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.
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.
||E0167, E0627, E0629
||E0167, E0627, E0629
Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items.