NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES
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. Information provided in this policy article relates to determinations other than those based on Social Security Act §1862(a)(1)(A) provisions (i.e. “reasonable and necessary”).
Walkers are covered under the Durable Medical Equipment benefit (Social Security Act §1861(s)(6)). In order for a beneficiary’s equipment to be eligible for reimbursement the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met.
Enhancement accessories of walkers will be denied as noncovered.
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed. Reg Vol 217)
Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated. The required Face-to-Face Encounter and Written Order Prior to Delivery List is available here.
Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.
If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD, it will be eligible for coverage.
POLICY SPECIFIC INFORMATION
In addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.
Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below.
When code E0147 is billed, the claim must include the manufacturer’s name and product name/number.
When code E1399 is billed, the claim must include the manufacturer name and the product name/number.
KX, GA, GY AND GZ MODIFIERS:
If a heavy duty walker (E0148, E0149) is provided and if the supplier has documentation in their records that the beneficiary's weight (within one month of providing the walker) is greater than 300 pounds, the KX modifier should be added to the code.
If the above criterion has 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 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.
If the walker that is provided is only needed for mobility outside the home, the GY modifier must be added to the codes for the item and all accessories.
Claims lines billed with codes E0148 and E0149 without a KX, GA, GY or GZ modifier will be rejected as missing information.
A wheeled walker (E0141, E0143, E0149) is one with either 2, 3, or 4 wheels. It may be fixed height or adjustable height. It may or may not include glide-type brakes (or equivalent). The wheels may be fixed or swivel.
A glide-type brake consists of a spring mechanism (or equivalent) which raises the leg post of the walker off the ground when the beneficiary is not pushing down on the frame.
Code E0144 describes a rigid or folding wheeled walker which has a frame that completely surrounds the beneficiary and an attached seat in the back.
A heavy duty walker (E0148, E0149) is one which is labeled as capable of supporting beneficiaries who weigh more than 300 pounds. It may be fixed height or adjustable height. It may be rigid or folding.
Code E0147 describes a 4-wheeled, adjustable height, folding-walker that has all of the following characteristics:
- Capable of supporting beneficiaries who weigh greater than 350 pounds,
- Hand operated brakes that cause the wheels to lock when the hand levers are released,
- The hand brakes can be set so that either or both can lock both wheels,
- The pressure required to operate each hand brake is individually adjustable,
- There is an additional braking mechanism on the front crossbar,
- At least two wheels have brakes that can be independently set through tension adjustability to give varying resistance.
The only walkers that may be billed using code E0147 are those products for which a written coding verification review (CVR) has been made by the Pricing, Data Analysis and Coding (PDAC) Contractor and subsequently published on the Product Classification List (PCL). Suppliers should contact the PDAC Contractor for guidance on the correct coding of these items.
If a product is billed to Medicare using a HCPCS code that requires written CVR, but the product is not on the PCL for that particular HCPCS code, then the claim line will be denied as incorrect coding.
Codes A4636, A4637, and E0159 are only used to bill for replacement items for covered, beneficiary-owned walkers. Codes E0154, E0156, E0157, and E0158 can be used for accessories provided with the initial issue of a walker or for replacement components. Code E0155 can be used for replacements on covered, beneficiary-owned wheeled walkers or when wheels are subsequently added to a covered, beneficiary-owned nonwheeled walker (E0130, E0135). Code E0155 cannot be used for wheels provided at the time of, or within one month of, the initial issue of a non-wheeled walker.
Hemi-walkers must be billed using code E0130 or E0135, not E1399.
A gait trainer (or sometimes referred to as a rollator) is a term used to describe certain devices that are used to support a beneficiary during ambulation. Gait trainers are billed using one of the codes for walkers. If a gait trainer has a feature described by one of the walker attachment codes (E0154, E0156, E0157) that code may be separately billed. Other unique features of gait trainers are not separately payable and may not be billed with code E1399. If a supplier chooses to bill separately for a feature of a gait trainer that is not described by a specific HCPCS code, then code A9900 must be used.
An enhancement accessory is one which does not contribute significantly to the therapeutic function of the walker. It may include, but is not limited to style, color, hand operated brakes (other than those described in code E0147), or basket (or equivalent). Use code A9270 when an enhancement accessory of a walker is billed.
Brakes other than hand operated brakes, provided at the same time as a walker (E0141, E0143, E0149) may not be billed separately to the DME MACs or the beneficiary upon initial issue. However if billed separately upon initial issue the brakes must be billed using A9900, and the brakes will deny as not separately payable. HCPCS code E0159 (Brake attachment for wheeled walker, replacement, each) is applicable for replacement brakes only.
A Column II code is included in the allowance for the corresponding Column I code when provided at the same time and must not be billed separately at the time of billing the Column I code.
|A4636, A4637, E0155, E0159
|A4636, A4637, E0155, E0159
|A4636, A4637, E0155, E0159
|A4636, A4637, E0155, E0156, E0159
|A4636, E0155, E0159
|A4636, A4637, E0155, E0159
Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items.