CPT code a9270, a43335, a9273 - bowl management devices

Procedure code and Description

HCPCS CODES:


Group 1 Codes:

A4335 INCONTINENCE SUPPLY; MISCELLANEOUS

A4337 INCONTINENCE SUPPLY, RECTAL INSERT, ANY TYPE, EACH

A4458 ENEMA BAG WITH TUBING, REUSABLE

A4459 MANUAL PUMP-OPERATED ENEMA SYSTEM, INCLUDES BALLOON, CATHETER AND ALL ACCESSORIES, REUSABLE, ANY TYPE

A4520 INCONTINENCE GARMENT, ANY TYPE, (E.G., BRIEF, DIAPER), EACH

A4554 DISPOSABLE UNDERPADS, ALL SIZES

A9270 NON-COVERED ITEM OR SERVICE

E0275 BED PAN, STANDARD, METAL OR PLASTIC

E0276 BED PAN, FRACTURE, METAL OR PLASTIC

E0350 CONTROL UNIT FOR ELECTRONIC BOWEL IRRIGATION/EVACUATION SYSTEM


E0352 DISPOSABLE PACK (WATER RESERVOIR BAG, SPECULUM, VALVING MECHANISM AND COLLECTION BAG/BOX) FOR USE WITH THE ELECTRONIC BOWEL IRRIGATION/EVACUATION SYSTEM


Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this local coverage determination, the criteria for "reasonable and necessary", based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.

Medicare does not automatically assume payment for a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item that was covered prior to a beneficiary becoming eligible for the Medicare Fee For Service (FFS) program. When a beneficiary receiving a DMEPOS item from another payer (including Medicare Advantage plans) becomes eligible for the Medicare FFS program, Medicare will pay for continued use of the DMEPOS item only if all Medicare coverage, coding and documentation requirements are met. Additional documentation to support that the item is reasonable and necessary, may be required upon request of the DME MAC.

For an item to be covered by Medicare, a detailed written order (DWO) must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed DWO, the item will be denied as not reasonable and necessary.

Benefit Category and other statutory requirements are discussed in the related Policy Article NONMEDICAL NECESSITY AND COVERAGE RULES section. Refer to the Policy article for information on these criteria.

Bed Pans (E0275, E0276) are covered for beneficiaries who are bed-confined (see NCD 280.1).

Rectal inserts and related accessories (A4337) will be denied as not reasonable and necessary because they do not meet the medical evidence requirements outlined in the Centers for Medicare & Medicaid Services (CMS) Program Integrity Manual (Internet-only Manual 100-08), Chapter 13, §13.7.1.

Electrical continence aids are in the experimental stage of development and there is no valid scientific documentation of their effectiveness and safety; therefore, they are denied as not reasonable and necessary (see NCD 230.15).

Rectal catheters/tubes and related collection systems will be denied as statutorily non-covered (no benefit – see related Policy Article).

Enema systems (gravity and manual pump), codes A4458 and A4459 respectively, will be denied as statutorily non-covered (no benefit – see related Policy Article).

Pulsed irrigation and evacuation systems (E0350, E0352) will be denied as statutorily non-covered (no benefit – see related Policy Article).

Incontinence garments (e.g., briefs, diapers) coded A4520 will be denied as statutorily non-covered (no benefit – see related Policy Article).

Disposable underpads (A4554) will be denied as statutorily non-covered (no benefit – see related Policy Article).

Toilet seats, raised toilet seats, toilet seat lift mechanisms, bidets and bidet toilet seats are discussed in the Commodes Local Coverage Determination and related Policy Article.


Coverage Guidance for Cold Therapy

Coverage Indications, Limitations, and/or Medical Necessity

For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this local coverage determination, the criteria for "reasonable and necessary", based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.

Medicare does not automatically assume payment for a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item that was covered prior to a beneficiary becoming eligible for the Medicare Fee For Service (FFS) program. When a beneficiary receiving a DMEPOS item from another payer (including Medicare Advantage plans) becomes eligible for the Medicare FFS program, Medicare will pay for continued use of the DMEPOS item only if all Medicare coverage, coding and documentation requirements are met. Additional documentation to support that the item is reasonable and necessary, may be required upon request of the DME MAC.

For an item to be covered by Medicare, a detailed written order (DWO) must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed DWO, the item will be denied as not reasonable and necessary.

A water circulating cold pad with pump (E0218) will be denied as not reasonable and necessary.



HCPCS MODIFIERS:


EY - No physician or other licensed health care provider order for this item or service


HCPCS CODES:



Group 1 Codes:

A9270 NON-COVERED ITEM OR SERVICE

A9273 HOT WATER BOTTLE, ICE CAP OR COLLAR, HEAT AND/OR COLD WRAP, ANY TYPE

E0218 WATER CIRCULATING COLD PAD WITH PUMP