Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Hospital Beds and Accessories
Policy #:MA05.002c

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.


Refer to the following News Article: Waiver of certain requirements during COVID-19 outbreak related to Durable Medical Equipment (DME), prosthetics, orthotics, and supplies for Medicare Advantage members

MEDICALLY NECESSARY

FIXED-HEIGHT HOSPITAL BEDS
A fixed-height hospital bed (E0250, E0251, E0290, E0291, E0328) is considered medically necessary and, therefore, covered when the individual meets one or more of the following medical necessity criteria:
  • The individual has a medical condition that requires positioning of the body in ways that are not feasible in an ordinary bed. The elevation of the head/upper body of less than 30 degrees does not usually require the use of a hospital bed.
  • The individual has a medical condition that requires positioning of the body in ways that are not feasible in an ordinary bed to alleviate pain.
  • The individual requires head elevation of more than 30 degrees most of the time due to congestive heart failure, problems with aspiration, or chronic pulmonary disease.
  • The individual requires traction equipment, which can only be attached to a hospital bed.

VARIABLE-HEIGHT HOSPITAL BEDS
A variable-height hospital bed (E0255, E0256, E0292, E0293) is considered medically necessary and, therefore, covered for individuals with severely debilitating diseases and conditions (including, but not limited to: severe arthritis and other injuries to the lower extremities, severe cardiac conditions, spinal cord injuries, amyotrophic lateral sclerosis, and multiple sclerosis) when both of the following criteria are met:
  • The individual meets one or more of the medical necessity criteria for a fixed-height hospital bed.
  • The individual requires a bed height that cannot be attained with a fixed-height hospital bed and that allows the individual the ability to transfer to a chair, wheelchair, standing position or if the variable height feature is required to assist the individual to ambulate.

SEMI-ELECTRIC HOSPITAL BEDS
A semi-electric hospital bed (E0260, E0261, E0294, E0295, E0329) is considered medically necessary and, therefore, covered when the individual meets one or more of the medical necessity criteria for a fixed-height hospital bed and requires the body position to be changed frequently and/or immediately when necessary.

HEAVY-DUTY, EXTRA-WIDE HOSPITAL BEDS
A heavy-duty, extra-wide hospital bed (E0301, E0303) is considered medically necessary and, therefore, covered when the individual meets one or more of the medical necessity criteria for a fixed-height hospital bed and when the individual's weight exceeds 350 pounds but is less than 600 pounds.

EXTRA-HEAVY-DUTY HOSPITAL BEDS
An extra-heavy-duty hospital bed (E0302, E0304) is considered medically necessary and, therefore, covered when the individual meets one or more of the medical necessity criteria for a fixed-height hospital bed and when the individual's weight exceeds 600 pounds.

If the individual does not meet any of the coverage criteria for any type of hospital bed, it will be considered not medically necessary and, therefore, not covered.

HOSPITAL BED ACCESSORIES
The following hospital bed accessories are considered medically necessary and, therefore, covered when the individual meets the medical necessity criteria for the specified bed, in addition to the specific criteria indicated below:
  • Bed cradle (E0280): When the individual has a medical condition that requires the prevention of contact with bed coverings (e.g., burns, diabetic ulcers, gout)
  • Trapeze equipment (E0910, E0940): When the individual requires this device to do any one of the following:
    • Sit up because of a respiratory condition
    • Change body position for other medical reasons
    • Get in or out of bed
  • Heavy-duty trapeze equipment (E0911, E0912): When the individual meets both of the following criteria:
    • The individual meets the criteria for regular trapeze equipment
    • The individual's weight exceeds 250 pounds
  • Side rails (E0305, E0310): When bed rails are required due to the individual's condition and the rails are an integral part of or an accessory to the hospital bed.
  • Replacement innerspring mattress (E0271) or foam rubber mattress (E0272): When an individual's medical condition requires a replacement innerspring mattress or foam rubber mattress and the member meets all of the criteria for replacement of durable medical equipment (DME) as listed in the Repair and Replacement of DME policy, the replacement mattress will be covered for a member-owned hospital bed.
  • Safety enclosure frame/canopy for use with hospital bed, any type (E0316): when required by an individual's condition and are an integral part of, or an accessory to a hospital bed.

