Or. Admin. Code § 410-122-0320

Current through Register Vol. 63, No. 12, December 1, 2024

Section 410-122-0320 - Manual Wheelchair Base

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

(a) The Division may cover a manual wheelchair 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 eating, toileting, grooming, dressing, and bathing. A mobility limitation is one that:

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

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

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

(E) The client is willing to use the requested manual wheelchair on a regular basis;

(F) The client has either:

(i) Sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the requested manual wheelchair during a typical day. Proper assessment of upper extremity function shall consider limitations of strength, endurance, range of motion, coordination, presence of pain, and deformity or absence of one or both upper extremities; or

(ii) A caregiver who is available, willing, and able to provide assistance with the wheelchair.

(b) The Division may authorize a manual wheelchair for any of the following situations, only when conditions of coverage as specified in section (1)(a) of this rule are met:

(A) When the wheelchair 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 manual wheelchair will be reasonably expected to significantly improve the client's ability to perform or obtain assistance to participate in MRADLs, a manual wheelchair 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 manual wheelchair 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 manual wheelchair.

(B) For a purchase request, when a client's current wheelchair is no longer medically appropriate, or repair and modifications to the wheelchair exceed replacement cost;

(C) When a covered, client-owned wheelchair is in need of repair, the Division may pay for one month's rental of a wheelchair. (See OAR 410-122-0184 Repairs, Maintenance, Replacement, Delivery and Dispensing.)

(c) The Division may not reimburse for another wheelchair if the client has a medically appropriate wheelchair, regardless of payer;

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

(e) The Division may not cover services or upgrades that primarily allow performance of leisure or recreational activities. Such services include but are not limited to backup wheelchairs, backpacks, accessory bags, awnings, additional positioning equipment if wheelchair meets the same need, custom colors, and wheelchair gloves;

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

(g) The Division may cover an adult tilt-in-space wheelchair (E1161) when a client meets all of the following conditions:

(A) A standard base with a reclining back option will not meet the client's needs;

(B) Requires assistance with transfers;

(C) The client's plan of care addresses the need to change position at frequent intervals, and the client is not left in the tilt position most of the time; and

(D) Has one of the following:

(i) High risk of skin breakdown;

(ii) Poor postural control, especially of the head and trunk;

(iii) Hyper/hypotonia;

(iv) Need for frequent changes in position and has poor upright sitting.

(E) Tilt-n-space wheelchairs 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;

(F) 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;

(G) 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 evaluation;

(H) The ATP may not conduct the provider evaluation at the time of delivery of the wheelchair to the client's residence;

(h) One month's rental for a manual adult tilt-in-space wheelchair (E1161) may be covered for a client residing in a nursing facility when all of the following conditions are met:

(A) The anticipated nursing facility length of stay is 30 days or less;

(B) The conditions of coverage for a manual tilt-in-space wheelchair as described in section (1) (g) (A)-(H) are met;

(C) The client is expected to have an ongoing need for this same wheelchair after discharge from the nursing facility;

(D) Coverage is limited to one month's rental.

(i) The Division may cover a standard hemi (low seat) wheelchair (K0002) when a client requires a lower seat height (17" to 18") because of short stature or needing assistance to place his feet on the ground for propulsion;

(j) The Division may cover a lightweight wheelchair (K0003) when a client:

(A) Cannot self-propel in a standard wheelchair using arms or legs; and

(B) Can and does self-propel in a lightweight wheelchair.

(k) High-strength lightweight wheelchair (K0004):

(A) The Division may cover a high-strength lightweight wheelchair (K0004) when a client:

(i) Self-propels the wheelchair while engaging in frequent activities that cannot be performed in a standard or lightweight wheelchair; or

(ii) Requires a seat width, depth, or height that cannot be accommodated in a standard, lightweight or hemi-wheelchair and spends at least two hours per day in the wheelchair.

(B) If the expected duration of need is less than three (3) months (e.g., post operative recovery), a high-strength lightweight wheelchair is rarely medically appropriate.

