LCD/NCD Portal

L11557 HOSPITAL BEDS AND ACCESSORIES

 

Region IV

DME

Jurisdiction C

 

08/05/2011

 

Indications and Limitations of Coverage and/or Medical Necessity

• For any item to be covered by Medicare, it must

o be eligible for a defined Medicare benefit category

o be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member

o Meet all other applicable Medicare statutory and regulatory requirements.

o For the items addressed in this local coverage determination, the criteria for "reasonable and necessary", based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following indications and limitations of coverage and/or medical necessity

• For an item to be covered by Medicare a written signed and dated order must be received by the supplier before a claim is submitted.

o If the supplier bills for an item addressed in this policy without first receiving the completed order, the item will be denied as not reasonable and necessary.

• A fixed height hospital bed (E0250, E0251, E0290, E0291, and E0328) is covered if one or more of the following criteria (1-4) are met:

o The patient has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed.

 Elevation of the head/upper body less than 30 degrees does not usually require the use of a hospital bed

o The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain

o The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration.

 Pillows or wedges must have been considered and ruled out

o The patient requires traction equipment, which can only be attached to a hospital bed.

• A variable height hospital bed (E0255, E0256, E0292, and E0293) is covered if the patient meets one of the criteria for a fixed height hospital bed and requires a bed height different than a fixed height hospital bed to permit transfers to chair, wheelchair or standing position.

• A semi-electric hospital bed (E0260, E0261, E0294, E0295, and E0329) is covered if the patient meets one of the criteria for a fixed height bed and requires frequent changes in body position and/or has an immediate need for a change in body position.

• A heavy duty extra wide hospital bed (E0301, E0303) is covered if the patient meets one of the criteria for a fixed height hospital bed and the patient's weight is more than 350 pounds, but does not exceed 600 pounds.

• An extra heavy-duty hospital bed (E0302, E0304) is covered if the patient meets one of the criteria for a hospital bed and the patient's weight exceeds 600 pounds.

• A total electric hospital bed (E0265, E0266, E0296, and E0297) is not covered; the height adjustment feature is a convenience feature. Total electric beds will be denied as not reasonable and necessary.

• For any of the above hospital beds (plus those coded E1399 - see Policy Article Coding Guidelines), if documentation does not justify the medical need of the type of bed billed, payment will be denied as not reasonable and necessary.

• If the patient does not meet any of the coverage criteria for any type of hospital bed it will be denied as not reasonable and necessary.

 

• ACCESSORIES:

o Trapeze equipment (E0910, E0940) is covered if the patient needs this device to sit up because of a respiratory condition, to change body position for other medical reasons, or to get in or out of bed.

o Heavy duty trapeze equipment (E0911, E0912) is covered if the patient meets the criteria for regular trapeze equipment and the patient's weight is more than 250 pounds.

o A bed cradle (E0280) is covered when it is necessary to prevent contact with the bed coverings.

o Side rails (E0305, E0310) or safety enclosures (E0316) are covered when they are required by the patient's condition and they are an integral part of, or an accessory to, a covered hospital bed.

o If a patient's condition requires a replacement innerspring mattress (E0271) or foam rubber mattress (E0272) it will be covered for a patient owned hospital bed.

 

 

Bill Type Codes:

• Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service.

• Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type.

• Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

 

Revenue Codes:

• Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service.

• In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination.

• Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

 

 

CPT/HCPCS Codes

The appearance of a code in this section does not necessarily indicate coverage.

 

HCPCS MODIFIERS:

 

EY - No physician or other licensed health care provider order for this item or service

 

GA – Waiver of liability statement issued as required by payer policy, individual case

 

GK - Reasonable and necessary item/service associated with a GA or GZ modifier

 

GL - Medically unnecessary upgrade provided instead of non-upgraded item, no charge, no ABN

 

GZ – Item or service expected to be denied as not reasonable and necessary

 

KX - Requirements specified in the medical policy have been met

 

HCPCS CODES:

 

FIXED HEIGHT BEDS

 

E0250 HOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE SIDE RAILS, WITH MATTRESS

