Local Coverage Determination (LCD)

Transcutaneous Electrical Joint Stimulation Devices (TEJSD)

L34821

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Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
CGS Administrators, LLC	DME MAC	17013 - DME MAC	J-B	Illinois Indiana Kentucky Michigan Minnesota Ohio Wisconsin
CGS Administrators, LLC	DME MAC	18003 - DME MAC	J-C	Alabama Arkansas Colorado Florida Georgia Louisiana Mississippi New Mexico North Carolina Oklahoma Puerto Rico South Carolina Tennessee Texas Virgin Islands Virginia West Virginia
Noridian Healthcare Solutions, LLC	DME MAC	16013 - DME MAC	J-A	Connecticut Delaware District of Columbia Maine Maryland Massachusetts New Hampshire New Jersey New York - Entire State Pennsylvania Rhode Island Vermont
Noridian Healthcare Solutions, LLC	DME MAC	19003 - DME MAC	J-D	Alaska American Samoa Arizona California - Entire State Guam Hawaii Idaho Iowa Kansas Missouri - Entire State Montana Nebraska Nevada North Dakota Northern Mariana Islands Oregon South Dakota Utah Washington Wyoming

LCD Information

Document Information

LCD ID
L34821

LCD Title
Transcutaneous Electrical Joint Stimulation Devices (TEJSD)

Proposed LCD in Comment Period
N/A

Source Proposed LCD
N/A

Original Effective Date
For services performed on or after 10/01/2015

Revision Effective Date
For services performed on or after 01/01/2020

Revision Ending Date
N/A

Retirement Date
N/A

Notice Period Start Date
06/12/2014

Notice Period End Date
07/31/2014

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Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

N/A

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

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.

The purpose of a Local Coverage Determination (LCD) is to provide information regarding “reasonable and necessary” criteria based on Social Security Act § 1862(a)(1)(A) provisions.

In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement:

The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.
The LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.
Refer to the Supplier Manual for additional information on documentation requirements.
Refer to the DME MAC web sites for additional bulletin articles and other publications related to this LCD.

For the items addressed in this LCD, the “reasonable and necessary” criteria, based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.

DEFINITIONS

For purposes of this LCD the terms “arthritis”, “degenerative joint disease”, and “osteoarthritis” are used interchangeably and refer to the disease osteoarthritis. Arthritis due to other etiologies such as rheumatoid disease, gout, psoriasis, etc. (not all-inclusive) is not included by the use of these terms.

Transcutaneous electrical joint stimulation is administered by a noninvasive device that delivers electrical stimulation intended to reduce the level of pain and symptoms associated with arthritis in a joint. Devices that provide electrical stimulation have considerable variation in the parameters of the current, how the current is applied, etc. This LCD is applicable regardless of the individual characteristics of any given device.

INDICATIONS

There is insufficient published clinical evidence to establish that treatment with Transcutaneous Electrical Joint Stimulation Devices (TEJSD) (HCPCS code E0762) meets the requirements to be considered reasonable and necessary for the treatment of osteoarthritis or any other condition. Claims for TEJSD (code E0762) will be denied as not reasonable and necessary.

There is insufficient published clinical evidence to establish that treatment with other electro-magnetic devices such as transcutaneous electrical stimulation devices (TENS), neuromuscular stimulators (NMES), functional electrical stimulators (FES), light treatment devices (any type), infrared treatment devices (any type), etc. (not all-inclusive), singly or in any combination, meet the requirements to be considered reasonable and necessary for the treatment of osteoarthritis. Claims for these items will be denied as not reasonable and necessary.

TEJSD COMBINED WITH AN ORTHOSIS (Brace)

TEJSD is currently supplied as a stand-alone device or for use concurrently or in combination with a brace. Braces are separate DMEPOS items with independent coverage requirements that are unrelated to the coverage of TEJSD. When TEJSD is used concurrently or in combination with any type of brace, there no reimbursement possible for the TEJSD device. Refer to the applicable LCD and related Policy Article for information about the payment requirements for reimbursement of braces.

ACCCESSORIES / SUPPLIES

Claims for supplies used with a base item are not payable when the base item is not covered. Since code E0762 is not considered to be reasonable and necessary (see above), claims for codes A4465, A4495, A4557, and A4595 to be used with code E0762 will be denied as not reasonable and necessary.

There is no evidence of effectiveness of a TEJSD (E0762) when used with a conductive garment (E0731). Claims for code E0731 billed for use with an E0762 will be denied as not reasonable and necessary.

CODING

Refer to the related Policy Article CODING GUIDELINES section for additional information regarding coding of E0762.

GENERAL

A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving a completed SWO, the claim shall be denied as not reasonable and necessary.

For Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) base items that require a Written Order Prior to Delivery (WOPD), the supplier must have received a signed SWO before the DMEPOS item is delivered to a beneficiary. If a supplier delivers a DMEPOS item without first receiving a WOPD, the claim shall be denied as not reasonable and necessary. Refer to the LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.

For DMEPOS base items that require a WOPD, and also require separately billed associated options, accessories, and/or supplies, the supplier must have received a WOPD which lists the base item and which may list all the associated options, accessories, and/or supplies that are separately billed prior to the delivery of the items. In this scenario, if the supplier separately bills for associated options, accessories, and/or supplies without first receiving a completed and signed WOPD of the base item prior to delivery, the claim(s) shall be denied as not reasonable and necessary.

An item/service is correctly coded when it meets all the coding guidelines listed in CMS HCPCS guidelines, LCDs, LCD-related Policy Articles, or DME MAC articles. Claims that do not meet coding guidelines shall be denied as not reasonable and necessary/incorrectly coded.

Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD documentation in their files. Proof of delivery documentation must be made available to the Medicare contractor upon request. All services that do not have appropriate proof of delivery from the supplier shall be denied as not reasonable and necessary.

Summary of Evidence

Analysis of Evidence (Rationale for Determination)

Coding Information

CPT/HCPCS Codes

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Group 1

(1 Code)

Group 1 Paragraph The appearance of a code in this section does not necessarily indicate coverage.

HCPCS MODIFIERS:

EY – No physician or other health care provider order for this item or service

HCPCS CODES:

EQUIPMENT: Group 1 Codes

Code	Description
E0762	TRANSCUTANEOUS ELECTRICAL JOINT STIMULATION DEVICE SYSTEM, INCLUDES ALL ACCESSORIES

Group 2

(4 Codes)

Group 2 Paragraph SUPPLIES: Group 2 Codes

Code	Description
A4465	NON-ELASTIC BINDER FOR EXTREMITY
A4557	LEAD WIRES, (E.G., APNEA MONITOR), PER PAIR
A4595	ELECTRICAL STIMULATOR SUPPLIES, 2 LEAD, PER MONTH, (E.G., TENS, NMES)
E0731	FORM FITTING CONDUCTIVE GARMENT FOR DELIVERY OF TENS OR NMES (WITH CONDUCTIVE FIBERS SEPARATED FROM THE PATIENT'S SKIN BY LAYERS OF FABRIC)

General Information

Associated Information

DOCUMENTATION 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". It is expected that the beneficiary's medical records will reflect the need for the care provided. The beneficiary's medical records include the treating practitioner’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.

GENERAL DOCUMENTATION REQUIREMENTS

In order to justify payment for DMEPOS items, suppliers must meet the following requirements:

SWO
Medical Record Information (including continued need/use if applicable)
Correct Coding
Proof of Delivery

Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this policy under the Related Local Coverage Documents section for additional information regarding these requirements.

Refer to the Supplier Manual for additional information on documentation requirements.

Refer to the DME MAC web sites for additional bulletin articles and other publications related to this LCD.

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS

Items covered in this LCD have additional policy-specific requirements that must be met prior to Medicare reimbursement.

Refer to the LCD-related Policy article, located at the bottom of this policy under the Related Local Coverage Documents section for additional information.

Miscellaneous

Appendices

Utilization Guidelines

Refer to Coverage Indications, Limitations and/or Medical Necessity

Sources of Information
N/A

Bibliography

Revision History Information

Revision History Date	Revision History Number	Revision History Explanation	Reasons for Change
01/01/2020	R6	Revision Effective Date: 01/01/2020 GENERAL: Revised: Order information as a result of Final Rule 1713 CODING INFORMATION: Removed: Field titled “Bill Type” Removed: Field titled “Revenue Codes” Removed: Field titled “ICD-10 Codes that Support Medical Necessity” Removed: Field titled “ICD-10 Codes that DO NOT Support Medical Necessity” Removed: Field titled “Additional ICD-10 Information” DOCUMENTATION REQUIREMENTS: Revised: “physician’s” to “treating practitioner’s” GENERAL DOCUMENTATION REQUIREMENTS: Revised: “Prescriptions (orders)” to “SWO” 02/27/2020: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because they are due to non-discretionary coverage updates reflective of CMS FR-1713.	Provider Education/Guidance Other
01/01/2017	R5	Revision Effective Date: 01/01/2017 COVERAGE INDICATIONS, INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY: Removed: Standard Documentation Language Added: New reference language and directions to Standard Documentation Requirements Added: General Requirements DOCUMENTATION REQUIREMENTS: Removed: Standard Documentation Language Added: General Documentation Requirements Added: New reference language and directions to Standard Documentation Requirements POLICY SPECIFIC DOCUMENTATION REQUIREMENTS: Removed: Standard Documentation Language Added: Direction to Standard Documentation Requirements Removed: Supplier Manual reference under Miscellaneous Removed: PIM reference under Appendices SOURCES OF INFORMATION AND BASIS FOR DECISION: Removed: Sources of Information RELATED LOCAL COVERAGE DOCUMENTS: Added: LCD-related Standard Documentation Requirements article	Provider Education/Guidance
07/01/2016	R4	Effective July 1, 2016 oversight for DME MAC LCDs 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 LCDs.	Change in Assigned States or Affiliated Contract Numbers
10/01/2015	R3	Revision Effective Date: 10/31/2014 Sources of Information and Basis for Decision: Removed: Non-working Medscape link #10	Other (Link no longer working)
10/01/2015	R2	Revision Effective Date: 10/31/2014 COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY: Revised: Standard Documentation Language to add covered prior to a beneficiary’s Medicare eligibility Revised: Standard Documentation Language for WOPD to make consistent with ACA requirements DOCUMENTATION REQUIREMENTS: Revised: Standard Documentation Language for WOPD to make consistent with ACA requirements Revised: Standard Documentation Language to add who can enter date of delivery date on the POD Added: Instructions for Equipment Retained from a Prior Payer	Provider Education/Guidance
10/01/2015	R1	Revision Effective Date: 10/01/2014 Draft LCD promoted to final	Other (Draft LCD promoted to final )

Associated Documents

Attachments
N/A

Updated On	Effective Dates	Status
02/21/2020	01/01/2020 - N/A	Currently in Effect	You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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Transcutaneous Electrical Joint Stimulation Devices (TEJSD)

Contractor Information

LCD Information

Document Information

CMS National Coverage Policy

Coverage Guidance

Coding Information

CPT/HCPCS Codes

Group 1

Group 2

General Information

Revision History Information

Associated Documents

Keywords

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