Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Patient Lifts
Policy #:MA05.031a

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

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.

COVERED PATIENT LIFTS

The following patient lifts are considered medically necessary and, therefore covered when the individual's medical condition is such that: 1) without the use of a patient lift the individual would be bed confined; and 2) transferring of the individual between a bed and a chair, wheelchair, or commode is required:
  • Patient lift with hydraulic mechanism (E0630)
  • Patient lift, electric, with seat or sling (E0635)
  • Patient lift, moveable from room to room with disassembly and reassembly, includes all components/accessories (E0639)
  • Patient lift, fixed system, includes all components/accessories (E0640)

The following multi-positional patient support systems are considered medically necessary and, therefore, covered when the above criteria are met and the individual requires supine positioning for transfers:
  • Multi-positional patient support system, with integrated lift, patient accessible controls (E0636)
  • Multi-positional patient transfer system, with integrated seat, operated by caregiver, patient weight capacity up to and including 300 lbs (E1035)
  • Multi-positional patient transfer system, extra-wide, with integrated seat, operated by caregiver, patient weight capacity greater than 300 lbs (E1036)

The initial seat or sling (E0621) is included as part of an initial patient lift. Therefore, it is not eligible for separate reimbursement consideration by the Company unless it is ordered as a replacement accessory for a covered patient lift.

NONCOVERED PATIENT LIFTS

A patient lift (bathroom or toilet), (E0625) is not covered by the Company because it is an item not covered by Medicare. Therefore, it is not eligible for reimbursement consideration.

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
E0625
E0621
E0630
E0621
E0635
E0621
E0636
E0621
E0639
E0621
E0640
E0621

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 (6) 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
E0636
Multipositional patient support system, with integrated lift, patient accessible controls
E1035
Multi-positional patient transfer system, with integrated seat, operated by care giver, patient weight capacity up to and including 300 lbs
E1036
Multi-positional patient transfer system, extra-wide, with integrated seat, operated by caregiver, patient weight capacity greater than 300 lbs

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.

BILLING REQUIREMENTS

To report the replacement of a seat or sling to a previously purchased patient lift (E0625, E0630, E0635, E0636, E0639,E0640) that is eligible for coverage by the Company, providers must use HCPCS code E0621 (sling or seat, patient lift, canvas or nylon).

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.
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, patient lifts 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 medical policy have been met.

However, patient lift (E0625) has been identified in this policy as not primarily medical in nature and, therefore, not eligible for coverage or reimbursement by the Company.

Description

A patient lift is a hydraulic or electrically powered device, either fixed or mobile, that is used to lift and transport an individual in the horizontal or other required position from one place to another (e.g., from a bed to a bath). Patient lifts are categorized as durable medical equipment (DME).

A hydraulic (Hoyer) lift is a patient lift with a standard lifting mechanism that is operated by the resistance offered or the pressure transmitted when a quantity of liquid (e.g., water, oil) is forced through a comparatively small orifice or tube. The device includes straps and a sling to support the patient. According to the US Food and Drug Administration (FDA), a hydraulic lift is considered a Class I medical device with general controls and is exempt from premarket notification procedures.

An electric lift is a patient lift with an enhanced lifting mechanism that is operated by electricity. The device includes straps and a sling to support the patient.

Multi-positional patient transfer systems are devices that can be positioned and adjusted such that the bed-bound patient can be transferred onto the device in the supine position. Once positioned on the device, the multi-position patient transfer system can be adjusted to a chair-like position with multiple degrees of recline and leg elevation.

Some patient lifts that are used in the home require modifications to a dwelling. Lifts requiring dwelling modifications include either of the following:
  • A portable ceiling lift system for the home with a track that makes it moveable from room to room
  • A fixed lift system that is permanently installed in the home

References

Centers for Medicare & Medicaid Services (CMS). Medicare Coverage Issues Manual. Durable medical equipment and prosthetic devices. Part 60-9: Durable medical equipment reference list. Patient lifts. [CMS Web site]. Available at: http://www.cms.hhs.gov/manuals/downloads/Pub06_PART_60.pdf. Accessed June 18, 2019.

Noridian Healthcare Solutions, LLC. Local Coverage Determination (LCD) Patient Lifts (L33799). Effective 01/01/2017. Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33799&ContrId=389
Accessed June 18, 2019.

Noridian Healthcare Solutions, LLC. Local Coverage Article: Patient Lifts - Policy Article (A52516).
Effective 01/01/2017. Available:
https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52516&ver=10&Cntrctr=389&name=&DocType=Active&DocStatus=Active&ContrVer=1&CntrctrSelected=389*1&s=9&LCntrctr=139*1&bc=AhAAAAMAAAAA&. Accessed June 18, 2019.

Noridian Healthcare Solutions, LLC. Noridian's Noncovered Items List. Revised Jan 29, 2018. Available at:
https://med.noridianmedicare.com/web/jadme/search-result/-/view/2230703/noncovered-items. Accessed June 18, 2019.



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)



COVERED PATIENT LIFTS

E0621 Sling or seat, patient lift, canvas or nylon

E0630 Patient lift, hydraulic or mechanical, includes any seat, sling, strap(s) or pad(s)

E0635 Patient lift, electric, with seat or sling

E0636 Multipositional patient support system, with integrated lift, patient accessible controls

E0639 Patient lift, moveable from room to room with disassembly and reassembly, includes all components/accessories

E0640 Patient lift, fixed system, includes all components/accessories

E1035 Multi-positional patient transfer system, with integrated seat, operated by care giver, patient weight capacity up to and including 300 lbs

E1036 Multi-positional patient transfer system, extra-wide, with integrated seat, operated by caregiver, patient weight capacity greater than 300 lbs


THE FOLLOWING CODE IS NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT WHEN REPORTED AS AN INITIAL SEAT OR SLING:

E0621 Sling or seat, patient lift, canvas or nylon


NONCOVERED PATIENT LIFTS

E0625 Patient lift, bathroom or toilet, not otherwise classified



Revenue Code Number(s)

N/A

Coding and Billing Requirements

To report the replacement of a seat or sling to a previously purchased patient lift that is eligible for coverage by the Company, providers must use HCPCS code E0621 (sling or seat, patient lift, canvas or nylon).

A Sling or seat, patient lift, canvas or nylon (E0621) is included in the reimbursement of the following patient lifts:

E0625 Patient lift, bathroom or toilet, not otherwise classified

E0630 Patient lift, hydraulic or mechanical, includes any seat, sling, strap(s) or pad(s)

E0635 Patient lift, electric, with seat or sling

E0636 Multipositional patient support system, with integrated lift, patient accessible controls

E0639 Patient lift, moveable from room to room with disassembly and reassembly, includes all components/accessories

E0640 Patient lift, fixed system, includes all components/accessories





Policy History

MA05.031a
07/31/2019The policy has been reviewed and reissued to communicate the Company's continuing position on Patient Lifts.




MA05.031a
04/25/2018This policy has been reviewed and reissued to communicate the Company's continuing coverage of patient lifts.
08/30/2017This policy has been reviewed and reissued to communicate the Company's continuing coverage of patient lifts.
06/03/2016 This policy will become effective 06/03/2016.

Billing requirements for HCPCS code E0621 was added to the policy section.

MA05.031
04/15/2015 This policy has been reviewed and reissued to communicate the Company's continuing coverage of patient lifts.
01/01/2015This is a new policy.





Version Effective Date: 06/03/2016
Version Issued Date: 06/03/2016
Version Reissued Date: 07/31/2019