(l) The Division may cover an ultra-lightweight wheelchair (K0005) when criteria (A) or (B) are met and (C) and (D) are met:

(A) The client must be a full-time manual wheelchair user; or

(B) The client 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, K0003 or K0004 manual wheelchair; and

(C) The client must have a specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and documents the medical necessity for the wheelchair and its special features, including a description of the client's mobility needs within the home and community. This may include what types of activities the client frequently encounters and whether the client is fully independent in the use of the wheelchair. Describe the features of the K0005 base that are needed compared to the K0004 base; and

(D) The wheelchair 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;

(m) The Division may cover a heavy-duty wheelchair (K0006) when a client weighs more than 250 pounds or has severe spasticity;

(n) The Division may cover an extra heavy-duty wheelchair (K0007) when a client weighs more than 300 pounds;

(o) For a client residing in a nursing facility, an extra heavy-duty wheelchair (K0007) may only be covered when a client weighs more than 350 pounds;

(p) For more information on coverage criteria regarding repairs and maintenance, see 410-122-0184 Repairs, Maintenance, Replacement and Delivery;

(q) The wheelchair requested must be the most appropriate and least costly alternative that shall meet the client's medical and functional needs.

(2) Coding Guidelines:

(a) Adult manual wheelchairs (K0001-K0007, K0009, E1161) have a seat width and a seat depth of 15" or greater;

(b) For codes K0001-K0007 and K0009, the wheels must be large enough and positioned so that the user can self-propel the wheelchair;

(c) In addition, specific codes are defined by the following characteristics:

(A) Adult tilt-in-space wheelchair (E1161):

(i) Ability to tilt the frame of the wheelchair greater than or equal to 20 degrees from horizontal while maintaining the same back-to-seat angle; and

(ii) Lifetime warranty on side frames and crossbraces;

(iii) Wheelchairs with less than 20 degrees of tilt must not be coded based upon the tilt feature. The appropriate base product must be coded as K0001-K0007. Coding as E1161 or K0108 is inappropriate coding.

(B) Standard wheelchair (K0001):

(i) Weight: Greater than 36 pounds;

(ii) Seat height: 19" or greater; and

(iii) Weight capacity: 250 pounds or less.

(C) Standard hemi (low seat) wheelchair (K0002):

(i) Weight: Greater than 36 pounds;

(ii) Seat height: Less than 19"; and

(iii) Weight capacity: 250 pounds or less.

(D) Lightweight wheelchair (K0003):

(i) Weight: 34-36 pounds; and

(ii) Weight capacity: 250 pounds or less.

(E) High strength, lightweight wheelchair (K0004):

(i) Weight: Less than 34 pounds; and

(ii) Lifetime warranty on side frames and crossbraces.

(F) Ultra-lightweight wheelchair (K0005):

(i) Weight: Less than 30 pounds;

(ii) Adjustable rear axle position; and

(iii) Lifetime warranty on side frames and crossbraces.

(G) Heavy duty wheelchair (K0006) has a weight capacity greater than 250 pounds;

(H) Extra heavy-duty wheelchair (K0007) has a weight capacity greater than 300 pounds.

(d) Coverage of all adult manual wheelchairs includes the following features:

(A) Seat width: 15"-19";

(B) Seat depth: 15"-19";

(C) Arm style: Fixed, swing-away, or detachable, fixed height;

(D) Footrests: Fixed, swing-away, or detachable.

(e) Codes K0003-K0007 and E1161 include any seat height;

(f) For individualized wheelchair features that are medically appropriate to meet the needs of a particular client, use the correct codes for the wheelchair base, options and accessories (see OAR 410-122-0340 Wheelchair Options/Accessories);

(g) For wheelchair frames that are modified in a unique way to accommodate the client, submit the code for the wheelchair base used and submit the modification with code K0108 (wheelchair component or accessory, not otherwise specified);

(h) Manual wheelchair bases (K0001-K0007, K0009) include construction of any type material, including but not limited to, titanium, carbon, or any other lightweight high strength material. Providers shall not bill for construction materials. Billing for construction material is considered incorrect coding and unbundling.

(3) Documentation requirements:

(a) Functional mobility evaluation:

(A) Providers must submit medical documentation that supports conditions of coverage in this rule are met for purchase and modifications of all covered, client-owned manual wheelchairs except for K0001, K0002, or K0003 (unless modifications are required);

(B) Information must include but is not limited to:

(i) The practitioner's face-to-face examination in accordance with OAR 410-122-0090. The face-to-face examination must occur no more than six (6) months prior to the start of services.

