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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”).
Hospital Beds 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 bed board (E0273, E0315) is noncovered since it is not primarily medical in nature.
An over bed table (E0274, E0315) is noncovered because it is not primarily medical in nature.
Trapeze bars attached to a bed (E0910, E0911) are noncovered when used on an ordinary bed.
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 discussed below.
MODIFIERS
KX, GA, AND GZ MODIFIERS:
Suppliers must add a KX modifier to a hospital bed code only if all of the criteria in the “Coverage Indications, Limitations and/or Medical Necessity” section of the related LCD have been met.
The KX modifier should also be added for an accessory when the applicable accessory criteria are met. If the requirements for the KX modifier are not met, the KX modifier must not be used.
If all of the coverage criteria have not been met, the GA or GZ modifier must be added to a claim line for a hospital bed and accessories. 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.
Claim lines billed without a KX, GA or GZ modifier will be rejected as missing information.
UPGRADE MODIFIERS:
When a hospital bed upgrade is provided, the GA, GK, GL and/or GZ modifiers must be used to indicate the upgrade. Fully electric hospital beds must always be billed with these modifiers.
CODING GUIDELINES
A fixed height hospital bed is one with manual head and leg elevation adjustments but no height adjustment.
A variable height hospital bed is one with manual height adjustment and with manual head and leg elevation adjustments.
A semi-electric bed is one with manual height adjustment and with electric head and leg elevation adjustments.
A total electric bed is one with electric height adjustment and with electric head and leg elevation adjustments.
An ordinary bed is one that is typically sold as furniture. It may consist of a frame, box spring and mattress. It is a fixed height and may or may not have head or leg elevation adjustments.
E0301 and E0303 are hospital beds that are capable of supporting a beneficiary who weighs more than 350 pounds, but no more than 600 pounds.
E0302 and E0304 are hospital beds that are capable of supporting a beneficiary who weighs more than 600 pounds.
E0316 is a safety enclosure used to prevent a beneficiary from leaving the bed.
E1399 should be used for products not described by the specific HCPCS codes above.
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.
Column I Column II E0250 E0271, E0272, E0305, E0310 E0251 E0305, E0310 E0255 E0271, E0272, E0305, E0310 E0256 E0305, E0310 E0260 E0271, E0272, E0305, E0310 E0261 E0305, E0310 E0265 E0271, E0272, E0305, E0310 E0266 E0305, E0310 E0290 E0271, E0272 E0292 E0271, E0272 E0294 E0271, E0272 E0296 E0271, E0272 E0301 E0305, E0310 E0302 E0305, E0310 E0303 E0271, E0272, E0305, E0310 E0304 E0271, E0272, E0305, E0310 E0328 E0271, E0272, E0305, E0310 E0329 E0271, E0272, E0305, E0310
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When mattress or bedside rails are provided at the same time as a hospital bed, use the single code that combines these items.
E0271, E0272: Mattress, innerspring/foam rubber
When combined with E0251, bill as E0250
When combined with E0291, bill as E0290
When combined with E0293, bill as E0292
When combined with E0295, bill as E0294
When combined with E0266, bill as E0265
When combined with E0297, bill as E0296
When combined with E0301, bill as E0303
When combined with E0302, bill as E0304
E0305, E0310: Bedside rails, half-length/full-length
When combined with E0290, bill as E0250
When combined with E0291, bill as E0251
When combined with E0292, bill as E0255
When combined with E0293, bill as E0256
When combined with E0294, bill as E0260
When combined with E0295, bill as E0261
When combined with E0296, bill as E0265
When combined with E0297, bill as E0266
E0271, E0272: Mattress, innerspring/foam rubber plus
E0305, E0310: Bedside rails, half-length/full-length
When combined with E0291, bill as E0250
When combined with E0293, bill as E0255
When combined with E0295, bill as E0260
When combined with E0297, bill as E0265
Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items.
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Beds and Medicare
Medicare will cover a hospital bed when you can show a medical necessity for the bed. You must also be covered under Medicare Part B and have been assessed by your doctor. The doctor must document your need in your medical records and write you an order (prescription) for the equipment. Only your doctor can prescribe the equipment for you.
The supplier must receive the order before Medicare is billed and it must be kept on file by the supplier.
To qualify for a hospital bed you must show that you:
The above is the basic criteria for coverage for hospital beds. There are a number of different kinds of beds, such as an adjustable hospital bed. Each will have additional requirements for coverage. Your treating doctor and/or your supplier will know what needs to be documented in order for you to qualify for the bed and equipment that is right for you. Adjustable beds, full-electric beds and electric hi-lo beds are considered convenience devices, and are not covered by Medicare.
After you have paid your annual deductible, you will pay 20% of the Medicare-approved amount for the hospital bed purchase or rental and maintenance. If you have Supplemental insurance you may have little to no out-of-pocket cost for a manual crank, or a semi-electric Hospital bed.
Those costs may be higher if the supplier doesn't accept assignment. Hospital beds are in the Capped Rental category, which means you may choose to rent or purchase the bed. Once Medicare has made 10 monthly rental payments you will be given an opportunity to purchase the bed. The supplier will send you a "Purchase Option" letter in the ninth month of the rental. You will have 30 days to reply.
If you reply and want to buy the bed:
If you do not answer or choose to continue renting:
You will save money if you order your items from a Medicare-approved provider that accepts the assignment. You may also buy your hospital bed from any store that sells them. However, if the supplier from which you order your bed is not enrolled in Medicare, Medicare will not pay for the equipment.
Things to review before you choose a supplier:
Medicare does not cover full electric hospital beds. They are considered a convenience device. However, you can apply the cost of the manual lift towards the purchase price of an full electric model by using an Advance Beneficiary Notice (ABN). You will have to pay the difference between the two items. In some cases it may be cheaper to purchase an electric bed directly from the medical equipment store.
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