evekhm/cms_iom_500 huggingface dataset:
Article - Lower Limb Prostheses - Policy Article (A52496)
PARTIAL FOOT AND TOE FILLER INSERTSCodes L5000, L5010, and L5020 describe products that are necessary for standing balance and toe off support in beneficiaries who are missing the forefoot or digits including the hallux (great toe) and who require the rigidity and support offered by these products, in order to achieve or maintain an effective gait.L5000 describes a shoe insert with a rigid longitudinal arch support that also incorporates material accommodating the void left by the missing digit(s) or forefoot. Additional soft material is added where contact is made with the residual limb or toes. These inserts are designed to provide standing balance and toe off support for improved gait. L5000 is inclusive of variations in materials or combinations such as differing stiffnesses or Shore value.L5010 describes a partial foot device including a molded socket for the residual limb with a proximal height terminating at the ankle or extending proximally as needed to achieve appropriate support and function. L5010 is inclusive of a rigid longitudinal arch support that also incorporates material accommodating the void left by the missing digit(s) or forefoot. Additional soft material is added where contact is made with the residual limb or toes. L5010 devices are designed to provide standing balance and toe off support for improved gait. All closures are included, any type. L5010 is inclusive of variations in materials or combinations such as differing stiffnesses or Shore value.L5020 describes a partial foot device including a molded socket for the residual limb with a proximal height terminating at or near the tibial tubercle to achieve appropriate support and function. L5020 is inclusive of a rigid longitudinal arch support that also incorporates material accommodating the void left by the missing digit(s) or forefoot. Additional soft material is added where contact is made with the residual limb or toes. L5020 devices are designed to provide standing balance and toe off support for improved gait. All closures are included, any type. L5020 is inclusive of variations in materials or combinations such as differing stiffnesses or Shore value.
Article - Lower Limb Prostheses - Policy Article (A52496)
MICROPROCESSOR ANKLE FOOT SYSTEMSWith the exception of items described by specific HCPCS codes, there should be no separate billing and there is no separate payment for a component or feature of a microprocessor controlled foot, including but not limited to real time gait analysis, continuous gait assessment, or electronically controlled static stance regulator.L5973 describes an endoskeletal device with integrated energy storage and release foot and microprocessor ankle system. The integrated microprocessor is programmable along with sensors to optimize plantar and dorsiflexion angles for stance and swing phase. L5973 includes foot cover, power source(s) and charger.A microprocessor ankle-foot system with power assist (BiOM Ankle-Foot System by iWalk, Inc) is coded as the combination of L5969 (ADDITION, ENDOSKELETAL ANKLE-FOOT OR ANKLE SYSTEM, POWER ASSIST, INCLUDES ANY TYPE MOTOR(S)) and L5973 (ENDOSKELETAL ANKLE FOOT SYSTEM, MICROPROCESSOR CONTROLLED FEATURE, DORSIFLEXION AND/OR PLANTAR FLEXION CONTROL, INCLUDES POWER SOURCE).
Article - Lower Limb Prostheses - Policy Article (A52496)
The right (RT) and left (LT) modifiers must be used with prosthesis codes. Effective for claims with dates of service (DOS) on or after 3/1/2019, when the same code for prostheses, sockets, or components for bilateral amputees are billed on the same date of service bill each item on two separate claim lines using theRT 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. Claim lines billed without the RT and/or LT modifiers,or with RTLT on the same claim line and 2 UOS,will be rejected as incorrect coding.Coding Batteries and Chargers Concurrently With a Powered Base ItemPowered base items are those that contain the power source (battery). At the time that a base item is billed, all necessary batteries and/or battery chargers are considered as included in the payment for the powered base item. There is no separate payment for batteries (L7360, L7364, and L7367) and/or battery chargers (L7362, L7366, and L7368) billed concurrently with a powered base item.Payments for items listed in Column II are included in the payment for each Column I code. Claims for Column II items billed with the provision of a Column I item will be denied as unbundling.Column IColumn IIBase codes with battery, charger and/or power includedBatteriesL5781L7360L5782L7364L5856L7367L5857L5858L5859ChargersL5973L7362L7366L7368Suppliers should contact the DME PDAC contractor for guidance on the correct coding of these items.
