CPT E0840, E0849, E0855 - Cervical Traction services

Procedure Group 1 Codes: and Description

E0840 TRACTION FRAME, ATTACHED TO HEADBOARD, CERVICAL TRACTION

E0849 TRACTION EQUIPMENT, CERVICAL, FREE-STANDING STAND/FRAME, PNEUMATIC, APPLYING TRACTION FORCE TO OTHER THAN MANDIBLE

E0850 TRACTION STAND, FREE STANDING, CERVICAL TRACTION

E0855 CERVICAL TRACTION EQUIPMENT NOT REQUIRING ADDITIONAL STAND OR FRAME

E0856 CERVICAL TRACTION DEVICE, WITH INFLATABLE AIR BLADDER(S)

E0860 TRACTION EQUIPMENT, OVERDOOR, CERVICAL


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.

While this Standard Documentation language makes reference to "Affordable Care Act Section 6407 (ACA 6407) requirements", technically these requirements are found in the Social Security Act Section 1843(a)(11)(B) and its implementing regulation at 42 CFR 410.38. The CMS regulation contains the details for the face-to-face examination, written order prior to delivery and the list of items subject to these requirements.

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.

For some items in this policy to be covered by Medicare, a written order is required to be in the supplier’s file prior to delivery of the specified item(s). There are two differing order requirements that may apply depending upon the specific item prescribed:
The Affordable Care Act Section 6407 (ACA 6407) specifies the five elements that must be contained in this written order. For purposes of this policy, this order is termed the 5-element order (5EO).

A written order prior to delivery (WOPD) that meets all of the requirements of a standard detailed written order (DWO).

If the supplier delivers an item addressed in this policy without first receiving the completed order, the item will be denied. Refer to the DOCUMENTATION REQUIREMENTS section of this LCD and/or to the NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES section of the related Policy Article for information about these prescription requirements and the type of denial that will result from non-compliance.

Cervical traction devices (E0840-E0855 and E0860) are covered only if both of the following criteria are met:

The beneficiary has a musculoskeletal or neurologic impairment requiring traction equipment; and
The appropriate use of a home cervical traction device has been demonstrated to the beneficiary and the beneficiary tolerated the selected device.
If criteria 1 and 2 are not met, cervical traction will be denied as not reasonable and necessary.

Cervical traction applied via attachment to a headboard (E0840) or a free-standing frame (E0850) has no proven clinical advantage compared to cervical traction applied via an over-the-door mechanism (E0860). If an E0840 or E0850 is ordered, it will be denied as not reasonable and necessary.

Cervical traction devices described by code E0849 or E0855 are covered only when criteria 1 and 2 above and either criterion A, B or C below has been met:
The beneficiary has a diagnosis of temporomandibular joint (TMJ) dysfunction; and has received treatment for the TMJ condition; or,
The beneficiary has distortion of the lower jaw or neck anatomy (e.g., radical neck dissection) such that a chin halter is unable to be utilized; or,
The treating physician orders and/or documents the medical necessity for greater than 20 pounds of cervical traction in the home setting.
If the criteria for cervical traction are met but the additional criteria for E0849 or E0855 are not met, they will be denied as not reasonable and necessary.

E0856 describes a cervical traction device that can be used with ambulation. Therefore, it will be denied as not reasonable and necessary.


Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
N/A

Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

N/A

CPT/HCPCS Codes

Group 1 Paragraph: The appearance of a code in this section does not necessarily indicate coverage.

HCPCS MODIFIERS:

EY - No physician or other health care provider order for this item or service
GA – Waiver of liability statement issued as required by payer policy, individual case
GZ – Item or service expected to be denied as not reasonable and necessary
KX - Requirements specified in the medical policy have been met

HCPCS CODES: