Wheelchairs and K0004 Claim Documentation

Original Effective Date: 04/01/2000           
Revision Effective Date: 11/01/2013

According to the Regional Medical Review Policy on the Manual Wheelchair Base, a high strength, lightweight wheelchair (K0004) is covered when a patient meets the criteria in (1) and/or (2):

  • The patient self-propels the wheelchair while engaging in frequent activities that cannot be performed in a standard or lightweight wheelchair.
  • The patient requires a seat width, depth, or height that cannot be accommodated in a standard, lightweight or hemi-wheelchair and spends at least 2 hours per day in the wheelchair.

For a beneficiary that does not meet criteria number one but does meet criteria number two for a wheelchair coded K0004, coverage is considered for claims accompanied by documentation in additional to the Certificate of Medical Necessity (CMN). We recommend such documentation include:

  • the wheelchair dimension(s) that necessitated the K0004 wheelchair that was provided, and
  • an explanation of the reasons the patient needs the particular wheelchair dimension(s) that necessitate the use of the K0004 wheelchair.

The explanation in B should:

  • be derived from a patient-specific wheelchair evaluation,
  • include relevant patient measurements, and
  • provide detailed information on how the patient's
  • individual functional needs affect the wheelchair
  • dimension(s) that necessitate use of the K0004.

Patient measurements provided may include, but would not necessarily be limited to, the patient's hip-to-hip width, a measurement of the patient's most posterior point to the bend of knee, and/or height from seating surface to top of shoulder. The description of how the patient's functional needs affect the wheelchair dimensions may include, but would not necessarily be limited to, whether the patient self-propels, how the patient self-propels, and/or the degree of truncal support the patient requires and why. The documentation should relate the patient measurement and function to the wheelchair dimension(s).

The documentation provided will be used to determine whether the beneficiary meets the criteria for the K0004 wheelchair. If criteria for a K0004 are not met but criteria for a K0003 are met, payment will be based on the least costly medically appropriate alternative, K0003. If the criteria for a K0003 are not met, but are met for a standard wheelchair, payment will be made for the least costly medically appropriate alternative, K0001.

Last Updated May 11 , 2017