0016 - Continuous Passive Motion Billed without Total Knee Replacement or Total Knee Revision

Dynamic List Information
Dynamic List Data
Issue Name
0016 - Continuous Passive Motion Billed without Total Knee Replacement or Total Knee Revision
Review Type
Automated
Provider Type
DME Physician/DME Supplier
MAC Jurisdiction
All DME MACs
Date
2017-02-01
RAC Type
Approved

Description

Continuous Passive Motion devices are not covered if billed for more than three weeks following a qualified knee surgery or for patients who have not received a total knee replacement or revision.

Affected Code(s)

E0935- Continuous passive motion exercise, device for use on knee only

Applicable Policy References

1.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits
2.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items
3.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B
4.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
5.    42 Code of Federal Regulations (CFR), §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6.    42 CFR §405.929- Post-Payment Review
7.    42 CFR §405.930- Failure to Respond to Additional Documentation Request
8.    42 CFR §405.986- Good Cause for Reopening
9.    42 CFR §410.38- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions
10.    42 CFR §414.210(f)- Payment for Replacement of Equipment
11.    National Coverage Determination Manual, Chapter 1, Part 4, §280.1- Durable Medical Equipment Reference List
12.    Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and required as a Result of Services Which Are Not Covered Under Medicare
13.    Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies
14.    Medicare Claims Processing Manual Chapter 20, 30.2.1 - Daily Payment for Continuous Passive Motion (CPM) Devices
15.    Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
16.     HCPCS Level II Codebook