Article - Lower Limb Prostheses - Policy Article (A52496)
L5857L5858L5859ChargersL5973L7362L7366L7368Suppliers should contact the DME PDAC contractor for guidance on the correct coding of these items.CODING VERIFICATION REVIEWThe only products which may be billed using the following list of HCPCS codes are those 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). Information concerning the documentation that must be submitted to the PDAC for a CVR can be found on the PDAC web site or by contacting the PDAC. A PCL with products which have received a coding verification can be found on the PDAC web site. The effective date of the CVR is included for each code.Effective for claims with dates of service on or after January 1, 2014:L5969Effective for claims with dates of service on or after January 1, 2021:L5856, L5857, L5858, L5973, L5980, L5987If 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.
Article - Manual Wheelchair Bases - Policy Article (A52497)
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).Manual wheelchairs 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.If the manual wheelchair is only for use outside the home, it will be denied as noncovered, no benefit, as the DME benefit requires use within the home for coverage eligibility.Reimbursement for wheelchair codes includes all labor charges involved in the assembly of the wheelchair. Reimbursement also includes support services such as emergency services, delivery, set-up, education, and on-going assistance with use of the wheelchair.A custom manual wheelchair base (K0008) must be uniquely constructed or substantially modified for a specific beneficiary according to the description and orders of the beneficiarys treating practitioner. The beneficiarys needs cannot be accommodated by any other existing manual wheelchair and accessories, including customized seating arrangements. See 42 CFR Section 414.224, and Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 20, Section 30.3 for more information on customized DME.
Article - Manual Wheelchair Bases - Policy Article (A52497)
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 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 discussed below.
Article - Manual Wheelchair Bases - Policy Article (A52497)
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.Information showing that the coverage criteria in the Coverage Indications, Limitations, and/or Medical Necessity section of the related LCD have been met must be present in the beneficiarys medical record. Information about whether the beneficiarys home can accommodate the wheelchair (Criterion C), also called the home assessment, must be fully documented in the medical record or elsewhere by the supplier. For manual wheelchairs, the home assessment may be done directly by visiting the beneficiarys home or indirectly based upon information provided by the beneficiary or their designee. When the home assessment is based upon indirectly obtained information, the supplier must, at the time of delivery, verify that the item delivered meets the requirements specified in criterion C. Issues such as the physical layout of the home, surfaces to be traversed, and obstacles must be addressed by and documented in the home assessment. Information from the beneficiarys medical record and the suppliers records must be available upon request.If documentation of the medical necessity for a K0005 wheelchair is requested, it must include a description of the beneficiarys routine activities. This may include the types of activities the beneficiary frequently encounters and whether the beneficiary is fully independent in the use of the wheelchair. Describe the features of the K0005 base which are needed compared to the K0004 base.If documentation of the medical necessity for a K0008 wheelchair is requested, contractors must be able to determine that the item delivered is a customized item. Documentation must include a description of the beneficiarys unique physical and functional characteristics that require a customized manual wheelchair base. This must include a detailed description of the manufacturing of the wheelchair base, including types of materials used in custom fabricating or substantially modifying it, and the construction process and labor skills required to modify it. The record must document that the needs of the beneficiary cannot be met using another manual wheelchair base that incorporates seating modifications or other options or accessories (prefabricated and/or custom). The documentation must demonstrate that the K0008 is so different from another wheelchair base that the two items cannot be grouped together for pricing purposes.
