HCPCS Coding & Medicare Coverage

Both the APK2, the SofTech are coded E2609 for Medicare reimbursement and private insurance reimbursement, and you do not need a doctor’s prescription to order and purchase any wheelchair cushion directly from Aquila but you will need a prescription to run through Medicare or other insurance. Below is the coverage policy information for any Aquila custom wheelchair cushion system.

UPDATE:

We have recently heard from DME companies that the most Medicare will pay towards a SofTech is a few hundred dollars and that the process can take up to a year to come through.

Private insurance and/or workers’ compensation may offer a different outcome.

Both the APK2 and the SofTech are coded E2609 for Medicare reimbursement and private insurance reimbursement.

Coverage Policy Information

Code: E2609, Custom Fabricated Seat Cushion Coverage Policy
A custom fabricated seat cushion (E2609) is covered if the following criteria are met:
1. Patient meets all of the criteria for a prefabricated skin protection seat cushion or positioning seat cushion;
2. There is a comprehensive written evaluation by a licensed clinician (who is not an employee of or otherwise paid by a supplier) which clearly explains why a prefabricated seating system is not sufficient to meet the patient’s seating and positioning needs.
To get custom seating funded, one must not only be able to justify the prescribed intervention, but document what has been used, assessed, and ruled out, and why other simpler less costly options didn’t work.

If a custom fabricated wheelchair cushion is provided for a patient who does not meet the stated coverage criteria, but the coverage criteria for another type of cushion are met, payment will be based on the allowance for the least costly medically appropriate alternative; if the criteria for another type of cushion are not met, the custom fabricated cushion will be denied as not medically necessary.
Skin Protection & Positioning Cushions Medicare Funding for Cushions, effective Dec 1, 2009.
Coverage Criteria – SKIN PROTECTION AND POSITIONING E2607

A combination skin protection and positioning seat cushion E2607 is covered for a patient who meets the criteria for both a skin protection seat cushion and a positioning seat cushion. See below:

Coverage Criteria – SKIN PROTECTION:

A skin protection seat cushion E2603, E2604, K0734, K0735 is covered for a patient who meets both of the following criteria:
1. The patient has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the patient meets Medicare coverage criteria for it; and
2. The patient has either of the following: a. Current pressure ulcer (ICD-9 CM codes 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
3. Absent or impaired sensation in the area of contact with the seating surface or 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 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), muscular dystrophy (359.0, 359.1), hemiplegia (342.00-342.92, 438.20-438.22)*, Huntington’s chorea (333.4)*, idiopathic torsion dystonia (333.6)*, athetoid cerebral palsy (333.71)*
* Effective for dates of service on or after December 1, 2009.

Coverage Criteria – POSITIONING:

A positioning seat cushion E2605, E2606 is covered for a patient who meets both of the following criteria:
1. The patient has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the patient meets Medicare coverage criteria for it; and
2. The patient has any significant postural asymmetries that are due to one of the diagnoses listed in criterion 2b above or to one of the following diagnoses: monoplegia of the lower limb (344.30-344.32, 438.40-438.42) due to stroke, traumatic brain injury, or other etiology, spinocerebellar disease (334.0-334.9), above knee leg amputation (897.2-897.7)*, osteogenesis imperfecta (756.51)*, transverse myelitis (323.82)*.
*Effective for dates of service on or after December 1, 2009

Letter of Medical Necessity

What does a letter of medical necessity need to include?
The letter of medical necessity must clearly identify the status of the patient and justify the APK2 or SofTech wheelchair cushion. Include the following in your letter:
- Past patient history
- The diagnosis
- What level the patient is expected to reach with the Aquila cushion.
- Expected progression
- What the wheelchair cushion will do for the patient that an off the shelf cushion could not
- Why the patient needs the APK2 or SofTech wheelchair cushion
- What specific product features of the cushion are needed by this patient. For example, the alternation of inflated cells will provide necessary pressure relief to prevent further breakdown, the MCU will keep the skin dry to prevent maceration, the positioning pad will compensate for pelvic obliquity.
The letter must also list all alternatives tried which did not meet the needs of the patient. Client requires an Aquila custom wheelchair cushion due to (select from the following):
- Absent or impaired sensation
- Current or history of pressure sores. Provide specific information about the pressure sores such as location and stage (I, II, III or IV) and/or high risk for breakdown
- Dependency on a wheelchair for mobility and uses his/her wheelchair for ___ hours per day
- Profuse diaphoresis with resultant skin maceration and unsanitary micro-environment
- Bowel / bladder incontinence resulting in skin maceration and unsanitary micro-environment
- Repetitive motion injury
Wording & Language Examples for Your Letter
- The APK2 and SofTech cushion systems are custom designed to address individual problems such as complete offloading of ischials and/or sacral area which are at risk for pressure sores while providing alternating pressure relief to all areas of the posterior.
- The optional moisture control unit provides a high volume of air across the surface of the pad to help keep (clients name here) skin dry and cool to prevent skin maceration in all climates.
- The cushion cover is machine washable and made with anti-microbial fabric and the cushion surface is easily cleaned to maintain a sanitary micro environment.
- The adjustable inflation adjustment allows the client to adapt the cushion for varying conditions to minimize trauma and repetitive motion injuries associated with normal utilization of a wheelchair.

HCPCS Coding & Medicare Coverage

Coverage Policy Information

Letter of Medical Necessity

Get Relief & Healing from Pressure Injuries