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MEDICARE REIMBURSEMENT SCHEDULE
| HCPCS Codes | Wheelchair Seat Cushion Description | Product Information | New Purchase Allowable w/ KE Modifier (Manual Chair) | New Purchase Allowable w/o KE Modifier (Power Chair) | Retail | ||
CUSHIONS | |||||||
| E2601 | General Use Wheelchair Seat Cushion, width less than 22 inches, any depth | Curve ® | Curve® | $66.23 | $57.07 | $88.00 | |
| Elements® Gel | Elements | $66.23 | $57.07 | $109.00 | |||
| E2602 | General Use Wheelchair Seat Cushion, width 22 inches or greater, any depth | Curve® | Curve® | $129.28 | $111.42 | $185.00 | |
| Elements® Gel | Elements® | $129.28 | $111.42 | $195.00 | |||
| E2603 | Skin Protection Wheelchair Cushion, width less than 22 inches, any depth | Ascent | Ascent | $164.13 | $141.16 | $245.00 | |
| Hyalite® | Hyalite® | $164.13 | $141.46 | $237.00 | |||
| TruForm | TruForm | $164.13 | $141.46 | $195.00 | |||
| E2604 | Skin Protection Wheelchair Cushion, width 22 inches or greater, any depth | Ascent | Ascent | $203.99 | $175.83 | $306.00 | |
| Hyalite® | Hyalite® | $203.99 | $175.83 | $309.00 | |||
| E2605 | Positioning Wheelchair Seat Cushion, width less than 22 inches, any depth | Ridge | Ridge | $291.44 | $251.19 | $394.00 | |
| E2606 | Positioning Wheelchair Seat Cushion, width 22 inches or greater, any depth | Ridge | Ridge | $454.67 | $391.88 | $498.00 | |
| E2607 | Skin Protection and Positioning Wheelchair Cushion, width less than 22 inches, any depth | M2 | M2 | $313.83 | $270.49 | $312.00 | |
| Maxx | Maxx | $313.83 | $270.49 | $372.00 | |||
| E2608 | Skin Protection and Positioning Wheelchair Cushion, width 22 inches or greater, any depth | M2 | M2 | $376.87 | $324.83 | $418.00 | |
| Maxx | Maxx | $376.87 | $324.83 | $448.00 | |||
| Saddle 7 Series | Saddle 7 Series | $376.87 | $324.83 | $473.00 | |||
| E2609 | Custom fabricated wheelchair seat cushion, any size | Comfort Designs Custom Cushion | $varies | $varies | $324.00 | ||
| E2622 | Adjustable Skin Protection Wheelchair Cushion, width less than 22 inches, any depth | Adjuster w/Vicair® | Adjuster® | $355.88 | $309.32 | $441.00 | |
| E2623 | Adjustable Skin Protection Wheelchair Cushion, width 22 inches or greater, any depth | Adjuster w/Vicair® | Adjuster | $456.67 | $393.60 | $488.00 | |
| E2624 | Adjustable Skin Protection and Positioning Wheelchair Cushion, width less than 22 inches, any depth | Vector w/Vicair® | Vector® | $361.83 | $311.87 | $462.00 | |
| E2625 | Adjustable Skin Protection and Positioning Wheelchair Cushion, width 22 inches or greater, any depth | Vector w/Vicair® | Vector® | $458.06 | $394.80 | $509.00 | |
BACKS | |||||||
| E2611 | General Use Wheelchair Back Cushion, width less than 22 inches, any height, including any type mounting hardware | Elements Back | Elements Back | $338.18 | $291.49 | $354.00 | |
| Radius Back® | Radius Back® | $338.18 | $291.49 | $481.00 | |||
| Visco-Back® | Visco-Back® | $338.18 | $291.49 | $439.00 | |||
| E2612 | General Use Wheelchair Back Cushion, width 22 inches or greater, any height, including any type mounting hardware | Elements Back | Elements Back | $457.50 | $394.32 | $482.00 | |
| Radius Back® | Radius Back | $457.50 | $394.32 | $534.00 | |||
| Visco-Back® | Visco-Back® | $457.50 | $394.32 | $514.00 | |||
| E2613 | Positioning Wheelchair Back Cushion, Posterior, width less than 22 inches, any height, including any type mounting hardware | Acta-Back® | Acta-Back® | $425.55 | $366.78 | $507.00 | |
| IncrediBack® | Incrediback® | $425.55 | $366.78 | $435.00 | |||
| E2614 | Positioning Wheelchair Back Cushion, Posterior, width 22 inches or greater, any height, including any type mounting hardware | Acta-Back® | Acta-Back® | $588.92 | $507.60 | $596.00 | |
