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Medicare Reimbursement Schedule
Cushions, Backs, & Accessories
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HCPCS
Codes |
Wheelchair Seat
Cushion Description |
The Comfort Company
Product Assignments |
Medicare
PDF |
New Purchase Allowable
w/ KE Modifier
(Manual Chair) |
New Purchase Allowable
w/out KE Modifiers
(Power Chair) |
Retail |
Cushions
|
| E2601 |
General Use Wheelchair Seat Cushion,width less than 22 inches, any depth. |
Curve |
|
$64.22 |
$55.35 |
$84.00 |
| Elements Gel |
|
$64.22 |
$55.35 |
$84.00 |
| E2602 |
General Use Wheelchair Seat Cushion, width 22 inches or greater, any depth. |
Curve |
|
$125.37 |
$108.06 |
$179.00 |
| Elements Gel |
|
$125.37 |
$108.06 |
$179.00 |
| Support Pro 7 Series |
|
$125.37 |
$108.06 |
$315.00 |
| Support Pro 7 Series w/Gel |
|
$125.37 |
$108.06 |
$460.00 |
|
| E2603 |
Skin Protection Wheelchair Cushion, width less than 22 inches, any depth. |
TruForm 4" |
|
$159.17 |
$137.19 |
$205.00 |
| Ascent |
|
$159.17 |
$137.19 |
$226.00 |
| Hyalite |
|
$159.17 |
$137.19 |
$226.00 |
| E2604 |
Skin Protection Wheelchair Cushion, width 22 inches or greater, any depth. |
TruForm 4" |
|
$197.83 |
$170.51 |
$268.00 |
| Ascent |
|
$197.83 |
$170.51 |
$284.00 |
| Hyalite |
|
$197.83 |
$170.51 |
$295.00 |
|
| E2605 |
Positioning Wheelchair Seat Cushion, width less than 22 inches, any depth. |
Ridge |
|
$282.63 |
$243.60 |
$342.00 |
| E2606 |
Positioning Wheelchair Seat Cushion, width 22 inches or greater, any depth. |
Ridge |
|
$440.93 |
$380.04 |
$441.00 |
|
| E2607 |
Skin Protection and Positioning Wheelchair Cushion, width less than 22 inches, any depth. |
Saddle Zero Elevation |
|
$304.34 |
$262.31 |
$305.00 |
| Saddle Zero Elevation w/Gel |
|
$304.34 |
$262.31 |
$315.00 |
| Saddle Wedge |
|
$304.34 |
$262.31 |
$321.00 |
| Saddle Wedge w/Gel |
|
$304.34 |
$262.31 |
$331.00 |
| Saddle Anti-Thrust |
|
$304.34 |
$262.31 |
$321.00 |
| Saddle Anti Thrust w/Gel |
|
$304.34 |
$262.31 |
$331.00 |
| M2 |
|
$304.34 |
$262.31 |
$305.00 |
| Maxx |
|
$304.34 |
$262.31 |
$342.00 |
| E2608 |
Skin Protection and Positioning Wheelchair Cushion, width 22 inches or greater, any depth. |
Saddle Zero Elevation |
|
$365.49 |
$315.02 |
$389.00 |
| Saddle Zero Elevation w/Gel |
|
$365.49 |
$315.02 |
$483.00 |
| Saddle 7 Series |
|
$365.49 |
$315.02 |
$504.00 |
| Saddle 7 Series w/Gel |
|
$365.49 |
$315.02 |
$672.00 |
| Saddle Wedge |
|
$365.49 |
$315.02 |
$410.00 |
| Saddle Wedge w/Gel |
|
$365.49 |
$315.02 |
$504.00 |
| Saddle Anti-Thrust |
|
$365.49 |
$315.02 |
$410.00 |
| Saddle Anti Thrust w/Gel |
|
$365.49 |
$315.02 |
$504.00 |
| M2 |
|
$365.49 |
$315.02 |
$378.00 |
| Maxx |
|
$365.49 |
$315.02 |
$415.00 |
| E2609 |
Custom fabricated wheelchair seat cushion, any size |
Custom Designs Cushion |
--- |
varies |
$324.00 |
|
| K0734 |
Adjustable Skin Protection Wheelchair Cushion, width less than 22 inches, any depth. |
Adjuster w/ Vicair |
|
$348.04 |
$299.98 |
$420.00 |
| K0735 |
Adjustable Skin Protection Wheelchair Cushion, width 22 inches or greater, any depth. |
Adjuster w/ Vicair |
|
$442.87 |
$381.71 |
$420.00 |
|
| K0736 |
Adjustable Skin Protection and Positioning Wheelchair Cushion, width less than 22 inches, any depth. |
Vector w/ Vicair |
|
$350.90 |
$302.44 |
$440.00 |
| K0737 |
Adjustable Skin Protection and Positioning Wheelchair Cushion, width 22 inches or greater, any depth. |
Vector w/ Vicair |
|
$444.21 |
$382.87 |
$485.00 |
Backs
|
| E2611 |
General Use Wheelchair Back Cushion, width less than 22 inches. |
ViscoBack |
|
$327.97 |
$282.68 |
$452.00 |
| ViscoBack Tall |
|
$327.97 |
$282.68 |
$504.00 |
| ViscoBack Low |
|
$327.97 |
