Invacare Tracer SX5 Wheelchair Configuration and Order Form

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Account Information

Special Note: HCPCS codes are not intended to be, nor should be considered billing or legal advice. Providers are responsible for determining the appropriate billing codes when submitting claims to the Medicare Program and should consult an attorney or other advisor to discuss specific situations in further detail.

IVCT™ Tracer® SX5 Wheelchairs

TRSX56FBP 16" x 16" Frame with Flip-Back Fixed Height Desk Length Arm - $1,086.96 K0003
TRSX58FBP 18" x 16" Frame with Flip-Back Fixed Height Desk Length Arm - $1,086.96 K0003
TRSX58FBFP 18" x 16" Frame with Flip-Back Fixed Height Full Length Arm - $1,086.96 K0003
TRSX50FBP 20" x 16" Frame with Flip-Back Fixed Height Desk Length Arm - $1,086.96 K0006 + E2201
TRSX50FBFP 20" x 16" Frame with Flip-Back Fixed Height Full Length Arm - $1,086.96 K0006 + E2201
TRSX52FBP 22" x 16" Frame with Flip-Back Fixed Height Desk Length Arm - $1,086.96 K0006 + E2201

Stock Front Rigging Options

T93HAP Hemi Sw. Footrests Aluminum Footplates w/ Heel Loops - $99.13 E0951
T93HCP Hemi Sw. Footrests Composite Footplates w/ Heel Loops - $99.13 E0951
T94HAP Hemi Sw. Elev Legrests Aluminum Footplates & Padded Calf Pad - $191.86 K0195
T94HCP Hemi Sw. Elev Legrests Composite Footplates & Padded Calf Pad - $191.86 K0195
AHL4A/U67 Hemi Smart Leg Articulating Legrests Aluminum Footplates - $341.09 K0053
T93HEP Hemi Sw. Footrests Composite Footplates (no heel loop) - $69.28
T94HEP Hemi Sw. Legrest Composite Footplates & Non-Padded Calfpad - $117.25 K0195

Frame and Seat Selections

Chair Type

TRSX5 Tracer SX5 Builder Wheelchair - $1,446.00 K0003

Frame Type

The below selections are based on 24" wheels and 8" casters, see seat-to-floor matrix.

ADULT Adult 19 1/2" - No Charge
HEMI Hemi 17 1/2" - No Charge

Frame Width and Depth

WD46 14" Wide x 16" Deep - No Charge E1236
Wheelchair base code changes to E1236 due to 14" seat width.
WD66 16" Wide x 16" Deep - No Charge
WD86 18" Wide x 16" Deep - No Charge
WD06 20" Wide x 16" Deep - No Charge K0006 + E2201
20" and 22" widths have 300 lbs. weight limit requiring 1228 casters (upcharge necessary, see "Casters" section), and 24" rear wheels (no upcharge). Wheelchair base code changes to K0006 (instead of K0003).
WD26 22" Wide x 16" Deep - $152.08 K0006 + E2201
20" and 22" widths have 300 lbs. weight limit requiring 1228 casters (upcharge necessary, see "Casters" section), and 24" rear wheels (no upcharge). Wheelchair base code changes to K0006 (instead of K0003).

Arm and Back Options

Arm Type

The below arm types are flip-back, non-removable.

18FB Full Length Fixed Height Flip-Back 10" - No Charge
19FB Full Length Adj. Height Flip-Back 10"-14" - $139.23 E0973
28FB Desk Length Fixed Height Flip-Back 10" - No Charge
29FB Desk Length Adj. Height Flip-Back 10"-14" - $139.23 E0973

Back Type

BH16 Back Height 16" - Standard
BH18 Back Height 18" - No Charge

Color Options

Upholstery Colors

U240 Black Nylon Upholstery - Standard
U67 Black Vinyl - No Charge
U550 Midnight Blue Vinyl Upholstery - No Charge
U86 Ruby Red Vinyl - No Charge

Positioning Strap Options

Seat Positioning Straps

1515 Push Button Style Positioning Strap - $53.55 E0978
1321BK Hook and Loop Seat Positioning Strap - $42.84 E0978

Casters

Caster Options

AT902 6" Composite Urethane 3 Spoke - No Charge
AT903 8" x 1 1/4" Composite Urethane - No Charge
1255 8" x 1" Solid Rubber Dark Grey - Standard
1228 8" x 1 3/4" Semi Pneumatic Casters Lt Grey - $59.98

Wheels

Wheel Options

U1763BK 20" Composite Urethane Tires - $121.02
U1764BK 22" Composite Urethane Tires - $121.02
2244BK 24" Composite Pneumatic Tires - $128.52
4244BK 24" Comp Pneumatic w/FF Inserts - $148.51 E2211 + E2212
U2222C 24" Composite Urethane Corded Tires - Standard
U2244BK 24" Composite Urethane Treaded Tires - $152.08 E2211 + E2212

Wheel Options (One Arm Drive)

The below selections are not available with the amputee attachment.

