Medcare Quick Reference

Medicare Face-To-Face Rules

Oxygen, Positive Airway Pressure (PAP) devices and Negative Pressure Wound Therapy (NPWT), and some other items (such as nebulizers, beds, and wheelchairs) require documentation that the patient had an in-person, face-to-face examination by the treating practitioner prior to delivery of the applicable DME item(s).
The record of the face-to-face encounter must document that the beneficiary was evaluated and/or treated for a condition that supports the item ordered.
A specific diagnosis is not required in the medical record/chart notes. However, for equipment for which an in-person, face-to-face examination is required, the documentation requirements are in addition to those documents required in the National Coverage Determination (NCD) or Local Coverage Determination (LCD).
Note
Medicare Local Coverage Determination (LCD) for some products may provide different time frames in which a face-to-face evaluation must be conducted.
If there is a variance between the timeframes defined in the Affordable Care Act and the LCD, the Local Coverage Determinations timeframe should always be used.

Patient Lifts / Lift Chairs / Commodes

Bedside Commodes

  • Bedside commodes are only covered if the patient is room-confined or unable to get to toilet facilities. Commodes are not covered if they are placed over the toilet in the bathroom. Medical need must be documented in patient’s medical record.
  • Heavy duty commodes: Width equal to or greater than 23 inches and weight capacity 300 pounds or more.
  • Detachable arms are covered when used to facilitate transfers or fi the patient has a body configuration that requires extra width. This applies to any commode.
  • Supplier must have documentation on file detailing why patient is room-confined or unable to access toilet facilities.

Patient Lifts

  • Patient lifts (Hoyer or other types) are covered if transfer between bed and a chair, a wheelchair, or commode requires the assistance of more than one person and, without the use of a life, the patient would be bed confined.

Lift Chairs

  • All of the following criteria must be met in order to consider coverage:
  • Patient must be able to ambulate once standing (cannot be used in conjunction with a wheelchair or POV).
  • Has severe arthritis of hip or knee or severe neuromuscular disease. Diagnosis required.
  • Must be a part of the physician’s course of treatment and be prescribed to effect improvement, or arrest or retard deterioration of the patient’s condition.
  • Patient must be completely incapable of standing up from any chair in his/her home. The fact that a patient has difficulty or is even incapable of getting up from a chair, particularly a low chair, is not sufficient justification for a seat-life mechanism. Almost all patients who are capable of ambulating can get out of an ordinary chair if the seat height is appropriate and the chair has arms.
  • Once standing, the patient must have the ability to ambulate.

Support Surfaces / Beds

Support Surfaces

Group 1 (Overlays)
Patient must meet criteria 1, 2, or 3
  1. Completely immobile – Patient cannot make changes in body position without assistance, OR
  2. Limited mobility – Patient cannot independently make changes in body position significant enough to alleviate pressure, OR
  3. Any stage pressure ulcer on the trunk or pelvis.

If the patient meets criteria 2 or 3 above he/she must also have at least one of the following conditions:

  1. Impaired nutritional status
  2. Fecal or urinary incontinence
  3. Altered sensory preception
  4. Compromised circulatory status
 Group 2 (powered pressure-reducing mattresses)

Patient must meet criteria 1 AND 2 OR criterion 3 OR criterion 4 below.

  1. Multiple stage II pressure ulcers located on trunk or pelvis that have failed to improve over the last month AND
  2. Patient has been on a comprehensive ulcer treatment program for at least the past month, which has included: the use of an appropriate Group 1 support surface; regular assessment; appropriate turning, positioning and wound care; moisture and incontinence management; and nutritional assessment and intervention.
  3. Large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis OR
  4. Recent myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis (surgery within the past 60 days) and patient has been on a Group 2 or 3 support surface immediately prior to discharge from the hospital or nursing facility (discharge within the past 30 days).
Group 3 (air-fluidized bed)

Patient must meet ALL of the following.