Article - Manual Wheelchair Bases - Policy Article (A52497)
If documentation of the medical necessity for a transport chair (E1037, E1038 and E1039) is requested, it must include a description of why the beneficiary is unable to make use of a standard manual wheelchair (K0001, K0002, K0003, K0004, and K0005) on their own, and provide specific information that the beneficiary has a caregiver who is available, willing, and able to provide assistance with the wheelchair.SPECIALTY EVALUATION:The specialty evaluation provides detailed information explaining why the particular wheelchair and the special features of the wheelchair are necessary to address the beneficiarys mobility limitation. There must be a written report of this evaluation available on request. The PT, OT, or practitioner who performs the specialty evaluation may have no financial relationship with the supplier. (Exception: If the supplier is owned by a hospital, the PT, OT, or practitioner working in the inpatient or outpatient hospital setting may perform the specialty evaluation.)MODIFIERSKX, GA, GY, AND GZ MODIFIERS:Suppliers must add a KX modifier to the code for the manual wheelchair base 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 suppliers files and available to the DME MAC upon request. If the coverage criteria are not met, the KX modifier must not be used.If all of the coverage criteria in the Coverage Indications, Limitations, and/or Medical Necessity section of the related LCD 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.If the wheelchair is only to be used for mobility outside the home, the GY modifier must be added to the code.Claim lines billed without a KX, GA, GY, or GZ modifier will be rejected as missing information.CODING GUIDELINESFor Medicare coding purposes, all manual wheelchair base codes describe a complete product.This includes items described by HCPCS codes:Rollabout Chair (E1031)
Article - Manual Wheelchair Bases - Policy Article (A52497)
CODING GUIDELINESFor Medicare coding purposes, all manual wheelchair base codes describe a complete product.This includes items described by HCPCS codes:Rollabout Chair (E1031)Transport Chairs (E1037, E1038, E1039)Manual Wheelchair Bases (E1161, E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0009)A complete manual wheelchair base includes:A complete framePropulsion wheelsCastersBrakesA sling seat, seat pan which can accommodate a wheelchair seat cushion, or a seat frame structured in such a way as to be capable of accepting a seating systemA sling back, other seat back support which can accommodate a wheelchair back cushion, or a back frame structured in such a way as to be capable of accepting a back systemStandard leg and footrestsArmrestsSafety accessories (other than those separately billable in the Wheelchair Accessories Local Coverage Determination)Adult manual wheelchairs (K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0008, K0009, E1161) are those which have a seat width and a seat depth of 15 or greater. For codes K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0008, K0009, the wheels must be large enough and positioned such that the wheelchair could be propelled by the user. In addition, specific codes are defined by the following characteristics:Standard wheelchair (K0001)Weight: Greater than 36 lbs.Seat Height: 19 inches or greaterWeight capacity: 250 pounds or lessStandard hemi (low seat) wheelchair (K0002)Weight: Greater than 36 lbsSeat Height: Less than 19 inchesWeight capacity: 250 pounds or lessLightweight wheelchair (K0003)Weight: 34-36 lbsWeight capacity: 250 pounds or lessHigh strength, lightweight wheelchair (K0004)Weight: Less than 34 lbsLifetime Warranty on side frames and crossbraces
Article - Manual Wheelchair Bases - Policy Article (A52497)
Lightweight wheelchair (K0003)Weight: 34-36 lbsWeight capacity: 250 pounds or lessHigh strength, lightweight wheelchair (K0004)Weight: Less than 34 lbsLifetime Warranty on side frames and crossbracesUltralightweight wheelchair (K0005)Weight: Less than 30 lbsAdjustable rear axle positionLifetime Warranty on side frames and crossbracesHeavy duty wheelchair (K0006)Weight capacity: Greater than 250 poundsExtra heavy duty wheelchair (K0007)Weight capacity: Greater than 300 poundsCustom manual wheelchair/base (K0008)In addition to meeting the statutory criteria above in the Non-Medical Necessity Coverage and Payment Rules, custom manual wheelchairs must also have a lifetime warranty on side frames and crossbraces.Adult tilt-in-space wheelchair (E1161)Ability to tilt the frame of the wheelchair greater than or equal to 20 degrees from horizontal while maintaining the same back to seat angle. Lifetime Warranty: On side frames and crossbracesWheelchairs with less than 20 degrees of tilt must not to be coded based upon the tilt feature. The appropriate base product must be coded as K0001, K0002, K0003, K0004, K0005, K0006,or K0007. The product must not be coded as E1161 or K0108.Weight represents the weight of the wheelchair itself in pounds without the front rigging as in the case of the K0001, K0002, K0003, K0004, and K0005. Weight capacity represents the carrying capacity or the amount of weight (beneficiary plus all accessories) that the wheelchair can carry for safe operation as in the case of the K0001, K0002, K0003, K0006 and K0007.The following features are included in the allowance for all adult manual wheelchairs:Seat Width: 15" - 19"Seat Depth: 15"  19Arm Style: Fixed, swingaway, or detachable; fixed heightFootrests: Fixed, swingaway, or detachableCodes K0003, K0004, K0005, K0006, K0007, K0008 and E1161 include any seat height.
