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Medicare Reimbursement Schedule

Wheelchair Cushions

HCPCS CodesWheelchair Product DescriptionProduct LinkNew Purchase Allowable w/ KE Modifier
(Manual Chair)
New Purchase Allowable w/o KE Modifier
(Power Chair)
Retail
E2601General Use Wheelchair Seat Cushion, width less than 22 inches, any depthCurve$67.89$58.51$88.00
Elements with Gel$109.00
E2602General Use Wheelchair Seat Cushion, width 22 inches or greater, any depthCurve$132.53$114.23$185.00
Elements with Gel$195.00
E2603Skin Protection Wheelchair Seat Cushion, width less than 22 inches, any depthAscent$168.26$145.02$245.00
Hyalite$237.00
E2604Skin Protection Wheelchair Seat Cushion, width 22 inches or greater, any depthAscent$209.12$180.25$306.00
Hyalite$309.00
E2605Positioning Wheelchair Seat Cushion, width less than 22 inches, any depthRidge$294.36$253.71$394.00
E2606Positioning Wheelchair Seat Cushion, width 22 inches or greater, any depthRidge$459.22$395.80$498.00
E2607Skin Protection and Positioning Wheelchair Seat Cushion, width less than 22 inches, any depthM2$321.72$277.29$390.00
Maxx$372.00
Acta-Embrace$352.00
E2608Skin Protection and Positioning Wheelchair Seat Cushion, width 22 inches or greater, any depthM2$386.35$333.00$418.00
Maxx$448.00
Acta-Embrace$428.00
Saddle 7 Series$473.00
E2609Custom fabricated wheelchair seat cushion, any sizeInceptionVariesVariesVaries
E2622Adjustable Skin Protection Wheelchair Seat Cushion, width less than 22 inches, any depthAdjuster$367.90$317.10$441.00
Adjuster X$441.00
Liberty X$462.19
E2623Adjustable Skin Protection Wheelchair Seat Cushion, width 22 inches or greater, any depthAdjuster$468.16$403.50$488.00
Adjuster X$488.00
Liberty X$462.19
E2624Adjustable Skin Protection and Positioning Wheelchair Seat Cushion, width less than 22 inches, any depthVector$370.93$319.71$462.00
Vector X$462.00
Versa X$462.00
M2 ATI$524.00
Acta-Embrace ATI$352.00
E2625Adjustable Skin Protection and Positioning Wheelchair Seat Cushion, width 22 inches or greater, any depthVector$469.58$404.73$509.00
Vector X$509.00
Versa X$509.00
M2 ATI$552.00
Acta-Embrace ATI$428.00
*Reimbursements may vary slightly by state. Retail prices vary slightly by product size.

Back Supports

HCPCS CodesWheelchair Product DescriptionProduct LinkNew Purchase Allowable w/ KE Modifier
(Manual Chair)
New Purchase Allowable w/o KE Modifier
(Power Chair)
Retail
E2611General Use Wheelchair Back Support, width less than 22 inches, any height, including any type mounting hardwareElements Back$346.69$298.82$354.00
Radius Back$481.00
Visco Back$439.00
E2612General Use Wheelchair Back Support, width 22 inches or greater, any height, including any type mounting hardwareElements Back$469.01$404.24$482.00
Radius Back$534.00
Visco Back$514.00
E2613Positioning Wheelchair Back Support, Posterior, width less than 22 inches, any height, including any type mounting hardwareActa-Back$436.25$376.01$507.00
IncrediBack$435.00
Acta-Embrace Back$530.00
Acta-Embrace LTS$696.52
E2614Positioning Wheelchair Back Support, Posterior, width 22 inches or greater, any height, including any type mounting hardwareActa-Back$603.74$520.37$596.00
IncrediBack$536.00
Acta-Embrace Back$678.00
Acta-Embrace LTS$786.07
E2615Positioning Wheelchair Back Support, Posterior Lateral, width less than 22 inches, any height, including any type mounting hardwareActa-Back Deep$502.06$432.72$601.00
IncrediBack$493.00
Acta-Relief$684.08
E2616Positioning Wheelchair Back Support, Posterior Lateral, width 22 inches or greater, any height, including any type mounting hardwareActa-Back Deep$675.49$582.21$677.00
IncrediBack$621.00
E2617Custom Fabricated Wheelchair Back SupportCustom Acta-BackVariesVariesVaries
Custom Acta-Back DeepVaries
Custom Acta-EmbraceVaries
E2620Positioning Wheelchair Back Support, Planar with Lateral Supports, width less than 22 inches, any height, including any type mounting hardwareActa-Back Contour$607.92$637.96$605.00
Acta-Back LTS$671.00
Acta-Relief LTS$870.65
E2621Positioning Wheelchair Back Support, Planar with Lateral Supports, width 22 inches or greater, any height, including any type mounting hardwareActa-Back Contour$637.96$549.86$679.00
Acta-Back LTS$744.00
Acta-Relief LTS$870.65
*Reimbursements may vary slightly by state. Retail prices vary slightly by product size.

Accessories

HCPCS CodesWheelchair Product DescriptionProduct LinkNew Purchase Allowable w/ KE Modifier
(Manual Chair)
New Purchase Allowable w/o KE Modifier
(Power Chair)
Retail
E1020Residual Limb Support for a wheelchairQuick-Release Amp$266.18$229.42$338.00
Swing-Away Amp$348.00
E1028Manual swing-away, retractable or removable mounting hardwareSwing Away Arm Hardware$229.25$197.59$263.00
EAD Arm Hardware$322.00
Durasoft Half Lap Tray Hardware$243.00
Swing Away Lateral Hardware$263.00
Head Support Hardware$211.00
E2209Arm trough with or without hand supportComfort Arm$118.95$102.52$138.00
Molded Arm$73.00
E0956Lateral trunk or hip support, any type including fixed mounting hardwareFlat Top Lateral Roll$109.42$94.30$72.00
Lateral Pads$79.00
E0955Cushioned head support, any type including fixed mounting hardwareBodiLink Head Support$224.42$196.93$230.00
E0995Calf rest/padCalf Protector$33.75$29.08$55.00
E2619Replacement cushion coverCushion Cover$55.57$47.88$60.00
E0992Solid seat insertRigid InsertN/A$105.62$63.00
K0108Wheelchair accessory, not otherwise specifiedComfort Foot SingleVariesVaries--------
Comfort Foot Double--------
*Reimbursements may vary slightly by state. Retail prices vary slightly by product size.