(ii) Medical justification needs assessment, order, and specifications for the wheelchair completed by a physical therapist (PT), occupational therapist (OT), treating practitioner. The person who provides this information must have no direct or indirect financial relationship, agreement, or contract with the durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) provider requesting authorization;

(iii) Client identification and rehab technology supplier identification information that may be completed by the DMEPOS provider; and

(iv) Signature and date by the treating practitioner and the PT or OT.

(C) If the information on this form includes all the elements of an order, the provider may submit the completed form in lieu of an order.

(b) Additional documentation:

(A) Information from a PT, OT, treating practitioner that specifically indicates:

(i) A brief description of the client's impairment in functional mobility that establishes that they have a mobility limitation and how it interferes with the performance of activities of daily living;

(ii) Why an appropriately fitted cane or walker cannot sufficiently resolve the client's mobility limitation.

(B) Pertinent information from a PT, OT, treating practitioner about the following elements that support coverage criteria are met for a manual wheelchair; 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, power-operated vehicle (POV), or power wheelchair 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 individual:

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

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

(C) Documentation from a PT, OT, treating practitioner that clearly distinguishes the client's abilities and needs within the home and community;

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

(E) 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;

(F) If the client shall be using the wheelchair 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 wheelchair. This assessment must support that the client's home can accommodate and allow for the effective use of a wheelchair. This assessment must include but is not limited to evaluation of physical layout, doorway widths, doorway thresholds, surfaces, counter/table height, accessibility (e.g., ramps), electrical service, etc.; and

(G) All HCPCS codes, including the base, options and accessories, whether prior authorization (PA) is required or not, that shall be billed separately.

(c) A written order by the treating practitioner identifying the specific type of manual wheelchair needed. If the order does not specify the type requested by the DMEPOS provider on the authorization request, the provider must obtain another written order that lists the specific manual wheelchair that is being ordered and any options and accessories requested. The DMEPOS provider may enter the items on this order. This order must be signed and dated by the treating practitioner received by the DMEPOS provider, and submitted to the authorizing authority with a copy of the face-to-face examination required by OAR 410-122-0090;

(d) For purchase of K0001, K0002 or K0003 (without modifications), send documentation listed in (3) (b)(A-E);

(e) When code K0009 is requested, send all information from a PT, OT, treating practitioner that justifies the medical appropriateness for the item;

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

(g) For a manual wheelchair rental, submit all of the following:

(A) A written order from the treating practitioner identifying the specific type of manual wheelchair needed:

(i) If the order does not specify the type of wheelchair requested by the DMEPOS provider on the authorization request, the provider must obtain another written order that lists the specific manual wheelchair that is being ordered and any options and accessories requested;

(ii) The DMEPOS provider may enter the items on this order;

(iii) This order must be signed and dated by the treating practitioner received by the DMEPOS provider, and submitted to the authorizing authority.

(B) HCPCS codes;

(C) Documentation from the DMEPOS provider that supports the client's home can accommodate and allow for the effective use of the requested wheelchair.

(i) All documentation listed in section (3) of this rule must be kept on file by the DMEPOS provider;

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

(4) Table 122-0320 - Manual Wheelchair Base.

Or. Admin. Code § 410-122-0320

HR 13-1991, f. & cert. ef. 3-1-91; HR 10-1992, f. & cert. ef. 4-1-92; HR 32-1992, f. & cert. ef. 10-1-92; HR 9-1993 f. & cert. ef. 4-1-93; HR 10-1994, f. & cert. ef. 2-15-94; HR 18-1994(Temp), f. & cert. ef. 4-1-94; HR 26-1994, f. & cert. ef. 7-1-94; HR 41-1994, f. l2-30-94, cert. ef. 1-1-95; HR 17-1996, f. & cert. ef. 8-1-96; HR 7-1997, f. 2-28-97, cert. ef. 3-1-97; OMAP 11-1998, f. & cert. ef. 4-1-98; OMAP 13-1999, f. & cert. ef. 4-1-99; 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 21-2003, f. 3-26-03, cert. ef. 4-1-03; 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 12-2007, f. 6-29-07, cert. ef. 7-1-07; 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 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 8-2024, minor correction filed 01/04/2024, effective 1/4/2024

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Statutory/Other Authority: ORS 413.042 & 414.065

Statutes/Other Implemented: ORS 414.065