Article - Manual Wheelchair Bases - Policy Article (A52497)
Codes K0003, K0004, K0005, K0006, K0007, K0008 and E1161 include any seat height.Manual wheelchair bases (K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0008, andK0009) include construction of any type material, including but not limited to, titanium, carbon, or any other lightweight high strength material. Suppliers must not bill HCPCS code K0108 in addition to the base wheelchair for construction materials or for a heavy duty package reflecting the type of material used to construct the manual wheelchair base. Billing for construction material is considered incorrect coding  unbundling.Refer to the medical policy on Wheelchair Options and Accessories for information on other features included in the allowance for the wheelchair base.Effective for claims with dates of service on or after June 1, 2013, the only products which may be billed to Medicare using HCPCS code K0009, are those 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).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.A manual wheelchair with a seat width and/or depth of 14 or less is considered a pediatric size wheelchair and is billed with codes E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238 or E1229.Manual wheelchairs with additional options and accessories, other than tilt, are billed by selecting the correct code for the wheelchair base and then using appropriate codes for wheelchair options and accessories. (Refer to the Wheelchair Options and Accessories policy.)Suppliers should contact the PDAC contractor for guidance on the correct coding of these items.
Article - Power Mobility Devices - Policy Article (A52498)
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).Power mobility devices 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.The Medicare Prescription Drug, Improvement, and Modernization Act of 2003, added section 1834(a)(1)(E)(iv) which provides that payment may not be made for a motorized or power wheelchair unless the treating practitioner conducts the face-to-face encounter and writes the Standard Written Order (SWO). If the treating practitioner does not conduct the face-to-face encounter or write the SWO for the PMD base item, the claim will be denied as statutorily noncovered.A power mobility device may not be ordered by a podiatrist. If it is, it will be denied as statutorily noncovered.FACE-TO-FACE ENCOUNTER:
Article - Power Mobility Devices - Policy Article (A52498)
A power mobility device may not be ordered by a podiatrist. If it is, it will be denied as statutorily noncovered.FACE-TO-FACE ENCOUNTER:If the POV or PWC is a replacement during the 5-year useful lifetime of an item in the same performance group that was previously covered by Medicare, a face-to-face encounter is not required. Note: Replacement during an items useful lifetime is limited to situations involving loss or irreparable damage from a specific accident or natural disaster (e.g., fire, flood, etc.).The treating practitioner may conduct the entire mobility face-to-face encounter or may refer the beneficiary to a licensed/certified medical professional (LCMP), such as a physical therapist (PT) or occupational therapist (OT), who has experience and training in mobility evaluations to perform part of the face-to-face encounter. This person may have no financial relationship with the supplier. (Exception: If the supplier is owned by a hospital, the PT or OT working in the inpatient or outpatient hospital setting may perform part of the face-to-face encounter.)To accommodate the requirements at 42 CFR 410.38, when the treating practitioner sees the beneficiary, regardless of whether a referral to an LCMP is made, that visit date starts the six (6) month timeline for completion of the SWO for the wheelchair base. If the treating practitioner chooses to refer the beneficiary to an LCMP for a mobility evaluation, the treating practitioner's co-signature, dating and indicating agreement or disagreement with the LCMP evaluation must occur within this six (6) month timeframe. In cases where the LCMP evaluation is being adopted into the practitioner's documentation to substantiate the need for the base item, the SWO may not be written until the LCMP report is signed, dated and agreement/disagreement indicated.