Medicare Power Wheelchair Codes

Since the implementation of the new Medicare power wheelchair funding codes in late 2006 - which also apply to Medicaid and many private insurances - providers and manufacturers have striven to fully understand the new "groups" and sub-classifications, aligning the proper codes with the right products. However, the question remains for consumer-beneficiaries, "How do the new codes apply to me?"

The answer is individually applicable, where health condition and physical needs certainly vary from one consumer-beneficiary to the next. However, by viewing the codes based on their technology-based definitions, and applying real-world examples of how they serve the user, the new codes become increasingly understandable for most consumer-beneficiaries.

Through this condensed explanation of the new Medicare power wheelchair codes, it is hoped that you, as consumer, have a realistic overview of the new codes, and how they apply toward products as a whole. This overview is not meant as a literal guide to Medicare policy, nor should it replace provider training and judgment toward funding submissions in any way. Further, your individual condition, circumstances, and coverage may vary in such ways that qualification for any component within this overview may not apply.

Groups, Sub-Classifications, and K-Codes
Power wheelchair funding "codes" are established step-by-step (formally called an "algorithm"), with "Groups," "sub-classifications," then the actual "K-code" for a particular power wheelchair technology.

Groups
The Group refers to the overall type of wheelchair technology and the role it serves. For example, a Group 1 is a very compact or transportable power wheelchair, incapable of advanced electronics, with basic seating; whereas, a Group 3 is a very high-end power wheelchair that features advanced electronics capabilities, high-end seating, and advanced performance. The Group 1 through Group 4 designations are sequential, meaning that the higher the number, the more advanced the product capabilities.

Sub-Classifications
Within each Group are sub-classifications designating weight capacity: Standard, Heavy Duty, Very Heavy Duty, and Extra Heavy duty. Weight capacities are defined as follows: Standard < 300 lbs.; Heavy Duty 301-450 lbs.; Very Heavy Duty 450-600 lbs.; and, Extra Heavy Duty > 601 lbs.

In addition to weight capacity designations, there are electronics and power seating designations: Single Power and Multiple Power. If the consumer-beneficiary only needs power tilt seating, for example, Single Power applies, whereas tilt and recline with three or more functions, or a ventilator, qualifies for Multiple Power.

K-Codes
Once the Group and sub-classifications are determined, in conjunction with such aspects as the type of seating required, an actual K-code aligns to fund a particular power wheelchair. For example, if one needs a "Group 2 Single Power" base for rehab-type seating, it points to the code of K0835. If one needs a "Group 2 Single Power Heavy Duty" base for rehab-type seating, it points to the code of K0837. There are an astounding number of K-codes, making a code's criteria and qualification very important to providers and consumers if the beneficiary is to receive funding approval for the best technology for his or her needs.

Therefore, an easy way of understanding the coding equation is: Group + Sub-classifications = K-Codes

Power Wheelchair and Group Qualification Criteria
Now that we understand how the literal codes unfold, let's return to the Group level, where power wheelchair performance is dictated, addressing the question of, what qualifies a consumer beneficiary for one Group versus another?

First, to qualify for any power wheelchair, the consumer-beneficiary must go through three basic qualifications stages:

I. Power Mobility Device Coverage
Patient has mobility limitation that significantly impairs mobility related activities of daily living abilities
oPrevents ability to accomplish
oCan't accomplish safely
oCan't accomplish in reasonable time
oLimitation not resolved by cane or walker
oLimitation not resolved by optimally configured manual wheelchair

II. Power Operated Vehicle (Scooter) Coverage
Patient meets basic Power Mobility Device coverage criteria and:
Patient able to:
o Transfer to/from Power Operated Vehicle
o Operate tiller system
o Maintain postural stability while operating Power Operated Vehicle in home
o Home is accessible to Power Operated Vehicle
o Patient weight is within limit of device.
o Patient is willing to use

III. Power Wheelchair Coverage
Patient meets basic Power Mobility Device coverage criteria and:
oPatient does not meet coverage criteria for Power Operated Vehicle
oPatient or caregiver has ability to operate
oHome is accessible to Power Wheelchair Coverage
oPatient weight is within limit of device
o Power Wheelchair Coverage significantly improves mobility related activities of daily living participation
oPatient is willing to use

In everyday terms, if it's medically justified that one needs a power mobility device to perform mobility related activities of daily living, but can't user power operated scooter due to the extent of disability, then he or she qualifies for a power wheelchair (assuming that the power wheelchair qualifications are met).