9456L One Arm Drive with U2222 LH - $649.03 E0958
9456R One Arm Drive with U2222 RH - $649.03 E0958

Handrim Options

COM Composite Handrims - Standard
Available with 24" rear wheels only.
CHDRM Chrome Plated Handrims - No Charge
AHDRM Aluminum Handrims - No Charge
Not available with U2222C rear wheels.

Wheel Locks

9690B Pull-To-Lock Wheel Locks (Std on Hemi) - No Charge
9691B Push-To-Lock Wheel Locks (Std on Adult) - No Charge

Accessories

Back Accessories

STC Stencil Back Upholstery - $31.06
1160 Carrying Pocket - $57.83

Seat Accessories

L8651 Omit Seat Upholstery - Less $10.00

Miscellaneous Accessories

1360 Adjustable Rear Anti-Tipper For 8" Casters - $87.82 E0971
1360A Adjustable Rear Anti-Tipper For 6" Casters - $87.82 E0971
9357L Amputee Attachment - $100.78 E0959
1329BK Toggle Wheel Lock Extension (8") - $41.77 E0961
1335 Non-Folding Device - $42.85
Not available on 20" and 22" widths. Not available with One Arm Drive.
1514 Overhead Anti-Theft Device - $49.27
Not available on 14" and 22" widths.
1497 Oxygen Holder Package Assembly - $161.72 E2208
Not available with One Arm Drive.
1496 IV/Oxygen Holder Package Assembly - $169.22 K0105 + E2208
Not available with One Arm Drive.
EXT2 Seat Extension Kit 2" - No Charge

Front Rigging Options

Front Riggings

T93HE Hemi Sw. Footrests Composite Footplates (no heel loop) - $69.28
Not available with 14" wide.
T93HA Hemi Sw. Footrests Aluminum Footplates w/ Heel Loops - $99.13 E0951
Not available with 14" wide.
T93HC Hemi Sw. Footrests Composite Footplates w/ Heel Loops - $99.13 E0951
Not available with 14" wide.
T94HE Hemi Sw. Legrest Composite Footplates & Non-Padded Calfpad - $117.25 K0195
T94HA Hemi Sw. Elev Legrests Aluminum Footplates & Padded Calf Pad - $191.86 K0195
Not available with 14" wide.
T94HC Hemi Sw. Elev Legrests Composite Footplates & Padded Calf Pad - $191.86 K0195
Not available with 14" wide. All calfpads are black.
AHL4A Hemi Smart Leg Articulating Legrests Aluminum Footplates - $341.09 K0053
Not available with 14" wide. All calfpads are black.
AHL4C Hemi Smart Leg Articulating Legrests Composite Footplates - $341.09 K0053
All calfpads are black.
AHS4A Hemi Smart Leg Articulating Legrestst-14" W Chairs - $341.09 K0053
All calfpads are black.
T93HS Hemi Footrests Aluminum Footplates w/ Heel Loops- 14" W Chairs - $95.93 E0951
Not available with 14" wide. All calfpads are black.
T94HS Hemi Elevating Legrests Aluminum Footplates & Padded Calf Pad- 14" W Chairs - $186.53 K0195
All calfpads are black.

Footplates Type

1350 Extra Large Footplates - $84.24 K0041
Not available with 14" wide.
AT5543 Adjustable Angle Flip-Up Footplates - $71.42 K0040

Footrest/Legrest Accessories

1820 Non - Removable Device - $12.79
1346 Heel Loops - $41.57 E0951
Already included on swingaway footrests T93HA, T93HC.

Specifications

Specification	Details
Seat Widths	14", 16", 20" or 22"
Overall Width	Seat Width plus 8 1/2"
Seat Depth	16"
Overall Depth	3 1/8" (18 x 16 without Front Riggings)
Back Heights	16" or 18"
Seat-to-Floor	17 1/2" or 19 1/2"
Weight Limit	250 lbs. (300 lbs. on 20" or 22" widths)
Chair Weight	34 3/4" (18 x 16 without Front Riggings)
Shipping Weight	44 1/4 lbs.

20-22 Wide (300 lb. weight limitation) Wheelchairs only: 8 x 1 3/4 inch semi-pneumatic front casters MUST be installed. DO NOT replace with any other size/style front caster. Otherwise, injury or damage may occur.

6-Inch Front Casters

SEAT-TO-FLOOR HEIGHT (IN INCHES)	FRONT CASTER MOUNTING POSITION	REAR WHEEL SIZE	REAR WHEEL MOUNTING POSITION
15 1/2	Top	20 Inch	Top
16 1/2	Middle	22 Inch	Top
17 1/2	Bottom	24 Inch	Top
17 1/2	Bottom	20 Inch	Bottom

8-Inch Front Casters

SEAT-TO-FLOOR HEIGHT (IN INCHES)	FRONT CASTER MOUNTING POSITION	REAR WHEEL SIZE	REAR WHEEL MOUNTING POSITION
17 1/2	Top	20 Inch	Bottom
17 1/2	Top	24 Inch	Top
18 1/2	Middle	22 Inch	Bottom
19 1/2	Bottom	24 Inch	Bottom

Rear Wheel Mounting Positions - Adult/Hemi Frame Style

Top

Bottom

6 or 8-Inch Fork Mounting Positions

Top

Middle

Bottom

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