| IncrediBack® | Incrediback® | $588.92 | $507.60 | $536.00 | |||
| E2615 | Positioning Wheelchair Back Cushion, Posterior Lateral, width less than 22 inches, any height, including any type mounting hardware | Acta-Back® Deep | Acta-Back® Deep | $489.75 | $422.10 | $601.00 | |
| IncrediBack® Deep | Incrediback® Deep | $489.75 | $422.10 | $493.00 | |||
| E2616 | Positioning Wheelchair Back Cushion, Posterior Lateral, width 22 inches or greater, any height, including any type mounting hardware | Acta-Back® Deep | Acta-Back® Deep | $658.92 | $567.93 | $677.00 | |
| IncrediBack® Deep | Incrediback® | $658.92 | $567.93 | $621.00 | |||
| E2617 | Custom Fabricated Wheelchair Back Cushion | Custom ActaRelief Back | $varies | $varies | $810.00 | ||
| Custom ActaBack | $varies | $varies | $672.00 | ||||
| Custom ActaBack Deep | $varies | $varies | $778.00 | ||||
| Custom Embrace Back | $varies | $varies | $672.00 | ||||
| E2620 | Positioning Wheelchair Back Cushion, Planar with Lateral Supports, width less than 22 inches, any height, including any type mounting hardware | Spider Deep Back | Spider-Back | $593.01 | $511.11 | $719.00 | |
| Visco-Back® Deep | Visco-Back® Deep | $593.01 | $511.11 | $539.00 | |||
| E2621 | Positioning Wheelchair Back Cushion, Planar with Lateral Supports, width 22 inches or greater, any height, including any type mounting hardware | Spider Deep Back | Spider-Back | $622.31 | $536.37 | $797.00 | |
| Visco-Back® Deep | Visco-Back® Deep | $622.31 | $536.37 | $613.00 | |||
ACCESSORIES | |||||||
| E1020 | Residual Limb Support for a wheelchair | Amp | Amp | $263.54 | $227.15 | $338.00 | |
| Swing Away Amp | Swing Away Amp | $263.54 | $227.15 | $348.00 | |||
| E1028 | Manual swing away, retractable or removable, mounting hardware | Swing Away Arm Hardware | Swing Away Amp | $223.62 | $192.74 | $263.00 | |
| EAD Arm Hardware | $223.62 | $192.74 | $322.00 | ||||
| DuraSoft Half Lap Tray Hardware | Lap Trays | $223.62 | $192.74 | $243.00 | |||
| Swing Away Lateral Hardware | Swing Away Amp | $223.62 | $192.74 | $263.00 | |||
| Headrest Hardware | Headrest | $223.62 | $192.74 | $211.00 | |||
| E2209 | Arm trough with or without hand support | Comfort Arm® | Comfort Arm® | $116.03 | $100.00 | $138.00 | |
| Molded Arm | Molded Arm | $116.03 | $100.00 | $73.00 | |||
| E0956 | Lateral trunk or hip support, any type including fixed mounting hardware | Flat Top Lateral Roll | Flat Top Lateral Roll | $106.74 | $91.99 | $72.00 | |
| Lateral Pads | Laterals | $106.74 | $91.99 | $79.00 | |||
| E0955 | Cushioned headrest, any type including fixed mounting hardware | Headrest | Headrest | $218.91 | $188.68 | $230.00 | |
| E0995 | Calf rest/pad | Calf Protector | Calf Protector | $32.92 | $28.37 | $55.00 | |
| E0978 | Positioning belt/safety belt, pelvic strap | Gait Belt | Gait Belt | $46.25 | $39.85 | $20.00 | |
| E0950 | Tray | DuraSoft Lap Tray | Lap Trays | $112.55 | $97.01 | $166.00 | |
| DuraSoft Half Tray | Lap Trays | $112.55 | $97.01 | $127.00 | |||
| Flip-Up Half Tray | Lap Trays | $112.55 | $97.01 | $156.00 | |||
| EconoSoft Lap Tray | Lap Trays | $112.55 | $97.01 | $84.00 | |||
| E2619 | Replacement Cushion Cover | Replacement Cushion Cover | Replacement Cushion Cover | $55.57 | $47.88 | $60.00 | |
| E0992 | Solid Seat Insert | Rigid Insert | Rigid Insert | $N/A | $103.03 | $63.00 | |
| K0108 | Wheelchair Accessory, not otherwise specified | Wheelchair Accessory | $ | $ | $ | ||
DOWNLOADS
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Seating Code Coverage Determinations
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Medicare Seating Code Explanations
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