Once one meets the qualifications for a power wheelchair, then the Group qualification must be determined, based on one's physical needs.

Group 1
Qualification: Patient must meet power mobility device and power wheelchair qualifications. (If one meets the qualifications for a power wheelchair, no additional criteria is required.)

Representative Products: Pride Mobility Z-Chair, Invacare At'M, Sunrise Medical Microlite Ruby PA

Minimum technology and performance characteristics:
- Standard integrated or remote proportional control input device
- Non-expandable controller
- Incapable of upgrade to expandable controller
- Incapable of upgrade to alternative control devices
- May have crossbrace construction
- Accommodates non-powered options and seating systems (e.g., recline-only backs, manually elevating legrests) (except Captain's Chairs)
- Length - less than or equal to 40 inches
- Width - less than or equal to 24 inches
- Minimum Top End Speed - 3 MPH
- Minimum Range - 5 miles
- Minimum Obstacle Climb - 20 mm
- Dynamic Stability Incline - 6 degrees
For Group 1 portable wheelchairs, the largest single component may not exceed 55 pounds.

All Group 2
Qualification: For Standard, Patient must meet power mobility device and power wheelchair qualifications.

For rehab seating, one must meet the coverage criteria for pressure relief and/or a positioning cushion.

For Single Power, one must require an alternate drive control interface or meet coverage criteria for a power tilt or a power recline seating system and have an Evaluation performed by PT, OT, Physician with specific training/experience in rehabilitation wheelchair evaluations.

For Multiple Power, one must use a ventilator which is mounted on the wheelchair or user meets coverage criteria for 2 power seating systems and has an evaluation performed by PT, OT, Physician with specific training/ experience in rehabilitation wheelchair evaluations.

Representative Products: Sunrise Medical Freestyle F11, Pride Mobility Jazzy 610, Invacare M51

Minimum technology and performance characteristics:
- Standard integrated or remote proportional control input device
- May have crossbrace construction
- Accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports) (except Captain's Chairs)
- Length - less than or equal to 48 inches
- Width - less than or equal to 34 inches
- Minimum Top End Speed - 3 MPH
- Minimum Range - 7 miles
- Minimum Obstacle Climb - 40 mm
- Dynamic Stability Incline - 6 degrees

All Group 3
Qualification: One has limitations due to neurologic, myopathic or congenital skeletal abnormality and has an evaluation performed by PT, OT, Physician with specific training / experience in rehabilitation wheelchair evaluations.

For Single Power, one must require an alternate drive control interface or meet coverage criteria for a power tilt or a power recline seating system and have an Evaluation performed by PT, OT, Physician with specific training/experience in rehabilitation wheelchair evaluations.

For Multiple Power, one must use a ventilator which is mounted on the wheelchair or user meets coverage criteria for 2 power seating systems and has an evaluation performed by PT, OT, Physician with specific training/ experience in rehabilitation wheelchair evaluations.

Representative Products: Permobil C400, Invacare TDX SP; Sunrise Medical Rhythm M3, Pride Mobility Quantum Q600

Minimum technology and performance characteristics:
- Standard integrated or remote proportional control input device
- May not have crossbrace construction
- Accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports) (except Captain's Chairs)
- Drive wheel suspension to reduce vibration
- Length - less than or equal to 48 inches
- Width - less than or equal to 34 inches
- Minimum Top End Speed - 4.5 MPH
- Minimum Range - 12 miles
- Minimum Obstacle Climb - 60 mm
- Dynamic Stability Incline - 7.5 degrees

All Group 4
Qualification: There is no set coverage for Group 4 power wheelchairs. Medicare considers Group 4 products unnecessary for use within the home, namely due to their advanced speed and range performance. Group 4 products billed to Medicare will be down coded to either Group 2 or Group 3, depending on which Group 2 or Group 3 coverage criteria are met.

