DME MAC JURISDICTION C - CGS

Supplier Documentation Chapter 3K0863 Power wheelchair, group 3 very heavy duty, multiple power option, sling/solid seat/back, patientweight capacity 451 to 600 poundsK0864 Power wheelchair, group 3 extra heavy duty, multiple power option, sling/solid seat/back, patientweight capacity 601 pounds or moreK0868 Power wheelchair, group 4 standard, sling/solid seat/back, patient weight capacity up to andincluding 300 poundsK0869 Power wheelchair, group 4 standard, captains chair, patient weight capacity up to andincluding 300 poundsK0870 Power wheelchair, group 4 heavy duty, sling/solid seat/back, patient weight capacity 301to 450poundsK0871 Power wheelchair, group 4 very heavy duty, sling/solid seat/back, patient weight capacity 451 to600 poundsK0877 Power wheelchair, group 4 standard, single power option, sling/solid seat/back, patient weightcapacity up to and including 300 poundsK0878 Power wheelchair, group 4 standard, single power option, captains chair, patient weightcapacity up to and including 300 poundsK0879 Power wheelchair, group 4 heavy duty, single power option, sling/solid seat/back, patient weightcapacity 301 to 450 poundsK0880 Power wheelchair, group 4 very heavy duty, single power option, sling/solid seat/back, patientweight 451 to 600 poundsK0884 Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient weightcapacity up to and including 300 poundsK0885 Power wheelchair, group 4 standard, multiple power option, captain’s chair, weightcapacity up to and including 300 poundsK0886 Power wheelchair, group 4 heavy duty, multiple power option, sling/solid seat/back, patientweight capacity 301 to 450 poundsK0890 Power wheelchair, group 5 pediatric, single power option, sling/solid seat/back, patient weightcapacity up to and including 125 poundsK0891 Power wheelchair, group 5 pediatric, multiple power option, sling/solid seat/back, patient weightcapacity up to and including 125 poundsK0898 Power wheelchair, not otherwise classifiedK0899 Power mobility device, not coded by SADMERC or does not meet criteriaE0984 Manual wheelchair accessory, power add-on to convert manual wheelchair to motorizedwheelchair, tiller controlE0986 Manual wheelchair accessory, push activated power assist, eachAll codes for options/accessories for power wheelchairsWheelchair SeatingE0955 Wheelchair accessory, headrest, cushioned, prefabricated, including fixed mountinghardware, eachE0956 Wheelchair accessory, lateral trunk or hip support, prefabricated, including fixed mountinghardware, eachE0957 Wheelchair accessory, medial thigh support, prefabricated, including fixed mountinghardware, eachE0960 Wheelchair accessory, shoulder harness/straps or chest strap, including any typemounting hardwareE0966 Manual wheelchair accessory, headrest extension, eachE0992 Manual wheelchair accessory, solid seat insertE1028 Wheelchair accessory, manual swing-away, retractable or removable mounting hardwarefor joystick, other control interface or positioning accessoryE2291 Back, planar, for pediatric size wheelchair including fixed attaching hardwareE2292 Seat, planar, for pediatric size wheelchair including fixed attaching hardwareE2293 Back, contoured, for pediatric size wheelchair including fixed attaching hardwareE2294 Seat, contoured, for pediatric size wheelchair including fixed attaching hardwareE2601 General use wheelchair seat cushion, width less than 22 inches, any depthE2602 General use wheelchair seat cushion, width 22 inches or greater, any depthDME MAC Jurisdiction C Supplier Manual Page 6