LCD/NCD Portal

L15905 CERVICAL TRACTION DEVICES

 

Region IV

DME

Jurisdiction C

 

08/05/2011

 

 

• 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.

• Cervical traction devices (E0840-E0855 and E0860) are covered only if both of the following criteria are met:

o The patient has a musculoskeletal or neurologic impairment requiring traction equipment

o The appropriate use of a home cervical traction device has been demonstrated to the patient and

o The patient tolerated the selected device.

• If criteria 1 and 2 are not met, cervical traction will be denied as not reasonable and necessary.

• Cervical traction applied via attachment to a headboard (E0840) or a free-standing frame (E0850) has no proven clinical advantage compared to cervical traction applied via an over-the-door mechanism (E0860).

o If an E0840 or E0850 is ordered, it will be denied as not reasonable and necessary.

• Cervical traction devices described by code E0849 or code E0855 are covered only when criteria 1 and 2 above and either criterion A, B or C below have been met:

o The patient has a diagnosis of temporomandibular joint (TMJ) dysfunction and has received treatment for the TMJ condition

o The patient has distortion of the lower jaw or neck anatomy (e.g., radical neck dissection) such that a chin halter is unable to be utilized

o The treating physician orders and/or documents the medical necessity for greater than 20 pounds of cervical traction in the home setting.

• If the criteria for cervical traction are met but the additional criteria for E0849 or E0855 are not met, they will be denied as not reasonable and necessary.

• E0856 describes a cervical traction device that can be used with ambulation. Therefore, it will be denied as not reasonable and necessary.

 

 

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

 

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:

E0840 TRACTION FRAME, ATTACHED TO HEADBOARD, CERVICAL TRACTION

E0849 TRACTION EQUIPMENT, CERVICAL, FREE-STANDING STAND/FRAME, PNEUMATIC, APPLYING TRACTION FORCE TO OTHER THAN MANDIBLE

E0850 TRACTION STAND, FREE STANDING, CERVICAL TRACTION

E0855 CERVICAL TRACTION EQUIPMENT NOT REQUIRING ADDITIONAL STAND OR FRAME

E0856 CERVICAL TRACTION DEVICE, CERVICAL COLLAR WITH INFLATABLE AIR BLADDER

E0860 TRACTION EQUIPMENT, OVERDOOR, CERVICAL

 

 

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 the cervical traction device must be signed and dated by the treating physician, kept on file by the supplier, and is 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:

• Suppliers must add a KX modifier to code E0849 or E0855 only if all of the criteria in the "Indications and Limitations of Coverage and/or Medical Necessity" section of this policy have been met and evidence of such is maintained in the supplier's files.

o This information must be available upon request.

• If all of the criteria in the Indications and Limitations of Coverage and/or Medical Necessity section have not been met, the GA or GZ modifier must be added to the code.

o 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.

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

 

Sources of Information and Basis for Decision

 

A18074 - Cervical Traction Devices- Policy Article - Effective September 2009

 

Local Coverage Determination (LCD) for Cervical Traction Devices (L15905)