RETIRED - Correct Coding - Custom Fabricated Wheelchair Seat and Back Cushions - JA DME

DME MAC Joint Publication

Coding verification by the Pricing, Data Analysis, and Coding (PDAC) contractor requires that each application have clear and detailed information describing the product to allow a determination of which HCPCS code most closely represents the item.  Incomplete or unclear information can delay processing or result in an incorrect coding determination.  This article will discuss the information necessary for coding of custom fabricated wheelchair seat and back cushions.

The custom fabricated seat and back cushion HCPCS codes are:

E2609 CUSTOM FABRICATED WHEELCHAIR SEAT CUSHION, ANY SIZE

E2617 CUSTOM FABRICATED WHEELCHAIR BACK CUSHION, ANY SIZE, INCLUDING ANY TYPE MOUNTING HARDWARE

The current CODING GUIDELINES section of the Wheelchair Seating LCD Related Policy Article provides the following guideline defining custom cushions:

A custom fabricated seat cushion (E2609) and a custom fabricated back cushion (E2617) are cushions that are individually made for a specific beneficiary starting with basic materials including:

• liquid foam or a block of foam; and,
• sheets of fabric or liquid coating material.

The cushion must be fabricated using molded-to-beneficiary-model technique, direct molded-to-beneficiary technique, CAD-CAM technology, or detailed measurements of the beneficiary used to create a configured cushion.  The cushion must have structural features that significantly exceed the minimum requirements for a seat or back positioning cushion.  The cushion must have a removable vapor permeable or waterproof cover, or it must have a waterproof surface.  A custom fabricated cushion may include certain prefabricated components (e.g., gel or multi-cellular air inserts); these components must not be billed separately.  If a custom fabricated seat and back are integrated into a one-piece cushion, code as E2609 plus E2617.

If foam-in-place or other material is used to fit a substantially prefabricated cushion to an individual beneficiary, the cushion must be billed as a prefabricated cushion, not custom fabricated.

The following list summarizes the key elements from the coding guideline to help DMEPOS manufacturers be sure that their HCPCS coding application addresses all the requirements for products to be assigned to HCPCS codes E2609 and E2617.  Each application must include sufficient information demonstrating that the product is:

• Individually made for a specific beneficiary
• Made by starting with basic materials including (not all-inclusive):
  • Liquid foam or a block of foam
  • Sheets of fabric or liquid coating material
• Fabricated to create a configured cushion using one or more of the following techniques to capture the individual shape of the beneficiary:
  • Molded-to-beneficiary-model technique
  • Direct molded-to-beneficiary technique
  • CAD-CAM technology:
    • Allows for the use of direct digital scanning of the beneficiary or of a mold made directly from the beneficiary
    • Allows for direct milling of either:
      • A beneficiary-specific model used to shape the cushion contour
      • The cushion contours
  • Detailed measurements of the beneficiary used
• Constructed with structural features that significantly exceed the minimum requirements for a prefabricated seat or back positioning cushion (see below)
• Provided with a removable vapor permeable or waterproof cover or have a waterproof surface
• Optionally may include certain prefabricated components (e.g., gel or multi-cellular air inserts)
• Not made with foam-in-place or other material that is used to fit a substantially prefabricated cushion to an individual beneficiary

The minimum structural requirements for prefabricated seat and back positioning cushions are described in the applicable Coding Guidelines.  The relevant structural criteria are listed below (note: these are not the complete coding guidelines for prefabricated positioning seat and back cushions):

A positioning seat cushion (E2605, E2606) is a prefabricated cushion that has the following characteristics:

1. It has the minimum structural features described in (a) or (b):
   1. The feature must be at least 25 mm in height in the pre-loaded state.  It has two or more of the following:
      1. A pre-ischial bar or ridge which is placed anterior to the ischial tuberosities and prevents forward migration of the pelvis; or,
      2. Two lateral pelvic supports which are placed posterior to the trochanters and are intended to maintain the pelvis in a centered position in the seat and/or provide lateral stability to the pelvis; or,
      3. A medial thigh support which is placed in contact with the adductor region of the thigh and provides the prescribed amount of abduction and prevents adduction of the thighs; or,
      4. Two lateral thigh supports which are placed anterior to the trochanters and provide lateral stability to the lower extremities and prevent unwanted abduction of the thighs. 
   2. It has two or more air compartments located in areas which address postural asymmetries, each of which must have a cell height of at least 50 mm, must allow the user to add or remove air, and must have a valve which retains the desired air volume.

A positioning back cushion (E2613-E2616, E2620, E2621) is a prefabricated cushion which has the following characteristics:

1. For codes E2613-E2616, there is at least 25 mm of posterior contour in the pre-loaded state.  A posterior contour is a backward curve measured from a horizontal line in the midline of the cushion; and,
2. For posterior-lateral cushions (E2615, E2616) and for planar cushions with lateral supports (E2620, E2621), there is at least 75 mm of lateral contour in the pre-loaded state.  A lateral contour is a backward curve measured from a horizontal line connecting the lateral extensions of the cushion; and,
3. For posterior pelvic cushions (E2613, E2614), there is mounting hardware that is adjustable for horizontal position, depth, and angle.

Coding applications for cushions seeking coding as E2609 or E2617 must have detailed information describing how each of the criteria that define custom cushion criteria are met.  Particular attention to the descriptions about how the structural features that are elements of the custom cushion are made and how those elements exceed the requirements for the corresponding structural feature in the comparable type of prefabricated positioning cushion is recommended.

Refer to the Wheelchair Seating LCD, related Policy Article, and Standard Documentation for more information about coverage, coding, and documentation.

Access the PDAC website at https://www.dmepdac.com/ for any questions about the correct coding of products or call the PDAC Contact Center at 877-735-1326 between the hours of 8:30 a.m. and 4:00 p.m. CT.

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