$282.68 |
$520.00 |
| Elements Back |
|
$327.97 |
$282.68 |
$347.00 |
| Radius Back |
|
$327.97 |
$282.68 |
$452.00 |
| Elements Back Low |
|
$327.97 |
$282.68 |
$347.00 |
| Radius Back Tall |
|
$327.97 |
$282.68 |
$475.00 |
| E2612 |
General Use Wheelchair Back Cushion, width 22 inches or greater. |
ViscoBack |
|
$443.67 |
$382.40 |
$504.00 |
| ViscoBack Tall |
|
$443.67 |
$382.40 |
$557.00 |
| Elements Back |
|
$443.67 |
$382.40 |
$473.00 |
| Radius Back |
|
$443.67 |
$382.40 |
$504.00 |
| Elements Low Back |
|
$443.67 |
$382.40 |
$473.00 |
| Radius Back Tall |
|
$443.67 |
$382.40 |
$540.00 |
|
| E2613 |
Positioning Wheelchair Back Cushion, posterior, width less than 22 inches. |
ActaBack |
|
$412.69 |
$355.70 |
$504.00 |
| ActaBack Tall |
|
$412.69 |
$355.70 |
$556.00 |
| ActaBack Low |
|
$412.69 |
$355.70 |
$588.00 |
| ActaBack 18" Tall |
|
$412.69 |
$355.70 |
$504.00 |
| Incrediback |
|
$412.69 |
$355.70 |
$426.00 |
| Incrediback Tall |
|
$412.69 |
$355.70 |
$499.00 |
| E2614 |
Positioning Wheelchair Back Cushion, posterior, width 22 inches or greater. |
ActaBack |
|
$571.13 |
$492.26 |
$578.00 |
| ActaBack Tall |
|
$571.13 |
$492.26 |
$630.00 |
| ActaBack 18" Tall |
|
$571.13 |
$492.26 |
$578.00 |
| Incrediback |
|
$571.13 |
$492.26 |
$525.00 |
| Incrediback Tall |
|
$571.13 |
$492.26 |
$599.00 |
|
| E2615 |
Positioning Wheelchair Back Cushion, posterior-lateral, width less than 22 inches. |
ActaBack Deep |
|
$474.94 |
$492.26 |
$630.00 |
| Incrediback Deep |
|
$474.94 |
$492.26 |
$483.00 |
| Incrediback Deep Tall |
|
$474.94 |
$492.26 |
$536.00 |
| E2616 |
Positioning Wheelchair Back Cushion, posterior-lateral, width 22 inches or greater. |
ActaBack Deep |
|
$639.01 |
$550.76 |
$725.00 |
| Incrediback Deep |
|
$639.01 |
$550.76 |
$609.00 |
| Incrediback Deep Tall |
|
$639.01 |
$550.76 |
$641.00 |
| E2617 |
Custom Fabricated Wheelchair Back Cushion |
Custom Designs Back |
|
varies |
$950.00 |
|
| E2620 |
Positioning Wheelchair Back Cushion, planar with lateral supports, width less than 22 inches. |
ViscoBack Deep |
|
$575.09 |
$495.67 |
$662.00 |
| Spider Deep Back |
|
$575.09 |
$495.67 |
$662.00 |
| E2621 |
Positioning Wheelchair Back Cushion, planar with lateral supports, width 22 inches or greater. |
ViscoBack Deep |
|
$603.50 |
$520.16 |
$872.00 |
| Spider Deep Back |
|
$603.50 |
$520.16 |
$872.00 |
Accessories
|
| E1020 |
Residual limb support for a wheelchair. |
Amp |
|
$255.58 |
$220.29 |
$305.00 |
| Swing Away Amp |
|
$255.58 |
$220.29 |
$315.00 |
| E1028 |
Manual swing-away, rectractable, or removable hardware. |
Swing Away Arm Hardware |
(no pdf available) |
$216.87 |
$186.92 |
$263.00 |
| EAD Arm Hardware |
$300.00 |
| DuraSoft Lap Tray Hardware |
$231.00 |
| Swing Away Lateral Hardware |
$263.00 |
| Headrest Hardware |
$279.00 |
| E2209 |
Arm trough with or without hand support. |
Comfort Arm |
|
$112.52 |
$96.98 |
$84.00 |
| Molded Arm |
|
$83.00 |
| E0956 |
Lateral trunk or hip support, any type including fixed
mounting hardware. |
Flat Top Lateral Roll |
|
$103.58 |
$89.21 |
$69.00 |
| Lateral Pads |
|
$53.00 |
| E0955 |
Cushioned headrest,
any type including fixed mounting hardware. |
Headrest |
|
$212.29 |
$182.97 |
$221.00 |
| E0995 |
Calf Rest/Pad. |
Calf Protector |
|
$31.92 |
$27.51 |
$53.00 |
| E0978 |
Positioning belt/safety belt, pelvic strap. |
Gait Belt |
(no pdf available) |
$47.26 |
$40.73 |
$19.00 |
| E0950 |
Tray. |
DuraSoft Lap Tray |
|
$193.03 |
$166.38 |
$231.00 |
| DuraSoft Half Tray |
|
$122.00 |
| Flip-Up Half Tray |
|
$137.00 |
| EconoSoft Lap Tray |
|
$84.00 |
| K0108 |
Wheelchair accessory not otherwise specified. |
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