LCD/NCD Portal

L4989

 

CANES AND CRUTCHES

 

 

08/05/2011

 

Region IV Jurisdiction C

 

• 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.

• Canes (E0100, E0105) and crutches (E0110 - E0116) are covered if all of the following criteria (1-3) are met:

o The patient has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADL) in the home.

o The MRADLs to be considered in this and all other statements in this policy are toileting, feeding, dressing, grooming, and bathing performed in customary locations in the home.

o A mobility limitation is one that:

 Prevents the patient from accomplishing the MRADL entirely.

 Places the patient at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL.

 Prevents the patient from completing the mobility-related activities of daily living within a reasonable time frame.

 The patient is able to safely use the cane or crutch.

 The functional mobility deficit can be sufficiently resolved by use of a cane or crutch.

• If all of the criteria are not met, the cane or crutch will be denied as not reasonable and necessary.

• The medical necessity for an underarm, articulating, spring assisted crutch (E0117) has not been established.

o Therefore, if an E0117 is ordered, it will be denied as NOT reasonable and necessary.

 

 

Coding Information

 

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

 

 

HCPCS CODES:

 

A4635 UNDERARM PAD, CRUTCH, REPLACEMENT, EACH

A4636 REPLACEMENT, HANDGRIP, CANE, CRUTCH, OR WALKER, EACH

A4637 REPLACEMENT, TIP, CANE, CRUTCH, WALKER, EACH.

A9270 NON-COVERED ITEM OR SERVICE

E0100 CANE, INCLUDES CANES OF ALL MATERIALS, ADJUSTABLE OR FIXED, WITH TIP

E0105 CANE, QUAD OR THREE PRONG, INCLUDES CANES OF ALL MATERIALS, ADJUSTABLE OR FIXED, WITH TIPS

E0110 CRUTCHES, FOREARM, INCLUDES CRUTCHES OF VARIOUS MATERIALS, ADJUSTABLE OR FIXED, PAIR, COMPLETE WITH TIPS AND HANDGRIPS

E0111 CRUTCH FOREARM, INCLUDES CRUTCHES OF VARIOUS MATERIALS, ADJUSTABLE OR FIXED, EACH, WITH TIP AND HANDGRIPS

E0112 CRUTCHES UNDERARM, WOOD, ADJUSTABLE OR FIXED, PAIR, WITH PADS, TIPS AND HANDGRIPS

E0113 CRUTCH UNDERARM, WOOD, ADJUSTABLE OR FIXED, EACH, WITH PAD, TIP AND HANDGRIP

E0114 CRUTCHES UNDERARM, OTHER THAN WOOD, ADJUSTABLE OR FIXED, PAIR, WITH PADS, TIPS AND HANDGRIPS

E0116 CRUTCH, UNDERARM, OTHER THAN WOOD, ADJUSTABLE OR FIXED, WITH PAD, TIP, HANDGRIP, WITH OR WITHOUT SHOCK ABSORBER, EACH

E0117 CRUTCH, UNDERARM, ARTICULATING, SPRING ASSISTED, EACH

E0118 CRUTCH SUBSTITUTE, LOWER LEG PLATFORM, WITH OR WITHOUT WHEELS, EACH

E0153 PLATFORM ATTACHMENT, FOREARM CRUTCH, EACH

 

 

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.

o 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.

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

Article(s)

A23925 - Canes and Crutches - Policy Article - Effective July 2009 opens in new window

 

CMS Pub. 100-3, Medicare National Coverage Determinations Manual, Chapter 1, Section 280.2, 280.3

 

Local Coverage Determination (LCD) for Canes and Crutches (L4989)