MEDICARE HCPCS CODING FOR MATRX PRODUCTS
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1 MEDICARE HCPCS CODING F MATRX PRODUCTS Cushions Retail Medicare Code Allowable Matrx-Vi Cushion (to 21") $ E2607 $ Matrx-Vi Cushion (22") $ E2608 $ Matrx-Vi Heavy Duty Cushion (to 21") $ E2607 $ Matrx-Vi Heavy Duty Cushion (22"+) $ E2608 $ Matrx Flo-tech Cushion $ K0734 $ Matrx Flo-tech Bariatric Cushion (to 21") $ K0734 $ Matrx Flo-tech Bariatric Cushion (to 22"+) $ K0735 $ Backs Retail Medicare Code Allowable Genera Back $ E2611 $ Contour Back (to 21") $ E2613 $ Contour Back (22") $ E2614 $ High Back $ E2620 $ Matrx Posture Back (to 21") $ E2615 $ Matrx Posture Back Deep (to 21") $ E2615 $ Matrx Posture Back Heavy Duty (to 21") $ E2615 $ Matrx Posture Back Heavy Duty (22"+) $ E2616 $ Matrx Posture Back Heavy Duty Deep (to 21") $ E2615 $ Matrx Posture Back Heavy Duty Deep (22"+) $ E2616 $ Matrx Elite Back $ E2620 $ Headrest Combinations Retail Medicare Code Allowable Standard Hardware/Onyx Pad $ E0956 $ Standard Hardware/Standard Pad $ E0956 $ Standard Hardware/Stealth Pad $ E0956 $ Standard Hardware/Otto Bock Pad $ E0956 $ MultiAxis Hardware/Standard Pad $ E0956+E1028 $ MultiAxis Hardware/Stealth Pad $ E0956+E1028 $ MultiAxis Hardware/OttoBock Pad $ E0956+E1028 $ Stealth Hardware/Standard Pad $ E0956+E1028 $ Stealth Hardware/Stealth Pad $ E0956+E1028 $ Stealth Hardware/Otto Bock Pad $ E0956+E1028 $ Lateral Support Combinations Retail Medicare Code Allowable Fixed Hardware/Small Pad (each) $ E0956 $ Fixed Hardware/Medium Pad (each) $ E0956 $ Fixed Hardware/Large Pad (each) $ E0956 $ Swing Away Hardware/Small Pad (each) $ E0956+E1028 $ Swing Away Hardware/Medium Pad (each) $ E0956+E1028 $ Swing Away Hardware/Large Pad (each) $ E0956+E1028 $ Elite Laterals (each) $ E0956 $ Elite Offset Laterals (each) $ E0956 $ 98.16
2 MEDICARE HCPCS CODING ELIGIBILITY REQUIREMENTS A general use wheelchair back cushion (E2611) is covered for a patient who meets the following criteria: E2611 General Use Back Genera Back up to and including 20" wide, The cushion will be denied as not medically necessary if: The patient does not have a covered wheelchair The patient has a POV or a power wheelchair with a captain's chair seat and/or back cushion If a general use seat and/or back cushion is provided with a power wheelchair with a sling/solid seat/back, total payment for those items (cushion(s) plus the wheelchair) will be based on: The allowance for the least costly medically appropriate alternative e.g., the code for the comparable power wheelchair with Captain's Chair, if that code exists. (See Power Mobility Device policy for additional information.) Toll Free:
3 CONTOUR BACK A positioning wheelchair back cushion - posterior (E2613, E2614) posterior/lateral (E2615, E2616) and planar back with lateral supports (E2620) is covered for a patient who meets the following criteria: The patient has any significant postural asymmetries that are due to one of the following diagnoses: Anterior Horn Cell Diseases including Amyotrophic Lateral Sclerosis ( , ) Monoplegia of the lower limb ( , ) Hemiplegia ( , ) Stroke, Traumatic Brain Injury, or other Etiology, Muscular Dystrophy (359.0, 359.1) Torsion Dystonias (333.4, 333.6, ) Spinocerebellar Disease ( ) E2613 Posterior MaTRx Contour Back For HCPCS codes E2613, E2614, E2615, E2616 and E2620 Athetoid Cerebral Palsy (333.71) Leukodystrophy - unspecified Cerebral Degeneration in childhood ( ) Huntington s Chorea (333.4) Idiopathic Torsion Dystonia (333.6) Friedreich s Ataxia - Spinocerebellar Disease unspecified ( ) Syringomyelia and Syringobulbia - Myelopathy in other diseases classified elsewhere ( ) Neuromyelitis Optica - Demyelinating Disease of Central Nervous System unspecified ( ) Flaccid Hemiplegia and Hemiparesis affecting unspecified side - unspecified Hemiplegia and Hemiparesis affecting non-dominant side ( ) Monoplegia of lower limb affecting unspecified side - Monoplegia of lower limb affecting non-dominant side ( , ) Congenital Hereditary Muscular Dystrophy (359.0) Hereditary Progressive Muscular Dystrophy (359.1) Hemiplegia affecting unspecified side - Hemiplegia affecting non-dominant side ( ) E2614 E2615 E2616 E2620 Posterior Posterior/lateral Posterior/lateral Planar back with lateral supports MaTRx Contour Back 22" wide, MaTRx Posture Back MaTRx Posture Back Deep MaTRx Posture Back MaTRx Posture Back Deep 22" wide and greater, MaTRx Elite Back MaTRx High Back up to and including 20" wide,
