Seating Perspectives
Cracking Cushion Codes
Q&A with Susan Cwiertnia, PT, MS, VARILITE
Sorting through the many seat cushion choices for complex rehab clients requires
more than clinical know-how; it also requires a thorough understanding of current
HCPCS codes. Cushion codes for skin protection and positioning — either separately
or in combination — get particularly intricate. Mobility Management asked
VARILITE’s Clinical Education Specialist, Susan Cwiertnia, PT, MS, for
the details. — Ed.
Q: What are the coverage criteria
differences among codes E2607-E2608; K0734-K0735 and K0736-K0737? From a clinical perspective,
how do an E2607-08 client, a K0736-K0737 client, and a K0734-K0735
client present?
Susan Cwiertnia: Qualifying for a
skin protection or skin protection and
positioning cushion is a lot like taking
those multiple choice tests in school
that we used to hate. Those tests were
frustrating because the answers were so
confusing. First, there was answer A to
consider. Next, answer B. And then C.
They all sounded like a possible correct
answer. If you read down further after
you thought you figured it out, answer
D might have been “all of the above,”
while answer E read something like “A
and B, but not C.”
The code K0734 is for a skin protection
wheelchair seat cushion, adjustable,
width less than 22", any depth.
The code K0735 is for a skin protection
wheelchair seat cushion, adjustable,
width 22" or greater, any depth. These
are considered to be your skin protection
cushions, and the requirements to
qualify for one of these focuses around
potential risk to develop a pressure
ulcer or having an existing pressure
ulcer.
Obviously, a client with a current
pressure ulcer would qualify for a skin
protection cushion. A client with a
history of a pressure ulcer would also
qualify for a skin protection cushion,
since they are more prone to developing
another pressure ulcer in the same area,
since those areas heal with weaker scar
tissue. The current or past history of
pressure ulcers has to be on the area
of contact with the seat surface, which
can be the lower back, hip or buttocks.
I have talked to providers that have
clearly documented even Stage I pressure
ulcers in the client’s records and
have been able to provide a skin protection
cushion for their client.
Q: Is a pressure ulcer the only way
that clients can qualify for a skin
protection cushion?
SC: They can also qualify if they lack
sensation in the areas of seated surface
contact, or have an inability to weight
shift due to a specific diagnosis. The
ICD-9 codes that are specified are
usually diagnoses that are higher risk
for skin breakdown because their
mobility for transfers and weight shifts
is more impaired, along with other
factors that make them more prone to
pressure ulcers. Examples of some of
the ICD-9 codes listed are quadriplegia,
paraplegia, spina bifida, post-polio
syndrome and MS.
Unfortunately, a client would have
to have one of these ICD-9 codes to
qualify if they didn’t have an existing
pressure ulcer or history of a pressure ulcer, because currently that is the
way Medicare chooses to define the
higher-risk client. Since no two people
with the same diagnosis ever present
exactly the same way or may have other
extenuating circumstances such as other
co-morbidities, it may leave out some
who would really benefit from a skin
protection cushion.
Until the LCD was changed in
December 2009, a person with the diagnosis
of stroke with hemiplegia qualified
only for a positioning cushion. The only
way they could qualify for a skin protection
cushion is if they had an existing
pressure ulcer, which is absurd because
that is what we are trying to prevent.
Q: And what are the criteria for skin
protection and positioning, combined
in one cushion?
SC: A combination skin protection
and positioning seat cushion (E2607,
E2608, K0736, K0737) is covered for a
patient who meets the criteria for both a
skin protection seat cushion and a positioning
seat cushion. This client would
have to have a diagnosis that is listed
in the ICD-9 codes for the skin protection
cushions, or they could qualify
by having a combination of a pressure
ulcer and a different diagnosis from a
second set of ICD-9 codes that represent
diagnoses that typically are not
at as high a risk for skin breakdown.
Examples of diagnoses from this group
of ICD-9 codes are myelitis, Friedreich’s
ataxia, and cerebellar ataxia.
Cushions in the codes K0734/K0735 are considered adjustable skin
protection cushions. They have to
test and meet all the same characteristics
and performance guidelines as their non-adjustable counterparts, the
E2603/E2604 skin protection cushion.
Adjustable means that the amount of
air or fl uid can be altered to match the
user’s needs.
The difference between the skin
protection and positioning codes
E2607/E2608 and K0736/K0737 is the
E codes are for non-adjustable cushions.
The adjustable part refers to the skin
protection-only features of the cushion
and not the positioning properties.
There is no way to generalize what
a client’s skin protection or postural
needs are based on a HCPCS code or
even a diagnosis. This is why wheelchair
seating is so complex and specialized,
requiring assistive technology to
be prescribed based on the individual’s
needs. The HCPCS codes require each
cushion in that category to meet specific
features and testing requirements,
but they may vary in many different
ways, such as in materials, design, ease
of use, etc. If you go to the Noridian
DME PDAC Web site and search the
code K0734, a list of 927 different
cushions from different manufacturers
would come up for that code. Testing
to specify what properties define skin
protection and other cushions are still
being developed — that may eventually
make the codes more specific.
Currently, the standards committee is
still working on development of testing
apparatuses and procedures.
This article originally appeared in the SCI Handbook October 2010 issue of Mobility Management.