HCPCS CODING ELIGIBILITY REQUIREMENTS …

1 HCPCS CODING ELIGIBILITY REQUIREMENTS medicare WHEELCHAIR CUSHIONSTART HERESTART HEREThe patient meets coverage criteria for a medicare approved wheelchair The patient meets coverage criteria for a medicare approved wheelchair CRITERIA 1 Does the patient have either of the following:Current pressure ulcerNOGeneral Use Wheelchair CushionPhysipro does not offer products in this category at this timeDoes the patient have any significant postural asymmetries that are due to one of the ICD-9 codes listed in CRITERIA 2 , or a combination of the CRITERIA 1 and one of the following ICD-9 codes:Osteogenesis Imperfecta ( )Other Causes of Myelitis ( )TiAifl()(l)(il) Pressure ulcer, low Pressure ulcer, hip Pressure ulcer, buttockOR past history of the pressure ulcer on seating Pressure ulcer, low Pressure ulcer, hip Pressureulcer,buttockYEST raumatic Amputation of leg(s) (complete) (partial) unilateral at or above knee without complication Traumatic Amputation of leg(s) (complete)(partial) bilateral (any level) complicated ( )Monoplegia of the Lower Limb ( ) ( )Friedreich'sAtaxia( ) Pressure ulcer, buttockCRITERIA 2OR, absent or impaired sensation OR inability to carry out functional weight shift due to one of the following ICD-9 codes.

2 Hemiplegia ( , ) due to strong, traumatic brain injury, or other etiologySpinal Cord Injury resulting in Quadriplegia or Paraplegia ( 1)Friedreich sAtaxia( )Spinocerebellar Disease, unspecified ( )Is there a comprehensive written Is there a comprehensive written evaluation by a licensed clinician (not an employee or paid by )Other Spinal Cord Disease ( )Multiple Sclerosis (340)Other Demyelinating Disease ( )Cerebral Palsy ( )Anterior Horn Cell Disease Including ALS ; SMA ( )Other Motor Neuron Disease ( )LEfff AP lili i (138)NOYES(pypysupplier) which clearly demonstrates why prefabricatedis insufficient?E2603/E2604E2603/E2604 Late Effects of Acute Poliomyelitis (138)Traumatic Brain Injury Resulting in Quadriplegia ( )Spina Bifida ( )Alzheimer's Disease ( )Parkinson s Disease ( )Childhood Cerebral Degeneration ( ),Huntington s Chorea ( )YESE2607/E2608E2607/E2608 Skin protection and Skin protection and positioning positioning hihiNOE2609E2609 Custom fabricated Custom fabricated wheelchair seat cushionwheelchair seat cushionE2603/E2604E2603/E2604 Skin Protection Skin Protection C3S Cushion C3S Cushion Brio Cushion Brio Cushion Idiopathic Torsion Dystonia ( )Athetoid Cerebral Palsy ( )Paralysis Agitans ( )Congenital Hereditary Muscular Dystrophy ( )Hereditary Progressive Muscular Dystrophy ( )

3 CushioncushionULTRA cushion ULTRA cushion ZeroZero--Pressure Pressure Resolve Resolve wheelchair seat cushionwheelchair seat cushionPhysipro does not offer Physipro does not offer products in this products in this category at this timecategory at this timeHCPCS CODING ELIGIBILITY REQUIREMENTS medicare WHEELCHAIR BACKRESTSTART HERESTART HEREThe patient meets coverage criteria for a medicare approved wheelchair The patient meets coverage criteria for a medicare approved wheelchair E2611/E2612E2611/E2612 YESDoes the patient have any significant postural asymmetries that areNOE2611/E2612E2611/E2612 General Use Back General Use Back PREMIUM BackPREMIUM BackTraumatic Amputation of the Leg(s) ( )Osteogenesis Imperfecta ( )Transverse Myelitis ( )Late Effects of Acute Poliomyelitis (138)Cerebral Degeneration Usually Manifest in Childhood ( )Does the patient have any significant postural asymmetries that aredue to a diagnoses listed below:YESIs there a comprehensive written evaluation by a licensedclinician (not an employee or paid by supplier) which clearly demonstrates why prefabricated is insufficient?

4 Cerebral Degeneration Usually Manifest in Childhood ( )Alzheimer's Disease ( )Paralysis Agitans ( )Huntington's Chorea ( )Idiopathi c Torsion Dystonia ( )Athetoid Cerebral Palsy ( )Spinocerebellar Diseases ( )Anterior Horn Cell Disease Including ALS (SMA) (335 0335 21)YESNOA nterior Horn Cell Disease Including ALS (SMA) ( )Other Motor Neuron Disease ( )Other Diseases of the Spinal Cord ( )Multiple Sclerosis (340)Other Demyelinating Diseases of CNS ( )Hemiplegia ( ), ( )Infantile Cerebral Palsy ( )QdiliQdiili(ib) (344 00344 1)E2613/E2613/E2614E2614 Posterior PositioningBackHP2 Backrest HP2 Backrest E2617E2617Ct fbitdCt fbitdQuadriplegia, Quadriparesis, Paraplegia(Lower Limbs) ( )Other Paralytic Syndromes (Monoplegia of the Lower Limbs) ( )Congenital Hereditary Muscular Dystrophy ( )Hereditary Progressive Muscular Dystrophy ( )Monoplegia of Lower Limb ( )Spina Bifida ( )Custom fabricated Custom fabricated wheelchair backwheelchair backPhysipro does not offer Physipro does not offer products in this products in this category at this timecategory at this timeE2615E2615 Posterior LateralPositioning BackPhysipro does not offer products in this category at this timeOsteogenesis Imerfecta ( )Traumatic Brain Injury Resulting in Quadriplegia ( )Above the Knee Amputation ( - )E2620E2620 Planar with Laterals Positioning BackPhysipro does not offer products in this category at this tim