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2
C
B
USHIONS AND
ACKS
Specialty wheelchair backs and
cushions, such as the Jay
Back and Cushion, are covered
items by Medicare with appropriate
justification. Coding for all Jay
products can be found on our
website at:
www.sunrisemedical.com.
3
H
EIGHT
A
DJUSTABLE
A
K0016
RMRESTS
• Patient's body dimensions
cannot be accommodated by
a standard height arm for
functional positioning, weight
shifts or lateral transfers.
• Adjustable height armrests are
required for upper extremity
support and postural stability.
4
A
-T
K0021
NTI
IPS
• Anti-tips are required to prevent
the wheelchair from falling over
backwards during transfers.
• Anti-tips are required for safety
to prevent the wheelchair from
tipping over when encountering
obstacles.
5
W
L
HEEL
OCKS
Anti-Rollback Devices
(Grade Aids)
K0080
• Upper extremity weakness, range
of motion, balance, endurance
and/or tonal anomalies require
the use of an anti-rollback
device for functional propulsion
of a manual wheelchair on
inclines and/or thresholds.
Wheel Lock Extensions
K0079
• Wheel lock extensions are needed
due to the client's weakness in
their upper extremities.
• This feature will allow independent
access to the wheel locks of the
wheelchair.
• Upper extremity weakness,upper/
lower extremity range of motion,
tonal anomalies, balance, vision/
perception and/or body dimension
require the use of wheel lock
extension for functional
transfers and/or independent
living activities.
Unilateral
K0108
• Can increase independence in
performing transfers and ADLS
while in the wheelchair by
providing a client who has
only one functioning upper
extremity a means of securing
the wheelchair.
2
®
C
LINICAL
®
2
1
Adjustable Axle Plate - K0005
• The adjustable axle allows the center of gravity
• The ability to create a "dump seat" with the
• The adjustable rear axle plate allows for vertical
• Upper extremity weakness, decreased range of
• Poor balance, postural control and/or tonal anomalies
Note: Please be sure to provide a separate list of
activities of daily living, including outside activities,
and document why a lower level wheelchair will
not meet the client's needs.
3
6
1
K0005
B
ENEFITS
of the wheelchair to be repositioned for
maximum user independent maneuverability.
adjustable axle plate and the adjustable caster
housing provides a minimal fixed tilt that will
assist in positioning, swallowing, breathing and head
support.
and horizontal wheel changes, as well as camber
options so the wheelchair can be adjusted to the
users' exact needs and abilities for maximizing
the energy expended to self-propel the wheelchair.
motion, spasticity and/or poor endurance prevent
the patient from functional propulsion of a high
strength lightweight wheelchair with fixed or
minimally adjustable axle plate.
require the ability to change seat angles which are a
component of rear angle adjustment.
2
7
2
9
5
4
Plastic Coated
K0059
Oblique
K0062/K0063
• Plastic coated/oblique handrims
are medically necessary due to
the beneficiary's weakness in
the hands and associated deficits
in strength. This feature will
facilitate independent propulsion
of the wheelchair within their
home environment.
• The client has decreased range
of motion and weakness of the
upper extremities. Plastic coated/
oblique handrims are required for
improving the patient's grip on
the handrim, which improves
stroke propulsion.
• A pelvic positioning belt is required
to maintain the pelvis in neutral
position due to upper extremity
functional limitation; it will also
increase client safety.
• A pelvic positioning belt is required
to position the client's hips at
the back of the wheelchair and
to prevent sliding forward in
wheelchair during mobility due
to weakness within the trunk.
Angle Adjustable
K0040
• Angle adjustable footplates are
medically necessary due to lack
of range of motion in the end
user's ankles.
• Angle adjustable footplates are
necessary in order to permit
angle adjustment of the feet to
accommodate fixed deformities.
• To accommodate dorsior planar
flexion of the ankles.
Heel Loops
K0034
• Heel loops are required to keep
the lower extremities in an
optimal position.
• To prevent foot/caster interference.
8
• Elevating legrests are required
to position the lower extremities
due to decreased flexion and
to prevent further decrease
in range of motion.
• Patient has compromised
circulation resulting in severe
lower extremity edema, in which
ELRs may be able to assist.
©2002 Sunrise Medical Inc.
932079 Rev.A
6
H
ANDRIMS
7
P
ELVIC
P
OSITIONING
D
- K0031
EVICE
8
F
OOT
P
LATES
9
L
/
EGREST
ELR - K0048
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