E0251 HOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS

E0290 HOSPITAL BED, FIXED HEIGHT, WITHOUT SIDE RAILS, WITH MATTRESS

E0291 HOSPITAL BED, FIXED HEIGHT, WITHOUT SIDE RAILS, WITHOUT MATTRESS

E0328 HOSPITAL BED, PEDIATRIC, MANUAL, 360 DEGREE SIDE ENCLOSURES, TOP OF HEADBOARD, FOOTBOARD AND SIDE RAILS UP TO 24 INCHES ABOVE THE SPRING, INCLUDES MATTRESS

 

 

VARIABLE HEIGHT BEDS

 

E0255 HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITH ANY TYPE SIDE RAILS, WITH MATTRESS

E0256 HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS

E0292 HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITHOUT SIDE RAILS, WITH MATTRESS

E0293 HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITHOUT SIDE RAILS, WITHOUT MATTRESS

 

 

SEMI-ELECTRIC BEDS

 

E0260 HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITH ANY TYPE SIDE RAILS, WITH MATTRESS

E0261 HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS

E0294 HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITHOUT SIDE RAILS, WITH MATTRESS

E0295 HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITHOUT SIDE RAILS, WITHOUT MATTRESS

E0329 HOSPITAL BED, PEDIATRIC, ELECTRIC OR SEMI-ELECTRIC, 360 DEGREE SIDE ENCLOSURES, TOP OF HEADBOARD, FOOTBOARD AND SIDE RAILS UP TO 24 INCHES ABOVE THE SPRING, INCLUDES MATTRESS

 

 

TOTAL ELECTRIC BEDS

 

E0265 HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITH ANY TYPE SIDE RAILS, WITH MATTRESS

E0266 HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS

E0296 HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS). WITHOUT SIDE RAILS, WITH MATTRESS

E0297 HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITHOUT SIDE RAILS, WITHOUT MATTRESS

 

 

HEAVY DUTY BEDS

 

E0301 HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 350 POUNDS, BUT LESS THAN OR EQUAL TO 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS

E0302 HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS

E0303 HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 350 POUNDS, BUT LESS THAN OR EQUAL TO 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITH MATTRESS

E0304 HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITH MATTRESS

 

 

ACCESSORIES

 

E0271 MATTRESS, INNERSPRING

E0272 MATTRESS, FOAM RUBBER

E0273 BED BOARD

E0274 OVER-BED TABLE

E0280 BED CRADLE, ANY TYPE

E0305 BED SIDE RAILS, HALF LENGTH

E0310 BED SIDE RAILS, FULL LENGTH

E0315 BED ACCESSORY: BOARD, TABLE, OR SUPPORT DEVICE, ANY TYPE

E0316 SAFETY ENCLOSURE FRAME/CANOPY FOR USE WITH HOSPITAL BED, ANY TYPE

E0910 TRAPEZE BARS, A/K/A PATIENT HELPER, ATTACHED TO BED, WITH GRAB BAR

E0911 TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY GREATER THAN 250 POUNDS, ATTACHED TO BED, WITH GRAB BAR

E0912 TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY GREATER THAN 250 POUNDS, FREE STANDING, COMPLETE WITH GRAB BAR

E0940 TRAPEZE BAR, FREE STANDING, COMPLETE WITH GRAB BAR

 

 

MISCELLANEOUS

 

E1399 DURABLE MEDICAL EQUIPMENT, MISCELLANEOUS

 

General Information

Documentations Requirements

• Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider".

o It is expected that the patient's medical records will reflect the need for the care provided.

o The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.

• An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request.

o Items billed before a signed and dated order has been received by the supplier must be submitted with an EY modifier added to each affected HCPCS code.

 

• KX, GA and GZ Modifiers

o Suppliers must add a KX modifier to a hospital bed code only if all of the criteria in the “Indications and Limitations of Coverage and/or Medical Necessity” section of this policy 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.

o 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.

o Claim lines billed without a KX, GA or GZ modifier will be rejected as missing information.

 

• UPGRADE MODIFIERS:

o 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.

o Refer to the Supplier Manual for more information on documentation requirements.

 

Sources of Information and Basis for Decision

 

A36959 - Hospital Beds And Accessories - Policy Article - Effective October 2009

 

Local Coverage Determination (LCD) for Hospital Beds And Accessories (L11557)