Patient Lifts - 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").

Patient lifts 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. E0625 is non-covered; not primarily medical in nature.

Home modifications are noncovered by Medicare. Therefore suppliers must not
submit claims for any structural changes or remodeling necessitated by the
installation of a lift system.

**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**

When an upgrade is provided, the GA, GK, GL, and/or GZ modifiers must be used
to indicate the upgrade.

KX, GA and GZ MODIFIERS

Suppliers must add a KX modifier to codes E0636, E1035 and E1036 only if all
of the coverage criteria in the "Coverage Indications, Limitations and or
Medical Necessity" section of the related LCD have been met and evidence of
such is retained in the supplier's files and available to the DME MAC upon
request.

If all of the criteria in the Coverage Indications, Limitations and/or Medical
Necessity section have not been met, the GA or GZ modifier must be added to
the code. 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.

Claims lines billed with codes without a KX, GA or GZ modifier will be
rejected as missing information.

**CODING GUIDELINES**

Heavy duty and bariatric lifts are included in the codes for patient lifts,
E0630, E0635, E0636, E0639, E0640.

A patient lift for a toilet/tub, any type (E0625) describes a device with
which the beneficiary can be transferred from the toilet/tub to another seat
(e.g., wheelchair). It is used for a beneficiary who is unable to ambulate.
Devices included in this code may be attached to the toilet, ceiling, floor,
or wall of the bathroom or may be freestanding. Some items may be placed in a
tub for lifting the beneficiary in and out of the tub but may not necessarily
be attached to the toilet, ceiling, floor, or wall of the bathroom.

A multi-positional patient support system, with integrated lift, patient
accessible controls (E0636) describes a device that can be used to transfer
the bed-bound beneficiary in either a sitting or supine position. It has
electric controls of the lift function.

Code E0635 describes a patient lift used to transfer the bed-bound beneficiary
by way of a sling or seat which is attached to the boom. The boom is attached
to a spreader bar (base) to counterbalance the weight of the patient. The
original device coded E0635 was the Hoyer by Ted Hoyer & Company, Inc.

Code E0639 describes a device in which the lift mechanism is part of a floor-
to-ceiling pole system that is not permanently attached to the floor and
ceiling and which is used in a room other than the bathroom. The
lift/transport mechanisms may be mechanical or electric. No separate payment
is made for installation. All costs associated with installation are included
in the payment for the device. When a device is only used in a bathroom, it is
coded E0625.

Code E0640 describes a device in which the lift mechanism is attached to
permanent ceiling tracks or a wall mounting system and which is used in a room
other than the bathroom. The lift/transport mechanisms may be mechanical or
electric. No separate payment is made for installation. All costs associated
with installation are included in the payment for the device. When a device is
only used in a bathroom, it is coded E0625.

A multi-positional patient transfer system, with integrated seat, operated by
caregiver (E1035, E1036) describes a device that can be positioned and
adjusted such that the bed-bound beneficiary can be transferred onto the
device in the supine position. Once positioned on the device, it can then be
adjusted to a chair-like position with multiple degrees of recline and leg
elevation. It has small, castor wheels that are not accessible by the
beneficiary for mobility. It has no electric controls.

The only products that may be billed with codes E0636, E0639, E0640, E1035, or
E1036 are those which have received a written Coding Verification Review from
the Pricing, Data Analysis, and Coding (PDAC) contractor and that are listed
in the Product Classification List on the PDAC web site.

A Column II code is included in the allowance for the corresponding Column I
code when provided at the same time.

Column I

|

Column II  
  
---|---  
  
E0625

|

E0621  
  
E0630

|

E0621  
  
E0635

|

E0621  
  
E0636

|

E0621  
  
E0639

|

E0621  
  
E0640

|

E0621  
  
  
Suppliers should contact the Pricing, Data Analysis, and Coding (PDAC)
contractor for guidance on the correct coding of these items.