  1. Stage III (full-thickness tissue loss) or stage IV (deep tissue destruction) pressure sore.
  2. Bedridden or chair bound as a result of severely limited mobility.
  3. In absence of an air-fluidized bed, the patient would require institutionalization.
  4. The air-fluidized bed is ordered in writing by the patient’s attending physician based upon a comprehensive assessment and evaluation of the patient after conservative treatment has been tried without success. Conservative treatment should generally include: frequent repositioning, use of Group 2; would management; nutritional optimization; education of patient and caregiver on the prevention and/or management of pressure ulcers and ; assessment by physician, nurse, or other licensed health care practitioner at least weekly.

Beds

Fixed-height hospital bed coverage is considered for a  when at least one of the following are met:

  • Has medical condition which requires positioning of the body in ways not feasible with an ordinary bed.
  • Patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain.
  • Requires the head of the bed to be elevated more than 30degrees most of the time because of CHF, COPD, or problems with aspirations.
  • Requires traction equipment that can only be attached to a hospital bed.

If a heavy duty-type bed is medically necessary, the weight must be at least 350 pounds and must be documented.

 

Semi-electric beds are considered for coverage if one of the above criteria is met AND if the patient requires frequent changes in body position such as to alleviate pain, prevent aspiration, or a respiratory issue.

 

Full electric beds are not covered by Medicare.

 

Detailed Written Order requirements:
  • Beneficiary’s name
  • Date of order
  • Detailed description of the item being ordered (be specific to the type of bed, for example: fixed height, semi-electric, high/low semi-electric bed, etc)
  • Any other items being billed
  • Length of need
  • Treating practitioner’s printed name and NPI
  • Treating practitioner’s signature and signature date

Mobility Equipment / Non-Invasive Ventilators

Mobility Equipment

Remember you must rule out each lower level item. Medicare pays for the least costly alternative.
  1. Cane – Written order and there is a mobility impairment but potential for ambulation.
  2. Walker – Written order and there is mobility impairment that cannot be corrected with a cane but potential for ambulation. Heavy duty would need weight greater than 300 pounds.
  3. Specialty Walker (HD – multiple braking system, variable wheel resistance walker) – patient meets criteria for a walker but cannot use standard due to severe neurologic disorder or other condition causing restricted use of one hand (obesity alone is not sufficient reason).
  4. Manual Wheelchairs – Must rule out use of cane/walker
    1. Standard – Rule out cane and walker; does not have to be able to self-propel, but needs manual wheelchair for use within the home.
    2. Hemi-height – Need manual wheelchair; need lower seat to floor height for transfers and/or to assist with self-propelling with feet.
    3. Lightweight – Rule out cane/walker and standard weight manual wheelchair. MUST be independent in self-propelling with the lightweight wheelchair (cannot be needed solely for caregiver convenience).
    4. High strength lightweight – Rule out standard, hemi-height and lightweight. Needs a seat width/seat depth/seat-to-floor height no available in ANY lower level base and/or patient is up in chair greater than two hours per day and highly active. Does not have to be self-propelled. Needs could relate to activity level or size of patient (i,e., extremely tall or very short and requires ultra-hemi seat height).
    5. Ultra Lightweight – As of March 1, 2013, requires AtP and PT/OT evaluation as well as face-face exam by physician and must have past history of use of same type base and activity both inside and outside the home. Patient must be a full-time independent manual wheelchair user and must require individualized fitting and adjustment such as, but not limited to, axle configuration, wheel chamber or seat and back angles that are not available on a lower-level wheelchair. Need to be very specific as to what is needed on this base that is NOT availale on a high-strength lightweight base (K0004).
    6. Heavy-duty base is covered if patient needs a manual wheelchair and weight is greater than 250 pounds.
    7. Extra heavy duty is covered if patients needs a manual wheelchairs and weight is greater than 300 pounds.
    8. A transport chair (E1037, E1038, E1039) is covered in lieu of a standard manual wheelchair for use within the home.

With all manual wheelchairs, the first rule to remember is that the need is for IN THE HOME and must rule out each lower-level item before a higher level is covered.

