L4991-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Commodes (L4991)

Contractor Information

Contractor Name

CGS Administrators, LLC

Contractor Number

18003

Contractor Type

DME MAC

Jurisdiction

J - G

LCD Information

Document Information

LCD ID Number L4991

LCD Title Commodes

Contractor's Determination Number COMM

AMA CPT/ADA CDT Copyright Statement

Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Alabama Arkansas Colorado Florida Georgia Louisiana Mississippi North Carolina New Mexico Oklahoma Puerto Rico South Carolina Tennessee Texas Virginia Virgin Islands West Virginia

Oversight Region Region IV

DME Region LCD Covers Jurisdiction C

Original Determination Effective Date

For services performed on or after 10/01/1993 Original Determination Ending Date

Revision Effective Date

For services performed on or after 08/05/2011

Revision Ending Date

CMS National Coverage Policy

CMS Publication 100-3 Medicare National Coverage Determinations Manual, Chapter 1, Section 280.1 Indications and Limitations of Coverage and/or Medical Necessity

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. 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. 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 commode is covered when the patient is physically incapable of utilizing regular toilet facilities. This would occur in the following situations:

1. The patient is confined to a single room, or

2. The patient is confined to one level of the home environment and there is no toilet on that level, or

3. The patient is confined to the home and there are no toilet facilities in the home.

An extra wide/heavy duty commode chair (E0168) is covered for a patient who weighs 300 pounds or more. If an E0168 commode is ordered and the patient does not weigh more than 300 pounds, it will be denied as not reasonable and necessary.

A commode chair with detachable arms (E0165) is covered if the detachable arms feature is necessary to facilitate transferring the patient or if the patient has a body configuration that requires extra width. If coverage criteria are not met payment will be denied as not reasonable and necessary.

Commode chair with seat lift mechanism (E0170, E0171) is covered if the patient has medical necessity for a commode and meets the coverage criteria for a seat lift mechanism (see Local Coverage Determination [LCD] and Policy Article on Seat Lift Mechanisms). However, a commode with seat lift mechanism is intended to allow the patient to walk after standing. If the patient can ambulate, he/she would rarely meet the coverage criterion for a commode. Therefore, if the patient is capable of walking from the bed to the bathroom, a KX modifier must not be added to the code for the commode with seat lift mechanism.

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

GY - Item or service statutorily excluded or does not meet the definition of any Medicare Benefit 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:

E0163 COMMODE CHAIR, MOBILE OR STATIONARY, WITH FIXED ARMS

E0165 COMMODE CHAIR, MOBILE OR STATIONARY, WITH DETACHABLE ARMS E0167 PAIL OR PAN FOR USE WITH COMMODE CHAIR, REPLACEMENT ONLY

E0168 COMMODE CHAIR, EXTRA WIDE AND/OR HEAVY DUTY, STATIONARY OR MOBILE, WITH OR WITHOUT ARMS, ANY TYPE, EACH

E0170 COMMODE CHAIR WITH INTEGRATED SEAT LIFT MECHANISM, ELECTRIC, ANY TYPE E0171 COMMODE CHAIR WITH INTEGRATED SEAT LIFT MECHANISM, NON-ELECTRIC, ANY TYPE E0172 SEAT LIFT MECHANISM PLACED OVER OR ON TOP OF TOILET, ANY TYPE

E0175 FOOT REST, FOR USE WITH COMMODE CHAIR, EACH E0244 RAISED TOILET SEAT

ICD-9 Codes that Support Medical Necessity Not specified.

AsteriskNoteText

Diagnoses that Support Medical Necessity Not specified.

ICD-9 Codes that DO NOT Support Medical Necessity Not specified.

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity Not specified.

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

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, GY, AND GZ MODIFIERS:

For all commodes (E0163-E0171), if it is used as a raised toilet seat by positioning it over the toilet, the GY modifier must be added to the code and the KX, GA, or GZ modifier must not be used. (Refer to the related Policy Article for additional information.)

For all commodes (E0163-E0171), if it is not used as a raised toilet seat, the modifier KX modifier must be added to the code only if all of the coverage criteria as described in the Indication and Limitations of Coverage and/or Medical Necessity section have been met.

In addition, for a commode chair with seat lift mechanism (E0170 and E0171), the KX modifier must only be used if the patient meets all of the criteria for a seat lift mechanism.

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. When there is an expectation of a medical necessity denial, suppliers must enter a GA modifier on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or a GZ modifier if they have not obtained a valid ABN.