4 CUSHION A combination skin protection and positioning wheelchair seat cushion (E2607 and E2608) is covered for a patient who meets the following criteria. The patient has either of the following: Current Pressure Ulcer (707.03, , ) Past history of a Pressure Ulcer on the area of contact with the seating surface (707.03, , ) The patient has Absent or Impaired Sensation in the area of contact with the seating surface or inability to carry out a functional weight shift due to one of the following diagnoses: Anterior Horn Cell Diseases including Amyotrophic Lateral Sclerosis ( , ) The patient has any significant postural asymmetries that are due to one of the following diagnoses: Monoplegia of the lower limb ( , ) Hemiplegia ( , ) Stroke, Traumatic Brain Injury, or other Etiology, Muscular Dystrophy (359.0, 359.1) Torsion Dystonias (333.4, 333.6, ) Spinocerebellar Disease ( ) For HCPCS codes E2607 and E2608 either one of the following ICD-9 codes: Leukodystrophy - unspecified Cerebral Degeneration in childhood ( ) Syringomyelia and Syringobulbia - Myelopathy in other diseases classified elsewhere ( ) Neuromyelitis Optica - Demyelinating Disease of Central Nervous System unspecified ( ) A combination of ICD-9 code , or one of the following ICD-9 codes: Athetoid Cerebral Palsy (333.71) Huntington s Chorea (333.4) Idiopathic Torsion Dystonia (333.6) Friedreich s Ataxia - Spinocerebellar Disease unspecified ( ) Flaccid Hemiplegia and Hemiparesis affecting unspecified side - unspecified Hemiplegia and Hemiparesis affecting non-dominant side ( ) Monoplegia of lower limb affecting unspecified side - Monoplegia of lower limb affecting non-dominant side ( , ) Congenital Hereditary Muscular Dystrophy (359.0) Hereditary Progressive Muscular Dystrophy (359.1) Hemiplegia affecting unspecified side - Hemiplegia affecting non-dominant side ( ) MEDICARE HCPCS CODING ELIGIBILITY REQUIREMENTS E2607 Combination Skin Protection and Positioning MaTRx-Vi Cushion E2608 Combination Skin Protection and Positioning MaTRx-Vi Cushion MaTRx-Vi Heavy Duty Cushion 22" wide and greater,
5 An adjustable skin protection wheelchair seat cushion (K0734 and K0735) is covered for a patient who meets the following criteria: The patient has either of the following: Current Pressure Ulcer (707.03, , ) Past history of a Pressure Ulcer on the area of contact with the seating surface (707.03, , ) The patient has Absent or Impaired Sensation in the area of contact with the seating surface or inability to carry out a functional weight shift due to one of the following diagnoses: Anterior Horn Cell Diseases including Amyotrophic Lateral Sclerosis ( , ) For HCPCS codes K0734 and KO735 Leukodystrophy - unspecified Cerebral Degeneration in childhood ( ) Syringomyelia and Syringobulbia - Myelopathy in other diseases classified elsewhere ( ) Neuromyelitis Optica - Demyelinating Disease of Central Nervous System unspecified ( ) Decubitus Ulcer, lower back (707.03) Decubitus Ulcer, hip (707.04) Decubitus Ulcer, buttock (707.05) K0734 Skin Protection, Adjustable Flo-tech Cushions K0735 Skin Protection, Adjustable Flo-tech Cushions 22" wide and greater, ** This information is not intended to be, nor should it be considered billing or legal advice. Providers are responsible for determining the appropriate billing codes when submitting claims to the Medicare Program and should consult an attorney or other advisor to discuss specific situations in further detail.
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