Detailed Written Order requirements:
  • Beneficiary’s name
  • Height and weight
  • Date of order
  • Detailed description of the item being ordered (be specific to the type of mobility equipment, for example: walker with wheels, lightweight manual wheelchair, hemi-height manual wheelchair, heavy duty manual wheelchair, etc.)
  • Any other items being billed
  • Length of need
  • Treating practitioner’s printed name and NPI
  • Treating practitioner’s signature and signature date

Non-invasive Ventilators

Non-invasive ventilator treatment is generally covered if treatment is needed for:

  • Neuromuscular disorder
  • Thoracic disorder diseases
  • Chronic respiratory failure associated with a respiratory illness such as chronic obstructive pulmonary disease (COPD)

If patient has had repeated hospital admissions due to respiratory failure, make sure that this information is documented because it will help meet coverage. If a ventilator is used, make sure follow-up visits are documented in the medical record by treating practitioner to show there was a decrease in admissions. Remember Medicare pays for least costly alternative, which means a BiPAP or BiPAP S/T needs to be considered, or tried and ruled out. Clinical documentation must be specific to the individual patient’s needs.

 

Make sure the documentation is very clear and thorough as to why the patient needs a ventilator versus a respiratory assist device such as a BiPAP or BiPAP S/T. The medical record needs to include documentation that supports the severity of the disease and why the ventilator is the appropriate piece of equipment for the patient.

 

Monthly rental payments include the payment for supplies and accessories. 

Detailed Written Order requirements:
  • Beneficiary’s name
  • Date of order
  • Detailed description of the item being ordered and any other items being billed
  • Length of need
  • Treating practitioner’s printed name and NPI
  • Treating practitioner’s signature and signature date

Home Oxygen

Group 1
  1. Patient has a severe lung disease or hypoxia-related symptom that might improve with therapy.
    Examples:

    1. COPD, diffuse interstitial lung disease, bronchiectasis, cystic fibrosis.
    2. Hypoxia-related symptoms suh as pulmonary hypertension, recurring CHF due to chronic cor pulmonale, erythrocytosis, impariemnt of cognitive process, nocturnal restlessness, and morning headache.
    3. Hypoxemia alone will not be covered. There needs to be an underlying condition causing the hypoxemia.
    4. Non-covered conditions: angina pectoris in absence of hypoxemia, breathlessness without cor pulmonale or hypoxemia, severe peripheral vascular disease, terminal illnesses that do not affect lungs, pneumonia.
  2. Blood gas study meets criteria indicated below:
    1. Method 1: On room air at rest while awake oxygen saturation equal to or less than 88 precent or ABG equal to or less than 55 mm Hg
    2. Method 2: If during exercise must have the following three tests documented:
      1. Oxygen saturation on room air at rest – should be above 88%
      2. Oxygen saturation on room air with exercise – needs to be equal to or less than 88%
      3. Oxygen saturation on oxygen with exercise – shows improvement with oxygen
    3. Method 3: During sleep on room air oxygen saturation equal to or less than 88% for at least 5 minutes and does not have to be continuous.

NOTE: If patient qualifies with method 2, then WHOMEVER does the testing must document and provide all three test results described above; otherwise the oxygen will not be covered.

  1. Alternative treatment measures, such as inhalers or nebulizer treatments, have been tried or considered, and ruled out or clinically ineffective.

For Group 1, all three items above need to be met.

Group 2
  1. with PO2 of 56-59 mm Hg or oxygen saturation of 89% at rest, while awake, during sleep for 5 minutes or during exercise as described under Group 1, AND
    1. Dependent edema suggesting CHF, OR
    2. Pulmonary HTN or cor pulmonale, determined by measurement of pulmonary artery pressure, echocardiogram, or “P” pulmonale on EKG, OR
    3. Erythrocythemia with hematocrit greater than 56 percent

For Group 1 and Group 2, there must be evidence of an in-person visit with the treating practitioner performed within 30 days before the initial set-up.

Blood gas study:

  1. Performed by a physician, qualified provider, or laboratory service that can bill Medicare such as an IDTF, and
  2. Study must have been performed:
    1. within 30 days of initial certification while patient is in a chronic stable state, OR
    2. during an inpatient hospital stay and done within two days prior to discharge date.
  3. If the testing was performed in an emergency room, then it’s considered an acute situation and would not be considered as acceptable for coverage.