CONCURRENT RENTAL OR OWNERSHIP OF A PRESSURE-REDUCING SUPPORT MATTRESS

When an individual owns or rents a medically necessary pressure-reducing support mattress (i.e., HCPCS codes: E0184, E0186, E0187, E0196, E0277, E0373) and a hospital bed becomes medically necessary, a hospital bed that includes a mattress will not be covered (e.g., E0250, E0255, E0260, E0290, E0292, E0294, E0303, E0304, E0328, and E0329).

In situations where the pressure-reducing support mattress is incompatible with the hospital bed (e.g., does not fit the hospital bed), the concurrent rental or ownership of a pressure-reducing support mattress statement of noncoverage does not apply.

NONCOVERED ITEMS

TOTAL ELECTRIC HOSPITAL BEDS
A total electric hospital bed (E0265, E0266, E0296, and E0297) is not covered by Medicare because the electric height adjustment feature is considered a convenience feature. Therefore, it is not eligible for reimbursement consideration.

INSTITUTIONAL HOSPITAL BED
An institutional hospital bed (E0270) is not covered by the Company because it is an item not covered by Medicare. Therefore, it is not eligible for reimbursement consideration.

HOSPITAL BED ACCESSORIES
The following hospital bed accessories are not covered by the Company because they are items not covered by Medicare. Therefore, they are not eligible for reimbursement consideration.
  • Bed board (E0273, E0315) (a device placed under a mattress to make the mattress firmer)
  • Overbed table (E0274, E0315)

COLUMN I/COLUMN II REIMBURSEMENT EDITS

The reimbursement for the item(s) represented by the code(s) in column II are included in the reimbursement for the item represented by the code in column I.

Column I
Column II
E0250E0271, E0272, E0305, E0310
E0251E0305, E0310
E0255E0271, E0272, E0305, E0310
E0256E0305, E0310
E0260E0271, E0272, E0305, E0310
E0261E0305, E0310
E0265E0271, E0272, E0305, E0310
E0266E0305, E0310
E0290E0271, E0272
E0292E0271, E0272
E0294E0271, E0272
E0296E0271, E0272
E0301E0305, E0310
E0302E0305, E0310
E0303E0271, E0272, E0305, E0310
E0304E0271, E0272, E0305, E0310
E0328E0271, E0272, E0305, E0310
E0329E0271, E0272, E0305, E0310


FACE-TO-FACE REQUIREMENTS

As a condition for payment, a professional provider must have a face-to-face examination with the individual for whom the item is ordered that meets all of the following requirements:
  • The treating professional provider must have an in-person examination with the individual within the six months prior to the date of the written order prior to delivery.
  • This examination must document that the individual was evaluated and/or treated for a condition that supports the need for the item(s) of DME ordered.

A new face-to-face examination is required each time a new prescription for one of the specified items is ordered. A new prescription is required:
  • For all claims for purchases or initial rentals
  • When there is a change in the prescription for the accessory, supply, drug, etc.
  • If periodic prescription renewal required per medical policy
  • When an item is replaced
  • When there is a change in the supplier
  • When required by state law

In this policy the specified items are:

