evekhm/cms_iom_500 huggingface dataset:
Article - Therapeutic Shoes for Persons with Diabetes - Policy Article (A52501)
The A5513 insert must retain its shape during use for the life of the insert. The base layer of the device must be at least 3/16 inch of 35 Shore A or higher material. The base layer is allowed to be thinner in the custom fabricated device because appropriate arch fill or other additional material will be layered up individually to maintain shape and achieve total contact and accommodate each beneficiarys specific needs. The central portion of the base layer of the heel may be thinner (but at least 1/16 inch) to allow for greater pressure reduction. The specified thickness of the lateral portions of the base layer must extend from the heel through the distal metatarsals and may be absent at the toes. The top layer of the device may be of a lower durometer and must also be heat moldable. The materials used should be suitable with regards to the beneficiarys condition.CodeA5514 describes a total contact, custom fabricated, multiple density, removable inlay that is directly milled from a rectified virtual model of the beneficiary's foot so that it conforms to the plantar surface and makes total contact with the foot, including the arch. A custom fabricated device is made from materials that do not have predefined trim lines for heel cup height, arch height and length, or toe shape.TheA5514 insert must retain its shape during use for the life of the insert.The base layer of the device must be at least 3/16 inch of 35 Shore A or higher material.The base layer is allowed to be thinner in the custom fabricated device because appropriate arch fill or other additional material will be layered up individually to maintain shape and achieve total contact and accommodate each beneficiary's specific needs.The central portion of the base layer of the heel may be thinner (but at least 1/16 inch) to allow for greater pressure reduction.The specified thickness of the lateral portions of the base layer must extend from the heel through the distal metatarsals and may be absent at the toes. The top layer of the device may be of a lower durometer and must also be heat moldable.The materials used should be suitable with regards to the beneficiary's condition.
Article - Therapeutic Shoes for Persons with Diabetes - Policy Article (A52501)
Rigid rocker bottoms (A5503) are exterior elevations with apex position for 51 percent to 75 percent distance measured from the back end of the heel. The apex is a narrowed or pointed end of an anatomical structure. The apex must be positioned behind the metatarsal heads and tapering off sharply to the front tip of the sole. Apex height helps to eliminate pressure at the metatarsal heads. Rigidity is ensured by the steel in the shoe. The heel of the shoe tapers off in the back in order to cause the heel to strike in the middle of the heel.Roller bottoms (sole or bar) (A5503) are the same as rocker bottoms, but the heel is tapered from the apex to the front tip of the sole.Wedges (posting) (A5504) are either of hind foot, fore foot, or both and may be in the middle or to the side. The function is to shift or transfer weight bearing upon standing or during ambulation to the opposite side for added support, stabilization, equalized weight distribution, or balance.Metatarsal bars (A5505) are exterior bars which are placed behind the metatarsal heads in order to remove pressure from the metatarsal heads. The bars are of various shapes, heights, and construction depending on the exact purpose.Offset heel (A5506) is a heel flanged at its base either in the middle, to the side, or a combination, that is then extended upward to the shoe in order to stabilize extreme positions of the hind foot.A deluxe feature (A5508) does not contribute to the therapeutic function of the shoe. It may include, but is not limited to style, color, or type of leather.Code A5507 is only to be used for not otherwise specified therapeutic modifications to the shoe or for repairs to a diabetic shoe(s).Deluxe features must be coded using code A5508.
Article - Therapeutic Shoes for Persons with Diabetes - Policy Article (A52501)
Code A5507 is only to be used for not otherwise specified therapeutic modifications to the shoe or for repairs to a diabetic shoe(s).Deluxe features must be coded using code A5508.Codes for inserts or modifications (A5503, A5504, A5505, A5506, A5507, A5508, A5510, A5512, A5513, A5514) may only be used for items related to diabetic shoes (A5500, A5501). They must not be used for items related to footwear coded with codes L3215, L3216, L3217, L3219, L3221, L3222, L3224, L3225, L3230, L3250, L3251, L3252, L3253. Inserts and modifications used with L-coded footwear must be coded using L codes (refer to the Orthopedic Footwear LCD and LCD-related Policy Article for more information).The right (RT) and/or left (LT) modifiers must be used when billing shoes, inserts, or modifications. Effective for claims with dates of service (DOS) on or after 3/1/2019, if bilateral items arebilled on the same date of service, billeach item on two separate claim lines using the RT and LT modifiers and 1 unit of service (UOS) on each claim line. Do not use the RTLT modifier on the same claim line and billed with 2 UOS. Claims billed without modifiers RT and/or LT,or with RTLT on the same claim line and 2 UOS,will be rejected as incorrect coding.Inserts for missing toes or partial foot amputation should be coded L5000 or L5999, whichever is applicable. When seeking coverage for devices for missing toes and partial foot amputations under the prosthetic devices benefit category, refer to the Lower Limb Prostheses LCD and LCD-related Policy Article for the applicable coding, coverage, and payment requirements.The only products that may be billed using codes A5512 are those that are specified in the Product Classification List (PCL) on the Pricing, Data Analysis, and Coding (PDAC) contractor web site.There are two categories of products that are billed with code A5513:
Article - Therapeutic Shoes for Persons with Diabetes - Policy Article (A52501)
There are two categories of products that are billed with code A5513:Inserts that are custom fabricated by a manufacturer/central fabrication facility and then sent to someone other than the beneficiary. These items may be billed using code A5513 only if they are listed on the PDAC web site.Inserts that are custom fabricated from raw materials that are dispensed directly to the beneficiary by the entity that fabricated the insert. These items do not have to be listed on the PDAC web site in order to be billed using code A5513. However, the supplier must provide a list of the materials that were used and a description of the custom fabrication process on request.The only products that may be billed using codes A5514 are those that are specified in the PCL on the PDAC contractor web site.If an insert is not included in one of these categories of items (A5512, A5513, A5514), it must be billed with code A5510 or A9270 (noncovered item).If a product is billed to Medicare using a HCPCS code that requires written coding verification review, but the product is not on the PCL for that particular HCPCS code, then the claim line will be denied as incorrect coding.Suppliers should contact the PDAC contractor for guidance on the correct coding of these items.