Helpful notes:

  • If portable oxygen is being ordered, there needs to be documentation in the medical records indicating the patient is mobile within the home.
  • Portable oxygen is considered when the blood gas study is performed while patient is awake or with exercise. At-night use only does not qualify for a portable unit.
  • A frequency of use must be indicated, i.e. 2 lpm continuous or 3 lpm at night. PRN, or as needed basis, is not covered at Medicare.
  • DMEPOS suppliers are not considered as qualified to perform blood gas studies.
  • If patient is under a Part A covered stay payment such as hospital, nursing facility, home health or hospice meets the qualified provider standard. Need to be sure that patient is under a Part A covered payment; if not, then the requirements are not met and qualification would be invalid.

Detailed Written Order (DWO) must contain the following:

  1. Beneficiary’s name
  2. Date of order
  3. Detailed description of the item being ordered.
  4. Route of administration
  5. Frequency of use
  6. Length of need
  7. Treating practitioner’s printed name and NPI
  8. Treating practitioner’s signature and date
  • The CMN can be the DWO but must contain all the information listed above.

Obstructive sleep apnea with use of home oxygen therapy:

For patients requiring the use of home oxygen with PAP device, both the PAP and oxygen policies must be met. The qualifying blodo gas study must be performed during a titration study at a sleep lab facility making sure the pressure is at an optimal setting. The oximetry study performed during this titration shows oxygen saturation of 88% or less for 5 total minutes (does not have to be continuous). There has to be a reduction in AHI/RDI reduced to less than or equal to an average of 10 events/hours or if the initial AHI/RDI was less than an average of 10 events per hour, then the titration demonstrates further reduction is AHI/RDI.

Recertification:

The following to be obtained with the recert CMN for either Group 1 or Group 2:

  1. Re-evaluation by treating physician documenting patient is benefiting from the oxygen therapy and has shown improvement.
  2. Copy of most recent blood gas study (can be from the initial test, if that is the most recent) BUT should not be the normal practice.

GROUP 1 = Required after 12 months of initial certification, which means the re-evaluation must occur within 90 days prior to the date of recertification.

GROUP 2 = Required after 3 months of initial certification, which means the re-evaluation must occur between the 61st-90th day following the initial date.

Respiratory Assist Device (RAD)

There are four different clinical groups characterized as follows:

GROUP I: Restrictive Thoracic Disorders
GROUP II: Severe Chronic Obstructive Pulmonary Disease (COPD)
GROUP III: Central Sleep Apnea (CSA) or Complex Sleep Apnea (Comp SA)
GROUP IV: Hypoventilation Syndrome

FOR INITIAL COVERAGE:
GROUP I: Restrictive Thoracic Disorders

  1. Neuromuscular disease or severe thoracic cage abnormality AND
  2. One of the following:
    1. Arterial blood gas PaCO2, while awake and breathing patient’s prescribed FIO2 is greater than 45 mm Hg, OR
    2. Sleep oximetry demonstrates oxygen saturation less than 88% for more than 5 minutes nocturnal, while breathing prescribed FiO2, OR
    3. For neuromuscular disease (only)
      1. Maximal inspiratory pressure less than 60cm H2OOR
      2. Forced vital capacity less than 50 percent predicted
    4. COPD does not contribute significantly to patient’s pulmonary function.

GROUP II: Severe COPD
Standard BiPAP without backup (E0470):

  1. ABG PaCO2, while awake and breathing patient’s prescribed FiO2 greater than 52 mm Hg; AND
  2. Sleep oximetry demonstrates oxygen saturation of less than or equal to 88% for at least 5 minutes nocturnal, done while breathing at 2 lpm or the patient’s prescribed FiO2 (whichever is higer); AND
  3. Prior to initiating therapy, sleep apnea and treatment with a continuous positive airway pressure device (CPAP) has been considered and ruled out. (Note: Formal sleep testing is not required if there is sufficient information in the medical record to demonstrate that the beneficiary does not suffer from some form of sleep apnea (Obstructive Sleep Apnea (OSA), CSA and/or Comp SA) as the predominant cause of awake hypercapnia or nocturnal arterial oxygen desaturation).