Code
Narrative
E0250
Hospital bed fixed height with any type of side rails, mattress
E0251
Hospital bed fixed height with any type side rails without mattress
E0255
Hospital bed variable height with any type side rails with mattress
E0256
Hospital bed variable height with any type side rails without mattress
E0260
Hospital bed semi-electric (Head and foot adjustment) with any type side rails with mattress
E0261
Hospital bed semi-electric (head and foot adjustment) with any type side rails without mattress
E0265
Hospital bed, total electric (head, foot and height adjustments), with any type side rails, with mattress
E0266
Hospital bed, total electric (head, foot and height adjustments), with any type side rails, without mattress
E0290
Hospital bed fixed height without rails with mattress
E0291
Hospital bed fixed height without rail without mattress
E0292
Hospital bed variable height without rail without mattress
E0293
Hospital bed variable height without rail with mattress
E0294
Hospital bed semi-electric (head and foot adjustment) without rail with mattress
E0295
Hospital bed semi-electric (head and foot adjustment) without rail without mattress
E0296
Hospital bed, total electric (head, foot and height adjustments), without side rails, with mattress
E0301
Hospital bed Heavy Duty extra wide, with weight capacity 350-600 lbs with any type of rail, without mattress
E0302
Hospital bed Heavy Duty extra wide, with weight capacity greater than 600 lbs with any type of rail, without mattress
E0303
Hospital bed Heavy Duty extra wide, with weight capacity 350-600 lbs with any type of rail, with mattress
E0304
Hospital bed Heavy Duty extra wide, with weight capacity greater than 600 lbs with any type of rail, with mattress

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.

Documentation of a face-to-face encounter between the treating professional provider and the individual meeting the above requirements, including an assessment of the individual’s clinical condition supporting the need for the prescribed DME item(s), must be provided to and kept on file by the DME supplier.

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

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

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, hospital beds and accessories 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 noncovered are not eligible for coverage or reimbursement by the Company.

Description

A hospital bed is a bed with head and leg elevation and, in some cases, height adjustment features that are used to assist individuals who require adjustment or repositioning to alleviate pain, prevent contractures, prevent respiratory infections, and allow individuals to transfer to and from the bed with increased independence.

There are several categories of hospital beds, including, but not limited to, the following:
  • Fixed-height hospital bed: Has manual head and leg elevation adjustments but no height adjustment.
  • Variable-height hospital bed: Has manual head and leg elevation adjustments and manual height adjustment.
  • Semi-electric hospital bed: Has electric head and leg elevation adjustments and manual height adjustment.
  • Heavy-duty, extra-wide hospital bed: Can support an individual whose weight is between 350 and 600 pounds and is available in semi-electric or total-electric models.
  • Extra-heavy-duty hospital bed: Can support an individual whose weight exceeds 600 pounds and is available in semi-electric or total-electric models.
  • Total-electric hospital bed: Has electric head and leg elevation adjustments and electric height adjustment.

The US Food and Drug Administration (FDA) considers manual adjustable hospital beds to be Class I devices, and alternating current (AC)--powered adjustable hospital beds to be Class II devices, both of which are exempt from premarket notification procedures.

Hospital bed accessories are additions to a bed that are not provided as part of the original bed. Accessories that may be needed for the essential functioning of the hospital bed in relation to the individual's condition include trapeze bars, bed cradles, or side rails.
References

Centers for Medicare & Medicaid Services (CMS). CMS Internet Only Manual Publication. Pub 100-03: Medicare National Coverage Determinations. Part 4 -- Chapter 1: Hospital Beds. 280.1. [CMS Web site]. 04/26/17. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part4.pdf. Accessed April 2, 2018.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 280.7: Hospital beds. [CMS Web site]. 05/89. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=227&ncdver=1&bc=AgAAgAAAAAA. Accessed April 2, 2018.

