## Definition
HCPCS Code K0835 designates a power wheelchair, specifically a Group 2 standard power wheelchair with no power options that is patient weight rated up to 300 pounds. This equipment serves as a mobility aid for individuals with significant functional impairments that hinder their ability to ambulate effectively without assistance. The wheelchair typically includes basic features and is designed to meet standard functional needs, suitable for use in a variety of home and community settings.
The code is categorized under the Healthcare Common Procedure Coding System, Level II, used predominantly for durable medical equipment, prosthetics, orthotics, and supplies furnished to Medicare beneficiaries. Group 2 power mobility devices, such as the K0835, are distinguished from Group 1 devices by their enhanced performance capabilities, including improved stability and drive-wheel functionality for use on uneven terrain when necessary.
This code is reserved for cases where the prescribing provider determines that a manual wheelchair, cane, or walker is insufficient to meet the patient’s mobility needs indoors. As such, K0835 is generally prescribed for individuals who require consistent, powered mobility assistance but do not need advanced functionalities like power tilt, recline, or other customizations.
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## Clinical Context
K0835 is most commonly prescribed for individuals with medical conditions such as advanced musculoskeletal disorders, neurological impairments, or other chronic diseases that severely limit mobility. Patients who qualify for this category of power wheelchair are those whose clinical assessments demonstrate that mobility deficits significantly restrict their performance of basic activities of daily living.
The equipment is considered medically necessary when the patient has the cognitive, visual, and functional capacity to safely operate a power wheelchair. Often, it is prescribed following a comprehensive evaluation by a physician and sometimes in conjunction with occupational or physical therapy to confirm the appropriateness of the device.
Additionally, K0835 is a suitable option for patients who require mobility solutions that can accommodate usage across multiple settings, including home spaces with limited accessibility features. While primarily used indoors, the device may be configured to provide basic outdoor functionality within the limitations of its design.
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## Common Modifiers
Several modifiers are associated with K0835 to indicate specific circumstances that may influence how the device is reimbursed. For example, the “RR” modifier is used to denote the item as being rented rather than purchased outright, often required for equipment under trial use or short-term medical necessity.
The “NU” modifier represents that the equipment is being purchased as a new item, typically when the patient demonstrates a long-term need for the wheelchair. Another frequent modifier, “KX,” is applied to confirm that documentation requirements have been met, signaling compliance with all medical necessity criteria.
Specific location-based modifiers, such as “RT” (right) or “LT” (left), are less commonly used with K0835, as this code typically does not pertain to anatomically specific devices. Still, location modifiers may be appended in rare cases or when paired with related accessories and components for the wheelchair.
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## Documentation Requirements
To justify reimbursement for K0835, stringent documentation requirements must be met to support its medical necessity. This includes a detailed evaluation from a treating physician describing the patient’s mobility limitations and why alternative devices (e.g., a manual wheelchair) are inappropriate for the patient’s condition.
The documentation must include assessments verifying the patient’s ability to safely operate the power wheelchair, as well as detailed records of a home assessment to ensure the environment is suitable for the device. Additionally, if applicable, consultation notes from supporting practitioners, such as occupational or physical therapists, must be part of the submitted records.
Suppliers are obligated to maintain comprehensive and accurate records, including signed physician prescriptions or detailed written orders, compliance with supplier standards, and certification that the patient has received training on proper equipment use. Non-compliance with these documentation standards often leads to claim delays or denials.
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## Common Denial Reasons
Claims for K0835 are frequently denied if the documentation fails to establish definitive medical necessity or if alternative, lower-cost mobility options are not appropriately ruled out. Denials may also occur in cases where the treating physician’s evaluation is incomplete or does not align with Medicare or payer policies for power mobility devices.
Another common reason for denial is the lack of a home assessment, as insurers must confirm that the environment accommodates the use of a power wheelchair. Procedural errors, such as missing or incorrectly applied modifiers, can also result in claim rejections or processing delays.
Finally, discrepancies between the patient’s condition and the selected code—for instance, prescribing K0835 to a patient requiring advanced power options—may lead to denial. Clear justification for why other codes or devices do not meet the patient’s needs is critical.
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## Special Considerations for Commercial Insurers
While K0835 is a code widely used by Medicare, coverage policies and criteria may vary significantly among commercial insurers. Commercial payers often have their unique documentation requirements, which may include additional forms or prior authorization beyond what Medicare mandates.
Cost-sharing obligations under private insurance plans may also differ, with some carriers requiring higher out-of-pocket expenses for durable medical equipment. Providers should carefully review individual plan details to ensure compliance and avoid unexpected payment denials.
Commercial insurers sometimes offer broader flexibility in terms of wheelchair upgrades or alternative accessories, provided there is sufficient justification. However, they may concurrently impose stricter timelines for submission and reimbursement compared to federal programs such as Medicare.
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## Similar Codes
K0835 is related to several other codes within the Group 2 power wheelchair category, each representing slightly different configurations or weight capacities. For example, HCPCS Code K0836 describes a Group 2 standard power wheelchair for patients weighing over 300 pounds, providing greater structural support.
Another closely related code, K0837, represents a Group 2 power wheelchair with a single power option, such as power tilt or recline, which is not included in basic models like the K0835. Yet another code, K0823, describes a Group 2 powered mobility device for individuals with less demanding mobility needs but with standard functionalities similar to K0835.
Providers must carefully differentiate between codes to ensure that the selected device aligns accurately with the patient’s clinical profile and insurer policies. Misclassification can lead to coverage denials or prolonged approval processes.