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”).
Heating pads 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 nonelectric heating pad or wrap (A9273) does not meet the definition of durable medical equipment (DME) and will be denied as noncovered.
Hydrocollator units (E0225, E0239) are considered institutional equipment and will be denied as statutorily 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 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.
A standard electric heating pad (E0210) is a flexible device containing electric resistive elements producing heat. It must have a fabric cover. It must have a timing device for automatic shut-off. It may include heat-retaining material (e.g., gel, fluid, vegetable matter). If so, the heat retaining materials must be contained in an enclosed pouch or bag in or around the heating elements. The heating pad must be certified by an Occupational Safety and Health Administration (OSHA) Nationally Recognized Testing Laboratory (NRTL) (29 CFR 1910.7). A heating pad that includes a cover or other element that utilizes water vapor (humidity) drawn from the air to create moisture when heated is billed using this code.
A moist electric heating pad (E0215) is a flexible device containing electric resistive elements producing heat. It must have a fabric cover. It must have a timing device for automatic shut-off. It must have a component that absorbs and retains liquid water. The water containing element must be protected from contact with the electrical components and the water must be in direct contact with the skin on application. The heating pad must be certified by an OSHA NRTL (29 CFR 1910.7). A cover or other element that utilizes water vapor (humidity) drawn from the air to create moisture when heated does not meet the definition of this code. Water must be added to the device to meet the description of this code.
A water circulating heat pad with pump (E0217) is a flexible pad containing a series of channels through which water is circulated by means of an electrical pumping mechanism. The water is heated in an external reservoir. The pump, pad, and all accessories needed for the pad to be functional are included in the code. The device must be certified by an OSHA NRTL (29 CFR 1910.7).
A hydrocollator unit (E0225, E0239) is a container which is filled with water and then heated. Bags of silicone dioxide or other material are placed in the heated water. These packs/pads are then applied to the body part over towels. They are used to heat the body part prior to physical therapy.
Code E0249 is a durable replacement pad used with a water circulating heat pump system (E0217). It is made of rubber, heavy plastic, or durable fabric. It can be cleaned and is designed for long term use. A replacement pad made of other material that is designed for shorter term use must be billed using code A9999 (Miscellaneous DME supply or accessory, not otherwise specified).
Heating pads that do not meet the coding criteria described above for E0210, E0215 or E0217 must be billed with code E1399.
Suppliers should contact the Pricing, Data Analysis, and Coding (PDAC) contractor for guidance on the correct coding of these items.