Article - Heating Pads and Heat Lamps - Policy Article (A52502)
CMS National Coverage PolicyN/AArticle TextNON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULESFor 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).Heating pads are covered under the Durable Medical Equipment benefit (Social Security Act 1861(s)(6)). In order for a beneficiarys 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 nonelectric heating pad or wrap (A9273) does not meet the definition of durable medical equipment (DME) and will be denied as noncovered.Hydrocollator units (E0225, E0239) are considered institutional equipment and will be denied as statutorily noncovered.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 availablehere.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.
Article - Heating Pads and Heat Lamps - Policy Article (A52502)
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 REQUIREMENTSIn 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.CODING GUIDELINESA standard electric heating pad (E0210) is a flexible device containing electric resistive elements producing heat. It must have a fabric cover. It must have a timing device for automatic shut-off. It may include heat-retaining material (e.g., gel, fluid, vegetable matter). If so, the heat retaining materials must be contained in an enclosed pouch or bag in or around the heating elements. The heating pad must be certified byan Occupational Safety and Health Administration (OSHA) Nationally Recognized Testing Laboratory (NRTL) (29 CFR 1910.7). A heating pad that includes a cover or other element that utilizes water vapor (humidity) drawn from the air to create moisture when heated is billed using this code.A moist electric heating pad (E0215) is a flexible device containing electric resistive elements producing heat. It must have a fabric cover. It must have a timing device for automatic shut-off. It must have a component that absorbs and retains liquid water. The water containing element must be protected from contact with the electrical components and the water must be in direct contact with the skin on application. The heating pad must be certified byan OSHA NRTL (29 CFR 1910.7). A cover or other element that utilizes water vapor (humidity) drawn from the air to create moisture when heated does not meet the definition of this code. Water must be added to the device to meet the description of this code.
Article - Heating Pads and Heat Lamps - Policy Article (A52502)
A water circulating heat pad with pump (E0217) is a flexible pad containing a series of channels through which water is circulated by means of an electrical pumping mechanism. The water is heated in an external reservoir. The pump, pad, and all accessories needed for the pad to be functional are included in the code. The device must be certified byan OSHA NRTL (29 CFR 1910.7).A hydrocollator unit (E0225, E0239) is a container which is filled with water and then heated. Bags of silicone dioxide or other material are placed in the heated water. These packs/pads are then applied to the body part over towels. They are used to heat the body part prior to physical therapy.Code E0249 is a durable replacement pad used with a water circulating heat pump system (E0217). It is made of rubber, heavy plastic, or durable fabric. It can be cleaned and is designed for long term use. A replacement pad made of other material that is designed for shorter term use must be billed using code A9999 (Miscellaneous DME supply or accessory, not otherwise specified).Heating pads that do not meet the coding criteria described above for E0210, E0215 or E0217 must be billed with code E1399.Suppliers should contact the Pricing, Data Analysis, and Coding (PDAC) contractor for guidance on the correct coding of these items.
Article - Walkers - Policy Article (A52503)
CMS National Coverage PolicyN/AArticle TextNON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULESFor 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).Walkers are covered under the Durable Medical Equipment benefit (Social Security Act 1861(s)(6)). In order for a beneficiarys 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.Enhancement accessories of walkers will be denied as noncovered.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 availablehere.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 INFORMATIONIn 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.
