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.

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