Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Continuous Passive Motion (CPM) Devices in the Home Setting
Policy #:MA05.019a

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

Continuous passive motion (CPM) devices used in the home setting are considered medically necessary and, therefore, covered for up to 3 weeks when applied within 2 days post-surgery for either of the following indications:
  • Individuals who have received a total knee replacement
  • Individuals who have received a revision to a previous total knee replacement (i.e., tibial components or femoral component)

All other uses of CPM devices are not covered by the Company because they are a service not covered by Medicare. Therefore, they are not eligible for reimbursement consideration.

Use of these devices longer than a 3-week period is considered not medically necessary and, therefore, not covered.

REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation:

PRESCRIPTION (ORDER) REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier, and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES
The durable medical equipment (DME) supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately seven days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately five days before the individual would exhaust their on-hand supply.

If required documentation is not available on file to support a claim at the time of an audit or record request, the durable medical equipment (DME) supplier may be required to reimburse the Company for overpayments.
Policy Guidelines

Continuous passive motion (CPM) devices are covered by the Company on a daily rental basis only.

This policy is consistent with Medicare's coverage criteria. The Company's payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, continuous passive motion devices are categorized as durable medical equipment (DME) and are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this policy are met.

However, services that are identified in this policy as not medically necessary are not eligible for coverage or reimbursement by the Company.

Description

Continuous passive motion (CPM) devices provide mechanical passive range of motion (ROM) to joints following surgery to maintain or restore strength, mobility, and functionality of articular tissues, cartilage, tendons, and ligaments. The device moves the joint (e.g., flexes and extends) continuously, without assistance from the individual, to promote healing by circulating synovial fluid while deterring adhesions, stiffness, and contractures. The affected joint is placed on the device and held in place by Velcro® straps. An electrical power unit is used to set a variable ROM and speed. The initial settings for ROM are based on the individual’s level of comfort and other factors that are assessed intraoperatively (e.g., initial degree of flexion and extension). Under the direction of the ordering professional provider, the ROM may be increased three to five degrees per day, depending on joint stability and individual comfort.
References

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD).280.1: Durable medical equipment reference list. [CMS Web site]. 05/05/05. Available at:
http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=190&ncdver=2&bc=BAABAAAAAAAA&. Accessed December 26, 2018.

Noridian Health care Solutions, LLC Payment Rules - Continuous Passive Motion Machines. DME MAC Joint Publication January 23, 2014. Available at: https://med.noridianmedicare.com/web/jadme/article-detail/-/view/2230703/payment-rules-continuous-passive-motion-machines. Accessed December 26, 2018.


Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

Z96.651 Presence of right artificial knee joint

Z96.652 Presence of left artificial knee joint

Z96.653 Presence of artificial knee joint, bilateral



HCPCS Level II Code Number(s)



MEDICALLY NECESSARY
E0935 Continuous passive motion exercise device for use on knee only

NOT COVERED
E0936 Continuous passive motion exercise device for use other than knee


Revenue Code Number(s)

N/A

Coding and Billing Requirements






Policy History

MA05.019a
02/27/2019The policy has been reviewed and reissued to communicate the Company's continuing position on Continuous Passive Motion (CPM) Devices in the Home Setting.
03/07/2018This version of the policy will become effective 03/07/2018. This policy has been updated to communicate the Company’s continuing position on Continuous Passive Motion (CPM) Devices in the Home Setting.

MA05.019
03/15/2017The policy has been reviewed and reissued to communicate the Company's continuing position on Continuous Passive Motion (CPM) Devices in the Home Setting
01/20/2016The policy has been reviewed and reissued to communicate the Company's continuing position on Continuous Passive Motion (CPM) Devices in the Home Setting
01/07/2015The policy has been updated to communicate the Company's continuing position on Continuous Passive Motion (CPM) Devices in the Home Setting
01/01/2015This is a new policy.






Version Effective Date: 03/07/2018
Version Issued Date: 03/07/2018
Version Reissued Date: 02/27/2019