Article - Walkers - Policy Article (A52503)
POLICY SPECIFIC INFORMATIONIn 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.When code E0147 is billed, the claim must include the manufacturers name and product name/number.When code E1399 is billed, the claim must include the manufacturer name and the product name/number.MODIFIERSKX, GA, GY AND GZ MODIFIERS:If a heavy duty walker (E0148, E0149) is provided and if the supplier has documentation in their records that the beneficiary's weight (within one month of providing the walker) is greater than 300 pounds, the KX modifier should be added to the code.If the above criterion has 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.If the walker that is provided is only needed for mobility outside the home, the GY modifier must be added to the codes for the item and all accessories.Claims lines billed with codes E0148 and E0149 without a KX, GA, GY or GZ modifier will be rejected as missing information.CODING GUIDELINESA wheeled walker (E0141, E0143, E0149) is one with either 2, 3, or 4 wheels. It may be fixed height or adjustable height. It may or may not include glide-type brakes (or equivalent). The wheels may be fixed or swivel.A glide-type brake consists of a spring mechanism (or equivalent) which raises the leg post of the walker off the ground when the beneficiary is not pushing down on the frame.Code E0144 describes a rigid or folding wheeled walker which has a frame that completely surrounds the beneficiary and an attached seat in the back.
Article - Walkers - Policy Article (A52503)
Code E0144 describes a rigid or folding wheeled walker which has a frame that completely surrounds the beneficiary and an attached seat in the back.A heavy duty walker (E0148, E0149) is one which is labeled as capable of supporting beneficiaries who weigh more than 300 pounds. It may be fixed height or adjustable height. It may be rigid or folding.Code E0147 describes a 4-wheeled, adjustable height, folding-walker that has all of the following characteristics:Capable of supporting beneficiaries who weigh greater than 350 pounds,Hand operated brakes that cause the wheels to lock when the hand levers are released,The hand brakes can be set so that either or both can lock both wheels,The pressure required to operate each hand brake is individually adjustable,There is an additional braking mechanism on the front crossbar,At least two wheels have brakes that can be independently set through tension adjustability to give varying resistance.The only walkers that may be billed using code E0147 are those products for which a written coding verification review (CVR) has been made by the Pricing, Data Analysis and Coding (PDAC) Contractor and subsequently published on the Product Classification List (PCL). Suppliers should contact the PDAC Contractor for guidance on the correct coding of these items.If a product is billed to Medicare using a HCPCS code that requires written CVR, but the product is not on the PCL for that particular HCPCS code, then the claim line will be denied as incorrect coding.Codes A4636, A4637, and E0159 are only used to bill for replacement items for covered, beneficiary-owned walkers. Codes E0154, E0156, E0157, and E0158 can be used for accessories provided with the initial issue of a walker or for replacement components. Code E0155 can be used for replacements on covered, beneficiary-owned wheeled walkers or when wheels are subsequently added to a covered, beneficiary-owned nonwheeled walker (E0130, E0135). Code E0155 cannot be used for wheels provided at the time of, or within one month of, the initial issue of a non-wheeled walker.Hemi-walkers must be billed using code E0130 or E0135, not E1399.
Article - Walkers - Policy Article (A52503)
Hemi-walkers must be billed using code E0130 or E0135, not E1399.A gait trainer (or sometimes referred to as a rollator) is a term used to describe certain devices that are used to support a beneficiary during ambulation. Gait trainers are billed using one of the codes for walkers. If a gait trainer has a feature described by one of the walker attachment codes (E0154, E0156, E0157) that code may be separately billed. Other unique features of gait trainers are not separately payable and may not be billed with code E1399. If a supplier chooses to bill separately for a feature of a gait trainer that is not described by a specific HCPCS code, then code A9900 must be used.An enhancement accessory is one which does not contribute significantly to the therapeutic function of the walker. It may include, but is not limited to style, color, hand operated brakes (other than those described in code E0147), or basket (or equivalent). Use code A9270 when an enhancement accessory of a walker is billed.Brakes other than hand operated brakes, provided at the same time as a walker (E0141, E0143, E0149) may not be billed separately to the DME MACs or the beneficiary upon initial issue. However if billed separately upon initial issue the brakes must be billed using A9900, and the brakes will deny as not separately payable. HCPCS code E0159 (Brake attachment for wheeled walker, replacement, each) is applicable for replacement brakes only.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 IColumn IIE0130A4636, A4637E0135A4636, A4637E0140A4636, A4637, E0155, E0159E0141A4636, A4637, E0155, E0159E0143A4636, A4637, E0155, E0159E0144A4636, A4637, E0155, E0156, E0159E0147A4636, E0155, E0159
Article - Walkers - Policy Article (A52503)
E0144A4636, A4637, E0155, E0156, E0159E0147A4636, E0155, E0159E0148A4636, A4637E0149A4636, A4637, E0155, E0159Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items.