Noridian Healthcare Services, LLC. Local Coverage Determination (LCD).L33820: Hospital Beds and Accessories. [Noridian Web site]. Original: 10/01/15. (Revised: 01/01/17). Available at:https://med.noridianmedicare.com/documents/2230703/7218263/Hospital+Beds+And+Accessories+LCD+and+PA. Accessed April 2, 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)

N/A


HCPCS Level II Code Number(s)



MEDICALLY NECESSARY

THE FOLLOWING CODES ARE USED TO REPRESENT FIXED HEIGHT HOSPITAL BEDS:

E0250 Hospital bed, fixed height, with any type side rails, with mattress

E0251 Hospital bed, fixed height, with any type side rails, without mattress

E0290 Hospital bed, fixed height, without side rails, with mattress

E0291 Hospital bed, fixed height, without side rails, without mattress

E0328 Hospital bed, pediatric, manual, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 in above the spring, includes mattress


THE FOLLOWING CODES ARE USED TO REPRESENT VARIABLE HEIGHT HOSPITAL BEDS:

E0255 Hospital bed, variable height, hi-lo, with any type side rails, with mattress

E0256 Hospital bed, variable height, hi-lo, with any type side rails, without mattress

E0292 Hospital bed, variable height, hi-lo, without side rails, with mattress

E0293 Hospital bed, variable height, hi-lo, without side rails, without mattress


THE FOLLOWING CODES ARE USED TO REPRESENT SEMI-ELECTRIC HOSPITAL BEDS:

E0260 Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress

E0261 Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattress

E0294 Hospital bed, semi-electric (head and foot adjustment), without side rails, with mattress

E0295 Hospital bed, semi-electric (head and foot adjustment), without side rails, without mattress

E0329 Hospital bed, pediatric, electric or semi-electric, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 in above the spring, includes mattress


THE FOLLOWING CODES ARE USED TO REPRESENT HEAVY DUTY HOSPITAL BEDS:

E0301 Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, without mattress

E0303 Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress


THE FOLLOWING CODES ARE USED TO REPRESENT EXTRA HEAVY DUTY HOSPITAL BEDS:

E0302 Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, without mattress

E0304 Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, with mattress


THE FOLLOWING CODES ARE USED TO REPRESENT HOSPITAL BED ACCESSORIES:

E0280 Bed cradle, any type

E0305 Bedside rails, half-length

E0310 Bedside rails, full-length

E0316 Safety enclosure frame/canopy for use with hospital bed, any type

E0910 Trapeze bars, also known as Patient Helper, attached to bed, with grab bar

E0911 Trapeze bar, heavy duty, for patient weight capacity greater than 250 pounds, attached to bed, with grab bar

E0912 Trapeze bar, heavy duty, for patient weight capacity greater than 250 pounds, free standing, complete with grab bar

E0940 Trapeze bar, freestanding, complete with grab bar


THE FOLLOWING CODES ARE COVERED FOR REPLACEMENT ON A MEMBER-OWNED HOSPITAL BED:

E0271 Mattress, innerspring

E0272 Mattress, foam rubber


NOT COVERED

E0265 Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, with mattress

E0266 Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, without mattress

E0270 Hospital bed, institutional type includes: oscillating, circulating, and stryker frame, with mattress

E0273 Bed board

E0274 Over-bed table

E0296 Hospital bed, total electric (head, foot, and height adjustments), without side rails, with mattress

E0297 Hospital bed, total electric (head, foot, and height adjustments), without side rails, without mattress

E0315 Bed accessory: board, table, or support device, any type




Revenue Code Number(s)

N/A

Coding and Billing Requirements






Policy History

MA05.002c
02/13/2019This policy has been reissued in accordance with the Company's annual review process.
05/09/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on Hospital Beds and Accessories.
09/20/2017This policy will become effective 09/20/2017.

The policy has been reviewed and reissued to communicate the Company’s continuing position on Hospital Beds and Accessories.

MA05.002b
07/13/2016This policy will become effective 07/13/2016.

Language related to pediatric beds was added to the policy section.

The following codes were added to the coding table: E0328, E0329.

MA05.002a
07/03/2015Revised policy# MA05.002a was issued as a result of the Company's annual review.

Language was added to the policy section addressing rental or ownership of a pressure-reducing support mattress.

MA05.002
01/01/2015This is a new policy.





Version Effective Date: 09/20/2017
Version Issued Date: 09/20/2017
Version Reissued Date: 02/14/2019