Medicare Reference Guides -- Recent Updates

* August 7, 2015 Print Run:

  •   Several policies updated to address changes from ICD-9 to ICD-10 codes.

  •   Minor changes made to Group II Support Surfaces and Enteral sections.

*  June 16, 2015 Print Run:

  • Updated ICD-9 codes that support medical necessity for tracheostomy care supplies.
  • Removed ICD-9 code information in urological supplies policy, and added statement concerning miscellaneous supplies and urethral inserts for adult females with stress incontinence.

*  May 6, 2015 Print Run:

  • Added information to Suction Policy regarding Wound Suction Pumps and associated supplies.

*  April 13, 2015 Print Run:

  • Removed E0457 and E0458 codes from Table A, Items Requiring a F2F Encounter and a WOPD.

*  March 15, 2015 Print Run: 

  • Made change to E0956 wheelchair table code description and replaced previous billing bullet for this code.

  • Added detailed information to the front section of the booklet regarding how to handle equipment from a previous provider (not in booklet in previous printings).
  • Updated "continued medical need" and "continued use" statements in front of the booklet.
  • Several updates made to PAP policy section.

*  February 9, 2015 Print Run: 

Added to "urological section" • "No more than 2 bedside drainage bags or 2 leg bags per month are covered. (NOTE:  DME MAC coverage determination varies)"

Also, updated information pertaining to "CPAP Continued Coverage Criteria: (After 3 month trial) 

To continue coverage for the positive airway pressure (PAP) device (CPAP or RAD) beyond an initial 3 month trial period, there must be:

A.       A face-to-face visit with the physician during the second or third month (31st to 91st day) of the trial that documents an improvement of the beneficiary’s symptoms; and..."

*  January26, 2015 Print Run: 

Added the following information regarding COVERAGE OF SECOND VENTILATOR:

Medicare does not cover spare or back-up equipment. Claims for backup equipment will be denied as not reasonable and necessary - same/similar equipment.

Backup equipment must be distinguished from multiple medically necessary items which are defined as, identical or similar devices each of which meets a different medical need for the beneficiary. Although Medicare does not pay separately for backup equipment, Medicare will make a separate payment for a second piece of equipment if it is required to serve a different purpose that is determined by the beneficiary's medical needs.

The following are examples of situations in which a beneficiary would qualify for both a primary ventilator and a secondary ventilator:

A beneficiary requires one type of ventilator (e.g. a negative pressure ventilator with a chest shell) for part of the day and needs a different type of ventilator (e.g. positive pressure ventilator with a nasal mask) during the rest of the day.

A beneficiary who is confined to a wheelchair requires a ventilator mounted on the wheelchair for use during the day and needs another ventilator of the same type for use while in bed. Without two pieces of equipment, the beneficiary may be prone to certain medical complications, may not be able to achieve certain appropriate medical outcomes, or may not be able to use the medical equipment effectively.