Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Commode Chairs
Policy #:MA05.036b

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.

MEDICALLY NECESSARY

A commode chair is considered medically necessary and, therefore, covered, when the individual is physically incapable of utilizing regular toilet facilities and meets at least one of the following indications:
  • The individual is confined to a single room.
  • The individual is confined to one level of the home environment and there is no toilet on that level.
  • The individual is confined to the home and there are no toilet facilities in the home.

An extra wide/heavy duty commode chair (E0168) is considered medically necessary and, therefore, covered, for individuals who weigh over 300 pounds.

A commode chair with detachable arms (E0165) is considered medically necessary and, therefore, covered, if the detachable arms feature meets at least one of the following indications:
  • To facilitate transferring the individual.
  • The individual has a body configuration that requires extra width.

A commode chair with seat lift mechanism (E0170, E0171) is considered medically necessary and, therefore, covered, if the individual meets the medical necessity criteria for a commode and also meets the coverage criteria for a seat lift mechanism (see specific policy on Seat Lift Mechanisms).
  • A commode chair with seat lift mechanism is intended to allow the individual to ambulate after standing; If the individual can ambulate, he or she would rarely meet the coverage criterion for a commode chair.

NOT MEDICALLY NECESSARY

A commode chair is considered not medically necessary and, therefore, not covered when the above criteria are not met.

NOT COVERED

A raised toilet seat (E0244) used for positioning over the toilet is not covered by the Company, because it is an item or service not covered by Medicare. Therefore, it is not eligible for reimbursement consideration.

Toilet seat lift mechanisms (E0172) are not covered by the Company, because they are an item or service not covered by Medicare, because they are considered not primarily medical in nature. Therefore, they are not eligible for reimbursement consideration.

A footrest (E0175) is not covered by the Company, because it is an item or service not covered by Medicare, because it is considered primarily not medical in nature. Therefore, it is not eligible for reimbursement consideration.

Bidets and bidet toilet seats are not covered by the Company, because they are items not covered by Medicare, because they are considered not primarily medical in nature. Therefore, they are not eligible for reimbursement consideration.

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.

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 IColumn II
E0163E0167
E0165E0167
E0168 E0167
E0170E0167, E0627, E0629
E0171E0167, E0627, E0629

Policy Guidelines

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, commode chairs are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

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

Description

A commode is a chair-like device that serves as a toilet, outside of the bathroom setting.

A commode chair with seat lift mechanism is a free-standing device that has a commode pan and that has an integrated seat that can be raised with or without a forward tilt while the individual is seated. An integrated device is one which is sold as a unit by the manufacturer and in which the lift and the commode cannot be separated without the use of tools.

A toilet seat lift mechanism is a device with a seat that can be raised with or without a forward tilt while the individual is seated, allowing the individual to stand and ambulate once he/she is in an upright position. It may be manually operated or electric. It is attached to the toilet.

A raised toilet seat is a device that adds height to the toilet seat. It is either fixed height or adjustable. It is either attached to the toilet or is unattached, resting on the bowl.

A freestanding raised toilet seat supported by legs on the floor is coded as a commode.

Extra wide/heavy duty commode chairs have a width of greater than or equal to 23 inches and are also capable of supporting a individual who weighs 300 pounds or more.

Bidets and bidets incorporated into toilet seats are cleansing devices that utilize a stream of water to irrigate and wash the buttocks and perineum area.
References

Noridian Healthcare Solutions. Local Coverage Determination(L33736). Commodes. [Noridian Healthcare Solutions Web site]. Original: 10/01/2015. (Revised: 01/01/2017). Available at: https://med.noridianmedicare.com/documents/2230703/7218263/Commodes. Accessed January 4, 2019.

Noridian Healthcare Solutions. Local Coverage Article(A52461). Commodes. [Noridian Healthcare Solutions Web site]. Original: 10/01/2015. (Revised: 01/01/2017). Available at: https://med.noridianmedicare.com/web/jadme/policies/lcd/active. Accessed January 4, 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)



MEDICALLY NECESSARY

E0163 Commode chair, mobile or stationary, with fixed arms

E0165 Commode chair, mobile or stationary, with detachable arms

E0167 Pail or pan for use with commode chair, replacement only

E0168 Commode chair, extra wide and/or heavy-duty, stationary or mobile, with or without arms, any type, each

E0170 Commode chair with integrated seat lift mechanism, electric, any type

E0171 Commode chair with integrated seat lift mechanism, nonelectric, any type


NOT COVERED

E0172 Seat lift mechanism placed over or on top of toilet, any type

E0175 Footrest, for use with commode chair, each

E0244 Raised toilet seat


THE FOLLOWING CODE IS USED TO REPRESENT BIDETS AND BIDET TOILET SEATS:
E1399 Durable medical equipment, miscellaneous



Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References




Policy History

MA05.036b
02/12/2020This policy has been reissued in accordance with the Company's annual review process.
02/13/2019This policy has been reviewed and reissued to communicate the Company's continuing position on Commode Chairs.
04/25/2018This policy has been reviewed and reissued to communicate the Company's continuing position on commode chairs.
03/24/2017The following criteria have been added to this policy:
  • Bidets and bidet toilet seats are not covered by the Company, because they are items not covered by Medicare, because they are considered not primarily medical in nature. Therefore, they are not eligible for reimbursement consideration.

The following HCPCS code has been added to this policy:

THE FOLLOWING CODE IS USED TO REPRESENT BIDETS AND BIDET TOILET SEATS:
E1399 Durable medical equipment, miscellaneous

MA05.036a
01/01/2017This policy has been identified for a HCPCS code update effective 01/01/2017.

The following codes were revised: E0627 & E0629.

The following code was termed and removed from the policy: E0628

MA05.036
10/26/2016This policy has been reviewed and reissued to communicate the Company's continuing position on commodes.
08/19/2015This policy has been reviewed and reissued to communicate the Company's continuing position on commodes.
01/01/2015This is a new policy.





Version Effective Date: 03/24/2017
Version Issued Date: 03/24/2017
Version Reissued Date: 02/14/2020