Medicare Reimbursement - Hudson Medical Supplies ONLY

Patient Qualifications and Requirements.

General Use Wheelchair Cushion (E2601, E2602) A General Use Cushion (E2601, E2602) is covered for a patient who has a wheelchair, which meets Medicare coverage criteria. If the patient does not have a wheelchair, then the cushion will be denied as not medically necessary.

Non-Adjustable Skin Protection Wheelchair Cushion (E2603, E2604) A Skin Protection Cushion (E2603, E2604) is covered for a patient who meets both of the following criteria:

1. The patient has a wheelchair and the patient meets Medicare
   coverage criteria for it; and
2. The patient has either of the following:

Current pressure ulcer (707.03, 707.04, 707.05) or past history of a pressure ulcer (707.03, 707.04, 707.05) on the area of contact with the seating surface; or,

Absent or impaired sensation in the area of contact with the seating surface; or the inability to carry out a functional weight shift due to one of the following diagnoses: spinal cord injury
resulting in quadriplegia or paraplegia (344.00-344.1), other spinal cord disease (336.0-336.3) multiple sclerosis (340), other demyelinating disease (341.0-341.9), cerebral palsy (343.0-
343.9), anterior horn cell diseases including ALS (amyotrophic lateral sclerosis) (335.0-335.21, 335.23-335.9), Post Polio Paralysis (138), traumatic brain injury resulting in Quadriplegia (344.09), spina bifida (741.00 741.93), childhood cerebral degeneration (330.0-330.9), Alzheimer's Disease (331.0), Parkinson's Disease (332.0).

The Following ICD-9 Codes are not sufficient by themselves to assure coverage: (138) Late Effects of Acute PolioMyelitis; (331.0) Alzheimer's Disease; (332.0) Paralysis; (340) Multiple Sclerosis; (707.03) Decubitus Ulcer, Lower Back; (707.04) Decubitus Ulcer, Hip; (707.05) Decubitus Ulcer, Buttock.

Positioning Wheelchair Cushion (E2605, E2606) A Positioning Cushion (E2605, E2606) is covered
who meets both of the following criteria:

1. The patient has a wheelchair and the patient Medicare coverage criteria for it; and
2. The patient has any significant postural are due to one of the diagnoses listed above or one of the following diagnosis: Monoplegia limb (344.30-344.32, 438.40-438.42) or hemiplegia
   342.92, 438.20-438.22) due to stroke, traumatic other etiology, muscular dystrophy (359.0, 359.1) dystonias (333.4, 333.6, 333.7), spinocerebellar disease

The Following ICD-9 Codes are not sufficient to assure coverage: (138) Late Effects of Acute (331.0) Alzheimer's Disease; (332.0) Paralysis Huntington's Chorea; (333.6) Idiopathic Torsion (333.7) Symptomatic Torsion Dystonia; (340) (359.0) Congenital Hereditary Muscular Dystrophy; Hereditary Progressive Muscular Dystrophy.

Non-Adjustable and Adjustable Skin Protection Wheelchair Cushion (E2607, E2608, K0736, K0737) A Skin Protection and Positioning Cushion (E2607, E2608) and an Adjustable Skin Protection and Positioning (K0736, K0737) is covered for a patient who meets the criteria for both a skin protection seat cushion and a positioning seat cushion.

1. The patient has a wheelchair and the patient meets Medicare
   coverage criteria for it; and
2. The patient meets the criteria for both a Skin Protection seat
   cushion and a Positioning seat cushion.

The following ICD-9 Codes are not sufficient by themselves to assure coverage: (138) Late Effects of Acute PolioMyelitis; (331.0) Alzheimer's Disease, (332.0) Paralysis Agitans; (340) Multiple Sclerosis or a combination of ICD-9 Code (707.03, 707.04 or 707.05) and one of the following ICD-9 codes: Huntington's Chorea (333.4), Idiopathic Torsion Dystonia (333.6), Symptomatic Torsion Dystonia (333.7), Congential Hereditary Muscular Dystrophy (350.0), Hereditary Pro-gressive Myscular Dystrophy (350.1).

Documentation Required For an item(s) to be considered for coverage and payment by Medicare, the information submitted by the supplier must be corroborated by documentation in the patient's medical records that Medicare coverage criteria have been met. The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals, or test reports. This documentation must be available to the DMERC upon request. An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available to the DMERC upon request.

Items delivered before a signed order has been received by the supplier, must be submitted with an EY modifier added to each affected HCPCS code. The ICD-9 code which justifies the need for these items must be included on the claim.

For a Skin Protection seat cushion (E2603, E2604) A KX modifier should be added to the code if either criterion (a), (b), or (c) is met:

1. If there is a past history of or current pressure ulcer in the area of contact with the seating surface; or
2. If there is absent or impaired sensation in the area of contact with the seating surface due to one of the diagnoses listed as a covered diagnosis; or
3. If there is an inability to carry out a functional weight shift due to one of the diagnoses listed as a covered diagnosis.

For a Positioning seat cushion (E2605, E2606), positioning back cushion (K0662-K0665), or positioning accessory (E0995- E0960), a KX modifier should be added to the code if the patient has significant postural asymmetries due to one of the diagnoses listed as a covered diagnosis.

For a Skin Protection and Positioning seat cushion (E2607, E2608) or Adjustable Skin Protection and Positioning seat cushion (K0736, K0737), a KX modifier should be added to the code if criterion (a) or (b) or (c) is met and criterion (d) is met:

1. If there is a past history or current pressure ulcer in the area of contact with the seating surface; or
2. If there is absent or impaired sensation in the area of contact with the seating surface due one of the diagnoses listed as a covered diagnosis for skin protection cushions (except 707.0); or
3. If there is an inability to carry out a functional weight shift due one of the diagnoses listed as a covered diagnosis for skin protection cushions (except 707.03, 707.04, 707.05); or
4. If the patient has significant postural asymmetries due one of the diagnoses listed as a covered diagnosis for skin protection cushions.

If the requirements for the KX modifier are not met, the supplier may submit additional documentation with the claim to justify coverage, but the KX modifier must not be used.

** The above information was available as of February 2005 and does not insure a provider will be reimbursed. This information is subject to change. For updated information, please refer to your DMERC website. Individual provider questions should be directed to your regional DMERC.