LCD/NCD Portal

L4991

 

COMMODES

 

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.

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

o The patient is confined to a single room

o The patient is confined to one level of the home environment and there is no toilet on that level

o 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.

o 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.

o 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).

o However, a commode with seat lift mechanism is intended to allow the patient to walk after standing.

o If the patient can ambulate, he/she would rarely meet the coverage criterion for a commode.

o 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.

 

 

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

 

 

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.

• 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:

o 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.)

o 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.

o 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.

o 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.

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

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

 

 

Sources of Information and Basis for Decision

 

A23837 - Commodes - Policy Article - Effective September 2009 opens in new window

 

Local Coverage Determination (LCD) for Commodes (L4991)