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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 §(a)(1)(A) provisions (i.e. &#;reasonable and necessary&#;).
Hospital Beds are covered under the Durable Medical Equipment benefit (Social Security Act §(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 (E, E) is noncovered since it is not primarily medical in nature.
An over bed table (E, E) is noncovered because it is not primarily medical in nature.
Trapeze bars attached to a bed (E, E) are noncovered when used on an ordinary bed.
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule (84 Fed. Reg Vol 217)
Final Rule (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 (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 (A) 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.
E and E are hospital beds that are capable of supporting a beneficiary who weighs more than 350 pounds, but no more than 600 pounds.
E and E are hospital beds that are capable of supporting a beneficiary who weighs more than 600 pounds.
E is a safety enclosure used to prevent a beneficiary from leaving the bed.
E 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 E E, E, E, E E E, E E E, E, E, E E E, E E E, E, E, E E E, E E E, E, E, E E E, E E E, E E E, E E E, E E E, E E E, E E E, E E E, E, E, E E E, E, E, E E E, E, E, E E E, E, E, E
When mattress or bedside rails are provided at the same time as a hospital bed, use the single code that combines these items.
E, E: Mattress, innerspring/foam rubber
When combined with E, bill as E
When combined with E, bill as E
When combined with E, bill as E
When combined with E, bill as E
When combined with E, bill as E
When combined with E, bill as E
When combined with E, bill as E
When combined with E, bill as E
E, E: Bedside rails, half-length/full-length
When combined with E, bill as E
When combined with E, bill as E
When combined with E, bill as E
When combined with E, bill as E
When combined with E, bill as E
When combined with E, bill as E
When combined with E, bill as E
When combined with E, bill as E
E, E: Mattress, innerspring/foam rubber plus
E, E: Bedside rails, half-length/full-length
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When combined with E, bill as E
When combined with E, bill as E
When combined with E, bill as E
When combined with E, bill as E
Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items.
When medically necessary, Medicare will cover hospital beds to use at home. You&#;ll need a doctor&#;s order stating that your condition requires one. Medicare Part B will pay 80% of the cost. Medigap or Medicare Advantage plans may pay more.
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Halfpoint Images/Getty ImagesYour doctor might order a hospital bed for you to use at home for many reasons, such as if you&#;re in severe pain, having trouble breathing, or experiencing swelling in your legs and feet.
Medicare will cover the hospital bed as long it&#;s medically necessary to help your condition. Your doctor will need to order the bed and show how it will help your condition.
Medicare pays for all medical equipment, including hospital beds, under Medicare Part B. Part B will pay 80% of the cost of your hospital bed.
You might be able to get more coverage if you have a Medigap or Medicare Advantage plan.
Hospital beds for home use are considered durable medical equipment (DME). Medicare covers DME under Part B. Your hospital bed will need to meet a few conditions in order to be covered.
Medicare will pay for your hospital bed if:
Medicare can provide coverage for you to either rent or buy a bed.
Whether you rent or buy will depend on the type of bed your doctor orders and the policies of the company you use. You might also rent a bed at first, then purchase it if you still need it later on.
You can get coverage for hospital beds through a few different parts of Medicare.
If you use Medicare parts A and B, together called original Medicare, your coverage will be through Medicare Part B. That&#;s because Medicare Part A covers inpatient stays and care you receive in hospitals and skilled nursing facilities.
Medicare Part B covers your other healthcare needs, including:
Part B will cover 80% of the Medicare-approved amount of your hospital bed. You&#;ll pay the remaining 20%.
You can also get coverage through a Medicare Part C plan. Part C plans, also known as Medicare Advantage plans, are offered by private companies that contract with Medicare.
They&#;re required to provide the same coverage as original Medicare. Plus, many Advantage plans go beyond the coverage of original Medicare to offer additional covered services.
So, since original Medicare covers hospital beds, all Advantage plans will also cover hospital beds. Your cost might be more or less than with original Medicare, depending on your plan.
Medicare Part D is prescription drug coverage. It won&#;t help you pay for any DME, including hospital beds.
Medigap, however, can help you pay for a hospital bed. This is Medicare supplement insurance. It covers some of the out-of-pocket costs of using original Medicare, like copayments and coinsurance amounts.
So, if you use Medicare Part B to get a hospital bed, a Medigap plan could cover the 20% coinsurance amount you&#;d normally need to pay.
A hospital bed is a bed that has extra features, such as side rails, gel cushioning, or the ability to raise your head or feet. Your doctor might order a hospital bed for home use if you have:
Medicare covers several types of hospital beds. This includes:
Bed types are all available with a mattress or without one. Medicare also covers mattresses pads, including:
Medicare will also cover some additional features if they&#;re medically necessary. However, it won&#;t cover things that are considered convenience features.
For example, Medicare will cover accessories like trapeze pull bars that help you sit up in bed but won&#;t cover things like over-the-bed tables, which are considered a convenience and not a necessity.
Any bed you order needs to be considered medically necessary for your condition. For example, to get approved for a bariatric bed, you&#;ll need to send a medically documented recent weight.
It&#;s also important to note that while Medicare covers semielectric beds with adjustable heads and feet, it doesn&#;t cover fully electric beds.
Fully electric beds have adjustable height in addition to the adjustable head and feet. Medicare considers adjustable height a convenience feature, and won&#;t pay for it.
The cost of a hospital bed depends on the type of bed your doctor orders.
According to Consumer Affairs, hospital bed costs start at around $500 and can often reach thousands of dollars. When you rent a hospital bed, Consumer Affairs reports, you can spend between $200 and $500 per month depending on the bed type.
Medicare can help you reduce this cost. Medicare Part B will pay 80% of your costs when you use original Medicare.
So, let&#;s say your doctor orders a bed with a cost of $1,000. In this case, Medicare would pay $800 and you&#;d pay $200. If you decide to rent a bed instead for $300 per month, Medicare would pay $240 and you&#;d pay $60.
If you have a Medigap plan, it can pick up those remaining costs, meaning you wouldn&#;t need to pay anything for your hospital bed.
Your costs with a Medicare Advantage plan will depend on the plan. Each Part C plan has its own copayment or coinsurance amounts. You can call your Advantage plan if you&#;re not sure.
Medicare will pay for a hospital bed for home use if it&#;s medically necessary and ordered by your doctor.
Medicare covers a variety of hospital beds to help with different conditions. Your doctor will need to specify your condition and why a hospital bed will help it.
Medicare will pay for you to buy or rent a bed. Original Medicare will pay 80% of the costs. A Medicare Advantage or Medigap plan might cover more.
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