BiPAP with backup (E0471):
Covered for COPD in following two situations:

Situation 1 – BiPAP with backup started any time after a period of initial use of BiPAP without backup if both A and B are met:

  1. ABG PaCO2, while awake and breathing beneficiary’s prescribed FiO2, shows that the beneficiary’s PaCO2 worsens greater than or equal to 7 mm Hg compared to original result from #1 above.
  2. Facility-based PSG demonstrates oxygen saturation less than or equal to 88% for at least 5 minutes nocturnal (minimum recording 2 hours) while using BiPAP without backup that is not caused by obstructive upper airway event.

Situation 2  – BiPAP with backup no sooner than 61 days after initial issue of BiPAP without backup if both A and B are met:

  1. ABG PaCO2 done while awake and breathing beneficiary’s prescribed FiO2, still remains greater than or equal to 52 mm Hg AND
  2. Sleep oximetry, while breathing with BiPAP without backup, demonstrates oxygen saturation less than or equal to 88% for at least 5 minutes nocturnal, (minimum recording time of 2 hours) while breathing oxygen at 2 lpm or prescribed FiO2, whichever is higher.

GROUP III: Central Sleep Apnea or Complex Sleep Apnea
Prior to initiating therapy, a complete, facility-based, attended polysomnogram must be performed documenting both A and B

  1. Diagnosis of central sleep apnea (CSA) or complex sleep apnea (CompSA), AND
  2. Significant improvement of the sleep-associated hypoventilation with the BiPAP with or without backup while breathing prescribed FiO2

Central sleep apnea (CSA) is defined as:

  1. An apnea-hypopnea index (AHI) greater than or equal to 5, AND
  2. The sum total of centra apneas plus central hypopneas is greater than 50% of the total apneas an hypopneas, AND
  3. A central apnea-central hypopnea index (CAHI) is greater than or equal to 5 per hour, AND
  4. Presence of at least one of the following:
    1. Sleepiness
    2. Difficulty initiating or maintaining sleep, frequent awakenings, or nonrestorative sleep
    3. Awakening sort of breath
    4. Snoring
    5. Witnessed Apneas
  5. There is no evidence of daytime or nocturnal hypoventilation

Complex sleep apnea (CompSA) is a form of central apnea specifically identified by all of the following:

  1. With use of a positive airway pressure device without a backup rate (E0601 or E0470), the polysomnogram (PSG) shows a pattern of apneas and hypopneas that demonstrates the presistence or emergence of central apneas or central hypopneas upon exposure to CPAP (E0601) or a bi-level device without backup rate (E0470) device when titrated to the point where obstructive events have been effectively treated (obstructive AHI less than 5 per hour).
  2. After  resolution of the obstructive events, the sum total of central apneas plus central hypopneas is greater than 50% of the total apneas and hypopneas; AND
  3. After resolution of the obstructive events, a central apnea-central hypopnea index (CAHI) greater than or equal to 5 per hour.
  • For diagnosis of CSA, the central apnea-central hypopnea index (CAHI) is defined as the average number of episodes of central apnea and central hypopnea per hour of sleep without the use of a positive airway pressure device. For CompSA, the CAHI is determined during the use of a positive airway pressure device after obstructive events have disappeared.
  • If the AHI or CAHI is calculated based on less than 2 hours of continuous recorded sleep, the total number of recorded events used to calculate the AHI or CAHI must be at least the number of events that would have been required in a 2-hour period (i.e., greater than or equal to 10 events).

GROUP IV: Hypoventilation Syndrome
BiPAP without backup covered if 1, 2, and either 3 or 4 are met:

  1. ABG PaCO2, done while awake breathing prescribed FiO2 is greater than or equal to 45 mm Hg.
  2. Spirometry shows FEVI/FVC greater than or equal to 70%.
  3. ABG PaCO2, done during sleep or immediately upon awaking breathing prescribed FiO2 shows the beneficiary’s PaCO2 worsened greater than or equal to 7 mm Hg compared to result in criterion 1 above.
  4. PSG demonstrates oxygen saturation less than or equal to 88% for at least 5 minutes nocturnal (minimum recording time of 2 hours) not caused by obstructive upper airway events.