Representative Products: Permobil Street, Invacare TDX 5PS, Pride Mobility Quantum Q6000MPSS, Sunrise Medical Quickie Rhythm M5, Bounder H-Frame

Minimum technology and performance characteristics:
- Standard integrated or remote proportional control input device
- May not have crossbrace construction
- Accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports) (except Captain's Chairs)
- Drive wheel suspension to reduce vibration
- Length - less than or equal to 48 inches
- Width - less than or equal to 34 inches
- Minimum Top End Speed - 6 MPH
- Minimum Range - 16 miles
- Minimum Obstacle Climb - 75 mm
- Dynamic Stability Incline - 9 degrees

All Group 5 (Pediatric)
Qualification: Patient meets basic coverage criteria and Patient is expected to grow; and weight =/<125 lbs.

For Single Power, one must require an alternate drive control interface or meet coverage criteria for a power tilt or a power recline seating system and have an Evaluation performed by PT, OT, Physician with specific training/experience in rehabilitation wheelchair evaluations.

For Multiple Power, one must use a ventilator which is mounted on the wheelchair or user meets coverage criteria for 2 power seating systems and has an evaluation performed by PT, OT, Physician with specific training/ experience in rehabilitation wheelchair evaluations.

Representative Products: Permobil Koala

Minimum technology and performance characteristics:
- Standard integrated or remote proportional control input device
- Expandable controller
- Capable of upgrade to alternative control devices
- Seat Width: minimum of 5 one-inch options
- Seat Depth: minimum of 3 one-inch options
- Seat Height: adjustment requirements =/> 3 inches
- Back Height: adjustment requirements minimum of 3 options
- Seat to Back Angle: range of adjustment-minimum of 12 degrees
- Accommodates non-powered options and seating systems
- Accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports)
- Adjustability for growth (minimum of 3 inches for width, depth and back height adjustment)
- Special developmental capability (i.e., seat to floor, standing, etc.)
- Drive wheel suspension to reduce vibration
- Length - less than or equal to 48 inches
- Width - less than or equal to 34 inches
- Minimum Top End Speed - 4 MPH
- Minimum Range - 12 miles
- Minimum Obstacle Climb - 60 mm
- Dynamic Stability Incline - 9 degrees
- Crash testing - Passed

Coding Made Simple
As complex as the new coding seems, it's fairly simple to understand in common terms. Group qualification is based on physical need, where less-involved conditions dictate a Group 1 or Group 2 product; advanced positioning needs dictate a Group 2 product; and profound disabilities dictate a Group 3 product. Once the Group is determined, then weight capacity and power function needs further narrow the selection to the exact K-code. The last component to the algorithm is that Medicare dictates downcoading to the least-costly alternative, so it's vital that a consumer-beneficiary meets all of the criteria for a particular classification, otherwise the funding submission will be downcoded, as in from Group 3 to Group 2, for example.

The new codes were a long time in coming, faced great debate, but are now in place, ultimately shaping the mobility of all power mobility consumers and beneficiaries. Surely, the new policy may prove liberating to many, and restrictive to some; however, there is some method to it, with provisions for disabilities ranging from less-involved to most complex - and there's meaningful equity to the qualifications throughout the spectrum of products funded. As a governmental funding source, Medicare may never allocate the type of criteria needed to truly liberate power wheelchair users, such as disbanding the in-home use policy that disqualifies Group 4 type products. However, there's empowerment to using any system to its fullest potential, and by having an understanding of the new codes, it's hopeful that when you, as a consumer-beneficiary, meet with your provider to order your next power wheelchair, you will have an understanding of not only what you need and want, but also what you qualify for, balancing the three aspects toward receiving truly liberating mobility technology.

Related Materials
A WheelchairJunkie's Complete List of all U.S. Power Wheelchair Models by Group and Codes (PDF)

Using Medicare's ABN Toward Upgrading Your Mobility