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”).
Patient lifts 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. E0625 is non-covered; not primarily medical in nature.
Home modifications are noncovered by Medicare. Therefore suppliers must not submit claims for any structural changes or remodeling necessitated by the installation of a lift system.
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
When an upgrade is provided, the GA, GK, GL, and/or GZ modifiers must be used to indicate the upgrade.
KX, GA and GZ MODIFIERS
Suppliers must add a KX modifier to codes E0636, E1035 and E1036 only if all of the coverage criteria in the “Coverage Indications, Limitations and or Medical Necessity” section of the related LCD have been met and evidence of such is retained in the supplier’s files and available to the DME MAC upon request.
If all of the criteria in the Coverage Indications, Limitations and/or Medical Necessity section have not been met, the GA or GZ modifier must be added to the code. 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.
Claims lines billed with codes without a KX, GA or GZ modifier will be rejected as missing information.
CODING GUIDELINES
Heavy duty and bariatric lifts are included in the codes for patient lifts, E0630, E0635, E0636, E0639, E0640.
A patient lift for a toilet/tub, any type (E0625) describes a device with which the beneficiary can be transferred from the toilet/tub to another seat (e.g., wheelchair). It is used for a beneficiary who is unable to ambulate. Devices included in this code may be attached to the toilet, ceiling, floor, or wall of the bathroom or may be freestanding. Some items may be placed in a tub for lifting the beneficiary in and out of the tub but may not necessarily be attached to the toilet, ceiling, floor, or wall of the bathroom.
A multi-positional patient support system, with integrated lift, patient accessible controls (E0636) describes a device that can be used to transfer the bed-bound beneficiary in either a sitting or supine position. It has electric controls of the lift function.
Code E0635 describes a patient lift used to transfer the bed-bound beneficiary by way of a sling or seat which is attached to the boom. The boom is attached to a spreader bar (base) to counterbalance the weight of the patient. The original device coded E0635 was the Hoyer by Ted Hoyer & Company, Inc.
Code E0639 describes a device in which the lift mechanism is part of a floor-to-ceiling pole system that is not permanently attached to the floor and ceiling and which is used in a room other than the bathroom. The lift/transport mechanisms may be mechanical or electric. No separate payment is made for installation. All costs associated with installation are included in the payment for the device. When a device is only used in a bathroom, it is coded E0625.
Code E0640 describes a device in which the lift mechanism is attached to permanent ceiling tracks or a wall mounting system and which is used in a room other than the bathroom. The lift/transport mechanisms may be mechanical or electric. No separate payment is made for installation. All costs associated with installation are included in the payment for the device. When a device is only used in a bathroom, it is coded E0625.
A multi-positional patient transfer system, with integrated seat, operated by caregiver (E1035, E1036) describes a device that can be positioned and adjusted such that the bed-bound beneficiary can be transferred onto the device in the supine position. Once positioned on the device, it can then be adjusted to a chair-like position with multiple degrees of recline and leg elevation. It has small, castor wheels that are not accessible by the beneficiary for mobility. It has no electric controls.
The only products that may be billed with codes E0636, E0639, E0640, E1035, or E1036 are those which have received a written Coding Verification Review from the Pricing, Data Analysis, and Coding (PDAC) contractor and that are listed in the Product Classification List on the PDAC web site.
A Column II code is included in the allowance for the corresponding Column I code when provided at the same time.
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Column I
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Column II
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E0625
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E0621
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E0630
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E0621
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E0635
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E0621
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E0636
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E0621
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E0639
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E0621
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E0640
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E0621
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Suppliers should contact the Pricing, Data Analysis, and Coding (PDAC) contractor for guidance on the correct coding of these items.
