NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES
For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Information provided in this policy article relates to determinations other than those based on Social Security Act §1862(a)(1)(A) provisions (i.e. “reasonable and necessary”).
Hospital Beds are covered under the Durable Medical Equipment benefit (Social Security Act §1861(s)(6)). In order for a beneficiary’s equipment to be eligible for reimbursement the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met.
A bed board (E0273, E0315) is noncovered since it is not primarily medical in nature.
An over bed table (E0274, E0315) is noncovered because it is not primarily medical in nature.
Trapeze bars attached to a bed (E0910, E0911) are noncovered when used on an ordinary bed.
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed. Reg Vol 217)
Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated. The required Face-to-Face Encounter and Written Order Prior to Delivery List is available here.
Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.
If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD, it will be eligible for coverage.
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS
In addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.
Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below.
MODIFIERS
KX, GA, AND GZ MODIFIERS:
Suppliers must add a KX modifier to a hospital bed code only if all of the criteria in the “Coverage Indications, Limitations and/or Medical Necessity” section of the related LCD have been met.
The KX modifier should also be added for an accessory when the applicable accessory criteria are met. If the requirements for the KX modifier are not met, the KX modifier must not be used.
If all of the coverage criteria have not been met, the GA or GZ modifier must be added to a claim line for a hospital bed and accessories. When there is an expectation of a medical necessity denial, suppliers must enter the GA modifier on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or the GZ modifier if they have not obtained a valid ABN.
Claim lines billed without a KX, GA or GZ modifier will be rejected as missing information.
UPGRADE MODIFIERS:
When a hospital bed upgrade is provided, the GA, GK, GL and/or GZ modifiers must be used to indicate the upgrade. Fully electric hospital beds must always be billed with these modifiers.
CODING GUIDELINES
A fixed height hospital bed is one with manual head and leg elevation adjustments but no height adjustment.
A variable height hospital bed is one with manual height adjustment and with manual head and leg elevation adjustments.
A semi-electric bed is one with manual height adjustment and with electric head and leg elevation adjustments.
A total electric bed is one with electric height adjustment and with electric head and leg elevation adjustments.
An ordinary bed is one that is typically sold as furniture. It may consist of a frame, box spring and mattress. It is a fixed height and may or may not have head or leg elevation adjustments.
E0301 and E0303 are hospital beds that are capable of supporting a beneficiary who weighs more than 350 pounds, but no more than 600 pounds.
E0302 and E0304 are hospital beds that are capable of supporting a beneficiary who weighs more than 600 pounds.
E0316 is a safety enclosure used to prevent a beneficiary from leaving the bed.
E1399 should be used for products not described by the specific HCPCS codes above.
A Column II code is included in the allowance for the corresponding Column I code when provided at the same time and must not be billed separately at the time of billing the Column I code.
| Column I |
Column II |
| E0250 |
E0271, E0272, E0305, E0310 |
| E0251 |
E0305, E0310 |
| E0255 |
E0271, E0272, E0305, E0310 |
| E0256 |
E0305, E0310 |
| E0260 |
E0271, E0272, E0305, E0310 |
| E0261 |
E0305, E0310 |
| E0265 |
E0271, E0272, E0305, E0310 |
| E0266 |
E0305, E0310 |
| E0290 |
E0271, E0272 |
| E0292 |
E0271, E0272 |
| E0294 |
E0271, E0272 |
| E0296 |
E0271, E0272 |
| E0301 |
E0305, E0310 |
| E0302 |
E0305, E0310 |
| E0303 |
E0271, E0272, E0305, E0310 |
| E0304 |
E0271, E0272, E0305, E0310 |
| E0328 |
E0271, E0272, E0305, E0310 |
| E0329 |
E0271, E0272, E0305, E0310 |
When mattress or bedside rails are provided at the same time as a hospital bed, use the single code that combines these items.
E0271, E0272: Mattress, innerspring/foam rubber
-
When combined with E0251, bill as E0250
-
When combined with E0291, bill as E0290
-
When combined with E0293, bill as E0292
-
When combined with E0295, bill as E0294
-
When combined with E0266, bill as E0265
-
When combined with E0297, bill as E0296
-
When combined with E0301, bill as E0303
-
When combined with E0302, bill as E0304
E0305, E0310: Bedside rails, half-length/full-length
-
When combined with E0290, bill as E0250
-
When combined with E0291, bill as E0251
-
When combined with E0292, bill as E0255
-
When combined with E0293, bill as E0256
-
When combined with E0294, bill as E0260
-
When combined with E0295, bill as E0261
-
When combined with E0296, bill as E0265
-
When combined with E0297, bill as E0266
E0271, E0272: Mattress, innerspring/foam rubber plus
E0305, E0310: Bedside rails, half-length/full-length
-
When combined with E0291, bill as E0250
-
When combined with E0293, bill as E0255
-
When combined with E0295, bill as E0260
-
When combined with E0297, bill as E0265
Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items.
