Hospital Beds And Accessories - Policy Article

**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](https://www.cms.gov/Research-Statistics-Data-and-
Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-
Review/FacetoFaceEncounterRequirementforCertainDurableMedicalEquipment).

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  
  






























  
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.