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

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

Appendices

Utilization Guidelines Refer to Indications and Limitations of Coverage and/or Medical Necessity.

Sources of Information and Basis for Decision

Reserved for future use. Advisory Committee Meeting Notes

Start Date of Comment Period 03/30/1993

End Date of Comment Period 05/14/1993

Start Date of Notice Period 08/01/1993

Revision History Number 009

Revision History Explanation Revision Effective Date: 02/04/2011 INDICATIONS AND LIMITATIONS OF COVERAGE:

Deleted: Least costly alternative language for code E0168 HCPCS CODES AND MODIFIERS:

Revised: GA modifier

Revision Effective Date: 09/01/2009

INDICATIONS AND LIMITATIONS OF COVERAGE AND/OR MEDICAL NECESSITY:

Removed: Reference to DMERC HCPCS CODES AND MODIFIERS:

Added: GA and GZ modifiers Revised: KX modifier DOCUMENTATION REQUIREMENTS:

Added: Instructions for the use of GA and GZ modifiers

03/01/2008 - In accordance with Section 911 of the Medicare Modernization Act, this policy was transitioned to DME MAC CIGNA Government Services (18003) LCD L11517 from DME PSC TrustSolutions (77012) LCD L11517.

06/01/2007 - In accordance with Section 911 of the Medicare Modernization Act of 2003, Virginia and West Virginia were transitioned from DME PSC TriCenturion (77011) to DME PSC TrustSolutions (77012).

Revision Effective Date: 01/01/2007

INDICATIONS AND LIMITATIONS OF COVERAGE AND/OR MEDICAL NECESSITY

Removed: Downcoding paragraph for E0164 and E0166 HCPCS CODES:

Added: E0172 and E0244 Removed: E0164 and E0166

Revised: E0163, E0165, and E0167 DOCUMENTATION REQUIREMENTS:

Removed: DMERC references

03/01/2006 - In accordance with Section 911 of the Medicare Modernization Act of 2003, this policy was transitioned to DME PSC TrustSolutions (77012) from DMERC Palmetto GBA (00885).

Revision Effective Date: 01/01/2006

INDICATIONS AND LIMITATIONS OF COVERAGE AND/OR MEDICAL NECESSITY

Removed: LCA statement for E0165. Revised: Statements related to E0165.

Revised: Statements for commodes E0170 and E0171. HCPCS CODES:

Added: E0170 and E0171 Removed: E0169

DOCUMENTATION REQUIREMENTS:

Added: E0170, E0171 as requiring the KX modifier if criteria for seat lift mechanism is met. Removed: Requirement for documentation of weight to be submitted on claim with E0168

Revision Effective Date: 04/01/2005 Documentation Requirements: Corrected: E0169 definition.

04/01/2005 - LMRP converted to LCD and Policy Article HCPCS CODES/MODIFIERS:

Added: GY modifier DOCUMENTATION REQUIREMENTS:

All codes now require the KX modifier.

Revision Effective Date: 04/01/2003 HCPCCS CODES AND MODIFIERS:

Added: EY modifier to HCPCS Modifier array. INDICATIONS AND LIMITATIONS OF COVERAGE:

Added:Standard language concerning coverage of items without an order. Added: Standard language concerning EY modifier.

CODING GUIDELINES:

Moved: Definition of extra wide /heavy duty commode chair (E0168) to Coding Guidelines section. DOCUMENTATION:

Added: Standard language concerning an order requirement. Added: Standard language concerning use of the EY modifier.

The revision dates listed below are the dates the revisions were published and not necessarily the effective dates for the revisions.

07/01/2002 - Replaced SADMERC reference with paragraph referring to SADMERC Web site.

04/01/2002 - Added new HCPCS E code replacing K code for extra wide, heavy-duty commodes. Added new HCPCS code for commode with seat lift mechanism and coverage criteria allowing for its reimbursement. Added a new KX modifier to be used with a commode with seat lift mechanism if coverage and payment rules have been fulfilled.

09/01/1999 – Added HCPCS code K0457 (extra wide/heavy duty commode chair). Added definition for extra wide/heavy duty commode chair. Revised Coverage and Payment Rules section. Added K0457 to bundling table in Coding Guidelines section. Added information for K0457 in Documentation section.

08/05/2011 - The Jurisdiction C contractor adopted a new business name. This LCD revision only includes the change from CIGNA Government Services to CGS Administrators, LLC. No coverage information was included in this revision and no provider action is needed regarding this revision.

Reason for Change Maintenance (annual review with new changes, formatting, etc.)