |
|
|
K0011 |
NU EP |
U1 U1 |
A(Motorized, power base or convention frame w/c DA/swing away footrests, programmable electronics and custom options) Standard-weight frame motorized/power, W/C with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking |
al Y* |
Purchase |
|
K0012 |
NU EP |
A(Motorized folding frame, DA, swing away footrests) Lightweight portable motorized/power W/C |
Y* |
Purchase |
|
|
K0012 |
NU EP |
U1 U1 |
A(Motorized folding frame, DA, swing away ELR) Lightweight portable motorized/power W/C |
Y* |
Purchase |
|
K00141,2 |
NU EP |
Other motorized/ power W/C base |
Y* |
Purchase |
|
|
K00141,2 |
NU EP |
U1 U1 |
A(Center Drive power base) Other motorized/ power W/C base |
Y* |
Purchase |
|
K00141,2 |
NU EP |
U3 U3 |
A(Motorized, Power Base or conventional frame W/C DA/swing away foot rests, programmable electronics and custom options) Other motorized/ power W/C base |
Y* |
Purchase |
|
K00141,2 |
NU EP |
U4 U4 |
A(Motorized, Power Base or conventional frame W/C DA/swing away elevated foot rests, programmable electronics and custom options) Other motorized/ power W/C base |
Y* |
Purchase |
|
K0017 |
NU EP |
***(Receiver for height adjustable arms) Detachable, adjustable height armrest, base, each |
N**** |
Purchase |
|
|
K0017 |
NU EP |
U1 U1 |
A(Dual post and adjustable height DA) Detachable, adjustable height armrest, base, each |
N**** |
Purchase |
|
K0019 |
NU EP |
Arm pad, each |
N |
Purchase |
|
|
K0020 |
NU EP |
Fixed, adjustable height armrest, pair |
N**** |
Purchase |
|
|
K0038** K0038 |
EP NU EP |
U1 |
A(Knee strap) Leg strap, each A(Single leg strap, each) Leg strap, each |
N N**** |
Purchase Purchase |
|
K0038 |
NU EP |
U2 U2 |
A(Foot straps, pair) Leg strap, each |
N**** |
Purchase |
|
K0039 |
NU EP |
Leg strap, H style, each |
N**** |
Purchase |
|
|
K0040 |
NU EP |
Adjustable angle footplate, each |
N**** |
Purchase |
|
|
K0043 |
NU EP |
A(SWFR, replacement) Footrest, lower extension tube, each |
N |
Purchase |
|
|
K0044 |
NU EP |
A(SWFR Hanger bracket, replacement) Footrest, upper hanger bracket, each |
N**** |
Purchase |
|
|
K0045 |
NU EP |
A(Padded custom foot box) Footrest, complete assembly |
N**** |
Purchase |
|
|
K0047 |
NU EP |
Elevating legrest, upper hanger bracket, each |
N**** |
Purchase |
|
|
K0056 |
NU EP |
Seat height less than 17 inches or equal to or greater than 21 inches for a high-strength, lightweight, or ultralightweight W/C |
N**** |
Manually Priced |
|
|
K0056 |
NU EP |
U1 U1 |
A(Seat height 19.5"5) Seat height less than 17 inches or equal to or greater than 21 inches for a high strength, lightweight or ultralightweight W/C |
N**** |
Purchase |
|
K0065 |
NU EP |
Spoke protectors, each |
N**** |
Purchase |
|
|
K0070 |
NU EP |
A(Wheel assembly, complete with pneumatic tires, 20"/22"/24"/26"/ea. replacement) Rear wheel assembly, complete with pneumatic tire, spokes or molded, each |
N**** |
Purchase |
|
|
K0071 |
NU EP |
U1 U1 |
A(Wheel assembly with pneumatic tires, 22", pair, rear wheels) Front caster assembly, complete, with pneumatic tire, each |
N**** |
Purchase |
|
K0071 |
NU EP |
A(Polyurethane casters, 5", pair, front casters) Front caster assembly, complete, with pneumatic tire, each |
N**** |
Purchase |
|
|
K0072 |
NU EP |
A(Polyurethane casters, 5", pair, front casters) Front caster assembly, complete, with semipneumatic tire, each |
N**** |
Purchase |
|
|
K0073 |
NU EP |
Caster pin lock, each |
N**** |
Purchase |
|
|
K0077 |
NU EP |
Front caster assembly, complete, with solid tire, each |
N |
Purchase |
|
|
K0108 |
NU EP |
A(W/C miscellaneous equipment; applicable pages from the manufacturer's catalog must be attached to the claim form.) Other accessories |
N**** |
Manually Priced |
|
|
S1002 |
EP |
A(Wheelchair, custom molded seating system only) Customized item, list in addition to code for basic item |
N**** |
Manually Priced |
|
|
S1002 |
NU EP |
U1 U1 |
A(Foam-in-place seat, Pindot quick foam contour system) Customized item, list in addition to code for basic item |
N**** |
Purchase |
The following procedure codes may only be billed on paper.
Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult (section 242.191)
|
No National Code Bill on paper |
M1 NU EP |
M2 |
Local Code Z1613 |
Description One-piece footboard (each) |
PA N**** |
Payment Method Purchase |
|
Bill on paper |
NU EP |
Z1793 |
Custom foot platform |
N**** |
Purchase |
|
|
Bill on paper |
EP |
Z1824** |
PC Car Seat/Snug Seat |
Y |
Purchase |
|
|
Bill on paper |
NU EP |
Z2137 |
Adjustable Rem. Abductor w/hardware (ea) |
N**** |
Purchase |
|
|
Bill on paper |
NU EP |
Z2138 |
Adjustable Flip Down Abductor w/hardware (ea) |
N**** |
Purchase |
|
Bill on paper |
NU EP |
Z2139 |
Lateral Hip/Thigh support w/hardware (ea) |
N**** |
Purchase |
|
Bill on paper |
NU EP |
Z2140 |
Adductor - no hardware |
N**** |
Purchase |
|
Bill on paper |
NU EP |
Z2141 |
Abductor - no hardware |
N**** |
Purchase |
|
Bill on paper |
NU EP |
Z2142 |
Hip guides - no hardware |
N |
Purchase |
|
Bill on paper |
NU EP |
Z2143 |
Fluid supplement |
N |
Purchase |
|
Bill on paper |
NU EP |
Z2145 |
Laterals - no hardware |
N**** |
Purchase |
|
Bill on paper |
NU |
Z2158 |
Air Exchange Seat Cover for Cushions (Replacement) |
N |
Purchase |
|
Bill on paper |
NU EP |
Z2159 |
Fluid Flo-lite pad (Replacement) |
N |
Purchase |
|
Bill on paper |
NU EP |
Z2175 |
Power W/C Sleeve Top or Bottom Stem Bearing (Replacement) |
N**** |
Purchase |
|
Bill on paper |
NU EP |
Z2178 |
SWFR Pivot Saddle (Replacement) |
N |
Purchase |
|
Bill on paper |
NU EP |
Z2180 |
SWFR Latch Block (Replacement) |
N |
Purchase |
|
Bill on paper |
NU EP |
Z2181 |
SWFR Composite Foot Plate (Replacement) |
N**** |
Purchase |
|
Bill on paper |
NU EP |
Z2183 |
Shoe Holders S/M/L/XL |
N**** |
Purchase |
|
Bill on paper |
NU EP |
Z2184 |
X-Tube Assembly Folding W/C (Replacement) |
N**** |
Purchase |
|
Bill on paper |
NU EP |
Z2185 |
Rigid Wheelchair Growth Kit |
N |
Purchase |
|
Bill on paper |
NU EP |
Z2186 |
Rigid Side Guard |
N**** |
Purchase |
|
Bill on paper |
NU EP |
Z2187 |
Fabric Side Guard |
N**** |
Purchase |
|
Bill on paper |
NU EP |
Z2188 |
Sub Occipital Three Piece Head Set W/REM Hardware |
N**** |
Purchase |
|
Bill on paper |
NU EP |
Z2189 |
Forehead Strap System |
N**** |
Purchase |
|
Bill on paper |
NU EP |
Z2190 |
Regular Links |
N**** |
Purchase |
|
Bill on paper |
NU EP |
Z2196 |
Swing Away Adj. Stroller Handles |
N**** |
Purchase |
|
Bill on paper |
NU EP |
Z2203 |
Elbow Block w/Bracket |
N**** |
Purchase |
|
Bill on paper |
NU EP |
Z2582 |
Quick Release Axle |
N**** |
Purchase |
|
Bill on paper |
NU EP |
Z2585 |
Growing Seat Pan |
N**** |
Purchase |
|
Bill on paper |
NU EP |
Z2586 |
Growing Back Upholstery |
N**** |
Purchase |
|
Bill on paper |
NU EP |
Z2588 |
Deep Contour Back 20" Width |
N**** |
Purchase |
|
Bill on paper |
NU EP |
Z2589 |
Adjustable Contour Lateral Pelvic Support |
N**** |
Purchase |
|
Bill on paper |
NU EP |
Z2592 |
Remote Joystick Module |
N**** |
Purchase |
|
Bill on paper |
NU EP |
Z2599 |
Transit Option |
N**** |
Purchase |
|
Bill on paper |
NU EP |
Z2604 |
Adjustable Back Upholstery |
N**** |
Purchase |
|
Bill on paper |
NU EP |
Z2616 |
Swing Away Mount (Joystick) |
N**** |
Purchase |
