DOCUMENTATION CHECKLIST

Manual Wheelchairs

Reference: LCD L11454 and PA A25378

Required Documentation in Supplier’s File

Claims for all Manual Wheelchairs

‰ Documentation of verbal order (if item is dispensed based on a verbal order) that
contains:
o Description of item
o Name of beneficiary
o Name of physician
o Start date of order

NOTE: Suppliers should not submit claims prior to obtaining a valid written order. Items
billed before a signed and dated order has been received must be submitted with modifier
EY.

‰ Valid written order that contains:

o Beneficiary's name
o Detailed description of item(s) to be dispensed
o Treating physician's signature
o Date treating physician signed the order
o Start date of order - only required if the start date is different than the signature date

‰ Beneficiary authorization

‰ Proof of delivery

‰ Medical records* documenting that all the following criteria are met:
o Patient has mobility limitation that significantly impairs his/her ability to
participate in one or more mobility-related activities of daily living (MRADLs)
such as toileting, feeding, dressing, grooming, and bathing in customary locations
in the home; and
o Mobility limitation cannot be sufficiently and safely resolved by use of
appropriately fitted cane or walker; and
o Patient is able to safely use a manual wheelchair; and
o Patient’s functional mobility deficit can be sufficiently resolved by the use of a
manual wheelchair.

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Manual Wheelchairs

Claims for a standard hemi-wheelchair (K0002)

‰ Medical record* supports patient requires a lower seat height (17”-18”) because:
o Short stature, or
o Need to place feet on ground for propulsion.

Claims for a lightweight wheelchair (K0003)

‰ Medical record* supports that patient:
o Cannot self-propel in a standard wheelchair using arms and/or legs; and
o Can and does self-propel in a lightweight wheelchair.

Claims for a high strength lightweight wheelchair (K0004)

‰ Medical record* supports that patient:
o Self-propels the wheelchair while engaging in frequent activities that cannot be
performed in a standard or lightweight wheelchair; and/or
o Requires seat width, depth, height that cannot be accommodated in a standard,
lightweight, or hemi-wheelchair and spends at least two hours per day in the
wheelchair.

Claims for an ultralightweight wheelchair (K0005)

‰ Payment is determined on an individual consideration basis.
‰ If requested, documentation must include:
o Description of patient’s routine activities; and
o Types of activities patient frequently encounters; and
o Information concerning whether or not patient is fully independent in use of the
wheelchair; and
o Description of the K0005 features that are needed compared to the K0004 base.

Claims for a heavy-duty wheelchair (K0006)

‰ Medical record* supports that patient:
o Weighs more than 250 pounds; and
o Has severe spasticity.

Claims for an extra heavy-duty wheelchair (K0007)

‰ Medical record* supports patient weighs more than 300 pounds.

Claims for other manual wheelchair base (K0009)

‰ Payment is determined on an individual consideration basis.
‰ If requested, claim must include:
o Manufacturer; and
o Product name/number; and

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Manual Wheelchairs

o Medical records* justifying medical necessity of the item that might include:
• Diagnosis
• Abilities and limitations as they relate to the equipment
• Duration of the condition
• Expected prognosis
• Past experience using similar equipment

Billing Reminders:
‰ The KX modifier must be added to codes for the manual wheelchair base only if all
the coverage criteria are met.
‰ Manual wheelchairs described by codes E1161, E1231 – E1234, K0005, and
K0009 are eligible for Advance Determination of Medicare Coverage (ADMC).
See the Coverage/MR tab of the NAS DME Web site for additional ADMC
information.

*NOTE: It is expected that the patient’s medical records will reflect the need for the care
provided. These records are not routinely submitted but must be available upon request.
Therefore, while it is not a requirement, it is a recommendation that suppliers obtain and
review the appropriate medical records and maintain a copy in the beneficiary’s file.
DISCLAIMER
The content of this document was prepared as an educational tool and is not intended to
grant rights or impose obligations. Use of this document is not intended to take the place
of either written law or regulations.

Updated 12/22/08