LCD Reference Article Article

Commodes - Policy Article

A52461

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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General Information

Source Article ID
N/A
Article ID
A52461
Original ICD-9 Article ID
Not Applicable
Article Title
Commodes - Policy Article
Article Type
Article
Original Effective Date
10/01/2015
Revision Effective Date
01/01/2020
Revision Ending Date
N/A
Retirement Date
N/A

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Current Dental Terminology © 2023 American Dental Association. All rights reserved.

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CMS National Coverage Policy

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Article Guidance

Article Text

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”).

Commodes 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.

A raised toilet seat (E0244) is noncovered; therefore, a commode chair that is used as a raised toilet seat by positioning it over the toilet is also noncovered. When a commode chair is provided for use in this manner, the GY modifier must be added to the code for the commode chair and the KX modifier must not be used.

Toilet seat lift mechanisms (E0172) are not primarily medical in nature; therefore do not meet the statutory definition of durable medical equipment. They are non-covered.

A footrest (E0175) is non-covered because it is not medical in nature.

Bidets and bidet toilet seats are non-covered because they are not primarily medical in nature.

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 prior to delivery, it will be eligible for coverage.

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS

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.

The diagnosis code that justifies the need for these items must be included on the claim.

KX, GA, GY, AND GZ MODIFIERS:

For commodes (E0163, E0165, E0168, E0170, and E0171) 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.

For commodes (E0163, E0165, E0168, E0170, and E0171) not used as a raised toilet seat, the KX modifier must be added to the code only if all of the coverage criteria as described in the Coverage Indication, Limitations and/or Medical Necessity section of the related LCD have been met.

For commode chairs with seat lift mechanism (E0170 and E0171), the KX modifier must be added to the code only if the beneficiary meets all of the criteria for a seat lift mechanism.

If all of the criteria in the Coverage Indication, Limitations and/or Medical Necessity section of the related LCD 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, GY, GZ or KX modifier will be rejected as missing information.

CODING GUIDELINES

A commode with seat lift mechanism (E0170, E0171) is a free-standing device that has a commode pan and that has an integrated seat that can be raised with or without a forward tilt while the beneficiary is seated. An integrated device is one which is sold as a unit by the manufacturer and in which the lift and the commode cannot be separated without the use of tools.

A toilet seat lift mechanism is a device with a seat that can be raised with or without a forward tilt while the beneficiary is seated, allowing the beneficiary to stand and ambulate once he/she is in an upright position. It may be manually operated or electric. It is attached to the toilet. These devices are coded as E0172.

A raised toilet seat (E0244) is a device that adds height to the toilet seat. It is either fixed height or adjustable. It is either attached to the toilet or is unattached, resting on the bowl.
Note: A freestanding raised toilet seat supported by legs on the floor is coded as a commode.

Bidets, bidets incorporated into toilet seats and similar genitalia/perineum/buttocks cleansing devices are products that utilize a stream of water to irrigate and wash the buttocks and perineal area. Bidets and similar devices are coded A9270 (NONCOVERED ITEM OR SERVICE).

Extra wide/heavy duty commode chairs (E0168) have a width of greater than or equal to 23 inches and are also capable of supporting a beneficiary who weighs 300 pounds or more.

A Column II code is included in the allowance for the corresponding Column I code when provided at the same time.

Column I Column II
E0163 E0167
E0165 E0167
E0168 E0167
E0170 E0167, E0627, E0629
E0171 E0167, E0627, E0629


Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items.

Response To Comments

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Coding Information

Bill Type Codes

Code Description

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Revenue Codes

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

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ICD-10-CM Codes that DO NOT Support Medical Necessity

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ICD-10-PCS Codes

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Additional ICD-10 Information

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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 article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description

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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 article, 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 article should be assumed to apply equally to all Revenue Codes.

Code Description

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Other Coding Information

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
01/01/2020 R7

Revision Effective Date: 01/01/2020
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 FED. REG VOL 217):
Revised: “provides” to “provide”
Removed: “The link will be located here once it is available.”
Added: “The required Face-to-Face Encounter and Written Order Prior to Delivery List is available here.” with a hyperlink to the list

04/14/2022: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

01/01/2020 R6

Revision Effective Date: 01/01/2020
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 Fed. Reg Vol 217):
Added: Section and related information based on Final Rule 1713
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Revised: Format of HCPCS code references, from code ‘spans’ to individually-listed HCPCS
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Covered” updated to “ICD-10 Codes that Support Medical Necessity”
ICD-10 CODES THAT DO NOT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Not Covered” updated to “ICD-10 Codes that DO NOT Support Medical Necessity”

02/13/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

01/01/2017 R5

02/07/2019: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This is an article and not a local coverage determination.

01/01/2017 R4 Revision Effective Date: 01/01/2017
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: Modifier instructions
CODING GUIDELINES:
Deleted: HCPCS code E0628 - crosswalked to HCPCS code E0627
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements Language Article
07/01/2016 R3 Revision Effective Date: 07/01/2016
Updated: Title to remove effective date
07/01/2016 R2 Effective July 1, 2016 oversight for DME MAC Articles is the responsibility of CGS Administrators, LLC 18003 and 17013 and Noridian Healthcare Solutions, LLC 19003 and 16013. No other changes have been made to the Articles.
10/01/2015 R1 Revision Effective Date: 04/01/2013 (August 2015 Publication)
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Added: Coverage statement for bidets and similar items
CODING GUIDELINES:
Added: Code description for bidets, bidet toilet seats and similar items
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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Public Versions
Updated On Effective Dates Status
04/07/2022 01/01/2020 - N/A Currently in Effect You are here
02/06/2020 01/01/2020 - N/A Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

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