LCD for Canes and Crutches (L11496)

LCD for Canes and Crutches (L11496)

Contractor Information

Contractor Name

TriCenturion

Contractor Number

77011

Contractor Type

DME PSC

DME MAC/DMERC this DME PSC is affiliated with

AdminaStar Federal, Inc (Region B), National Heritage Insurance Company (Region A)

LCD Information

LCD ID Number

L11496

LCD Title

Canes and Crutches

Contractor's Determination Number

C&C20070701

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

CMS National Coverage Policy

CMS Pub. 100-3, Medicare National Coverage Determinations Manual, Chapter 1, Section 280.2, 280.3

Primary Geographic Jurisdiction

Connecticut
District of Columbia
Delaware
Illinois
Indiana
Kentucky
Massachusetts
Maryland
Maine
Michigan
Minnesota
New Hampshire
New Jersey
New York - Entire State
Ohio
Pennsylvania
Rhode Island
Virginia
Vermont
Wisconsin
West Virginia

Oversight Region

Central Office

DME Region LCD Covers

Jurisdiction A/B

Original Determination Effective Date

For services performed on or after 10/01/1993

Original Determination Ending Date

Revision Effective Date

For services performed on or after 07/01/2007

Revision Ending Date

Indications and Limitations of Coverage 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 medical policy, the criteria for "reasonable and necessary" are defined by the following indications and limitations of coverage and/or medical necessity.

For an item to be covered by Medicare, a written signed and dated order 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 order, the item will be denied as not medically necessary.

Canes (E0100, E0105) and crutches (E0110 - E0116) are covered if all of the following criteria (1-3) are met:
1) The patient has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADL) in the home.

The MRADLs to be considered in this and all other statements in this policy are toileting, feeding, dressing, grooming, and bathing performed in customary locations in the home.

-A mobility limitation is one that:
a) Prevents the patient from accomplishing the MRADL entirely, or
b) Places the patient at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or
c) Prevents the patient from completing the mobility-related activities of daily living within a reasonable time frame.

and

2) The patient is able to safely use the cane or crutch; and

3) The functional mobility deficit can be sufficiently resolved by use of a cane or crutch.

If all of the criteria are not met, the cane or crutch will be denied as not medically necessary.

The medical necessity for an underarm, articulating, spring assisted crutch (E0117) has not been established. If an E0117 is ordered, payment will be based on the allowance for the least costly medically appropriate alternative, E0116.

Coverage Topic

Canes and Crutches
Durable Medical Equipment

Coding Information

CPT/HCPCS Codes

The appearance of a code in this section does not necessarily indicate coverage.

HCPCS MODIFIER:

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

A4635	UNDERARM PAD, CRUTCH, REPLACEMENT, EACH
A4636	REPLACEMENT, HANDGRIP, CANE, CRUTCH, OR WALKER, EACH
A4637	REPLACEMENT, TIP, CANE, CRUTCH, WALKER, EACH.
A9270	NON-COVERED ITEM OR SERVICE
E0100	CANE, INCLUDES CANES OF ALL MATERIALS, ADJUSTABLE OR FIXED, WITH TIP
E0105	CANE, QUAD OR THREE PRONG, INCLUDES CANES OF ALL MATERIALS, ADJUSTABLE OR FIXED, WITH TIPS
E0110	CRUTCHES, FOREARM, INCLUDES CRUTCHES OF VARIOUS MATERIALS, ADJUSTABLE OR FIXED, PAIR, COMPLETE WITH TIPS AND HANDGRIPS
E0111	CRUTCH FOREARM, INCLUDES CRUTCHES OF VARIOUS MATERIALS, ADJUSTABLE OR FIXED, EACH, WITH TIP AND HANDGRIPS
E0112	CRUTCHES UNDERARM, WOOD, ADJUSTABLE OR FIXED, PAIR, WITH PADS, TIPS AND HANDGRIPS
E0113	CRUTCH UNDERARM, WOOD, ADJUSTABLE OR FIXED, EACH, WITH PAD, TIP AND HANDGRIP
E0114	CRUTCHES UNDERARM, OTHER THAN WOOD, ADJUSTABLE OR FIXED, PAIR, WITH PADS, TIPS AND HANDGRIPS
E0116	CRUTCH, UNDERARM, OTHER THAN WOOD, ADJUSTABLE OR FIXED, WITH PAD, TIP, HANDGRIP, WITH OR WITHOUT SHOCK ABSORBER, EACH
E0117	CRUTCH, UNDERARM, ARTICULATING, SPRING ASSISTED, EACH
E0118	CRUTCH SUBSTITUTE, LOWER LEG PLATFORM, WITH OR WITHOUT WHEELS, EACH
E0153	PLATFORM ATTACHMENT, FOREARM CRUTCH, EACH

ICD-9 Codes that Support Medical Necessity

Not specified.

Diagnoses that Support Medical Necessity

Not specified.

ICD-9 Codes that DO NOT Support Medical Necessity

Not specified.

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity

Not specified.

General Information

Documentation Requirements

Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider." It is expected that the patient's medical records will reflect the need for the care provided. The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.

An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier and made available upon request. Items billed before a signed and dated order has been received by the supplier must be submitted with an EY modifier added to each affected HCPCS code.

Refer to the Supplier Manual for more information on documentation requirements.

Appendices

Utilization Guidelines

Refer to Indications and Limitations of Coverage and/or Medical Necessity.

Sources of Information and Basis for Decision

Advisory Committee Meeting Notes

Start Date of Comment Period

03/30/1993

End Date of Comment Period

05/14/1993

Start Date of Notice Period

08/01/1993

Revision History Number

C&C007

Revision History Explanation

Revision Effective Date: 07/01/2007
INDICATIONS AND LIMITATIONS OF COVERAGE:
Removed: DMERC references
DOCUMENTATION REQUIREMENTS:
Removed: DMERC references

03/01/2006 - In accordance with Section 911 of the Medicare Modernization Act of 2003, this policy was transitioned to DME PSC TriCenturion (77011) from DMERC Tricenturion (77011).

Revision Effective Date: 01/01/2006
HCPCS CODES:
Description Verbiage revised for E0116.

Revision Effective Date: 05/05/2005
INDICATIONS AND LIMITATIONS OF COVERAGE:
Updated to include NCD 280.3 revised May 2005
Deleted old coverage criteria.

Revision Effective Date: 01/01/2005
LMRP converted to LCD and Policy Article.

Revision Effective Date: 04/01/2004
HCPCS CODES AND MODIFIERS:
Added New HCPCS code E0118
Added A4635 and A4636 back to the HCPCS code array.

Correction 06/01/2003: Added EY modifier inadvertently omitted from 04/02/2003 revision.

Revision Effective Date: 04/02/2003
HCPCS CODES AND MODIFIERS:
Added HCPCS codes A4637, A9270, E0110, E0111, E0117, and E0153.
INDICATIONS AND LIMITATIONS OF COVERAGE:
Added introductory language regarding items covered by Medicare.Added standard language concerning coverage of items without an order.Added LCA statement concerning E0117 to pay comparable to E0116.
CODING GUIDELINES:
Added A9270 coding instructions for white cane. Added reference to SADMERC information.
DOCUMENTATION:
Added introductory language regarding medical necessity. Added standard language concerning an order and use of EY modifier for items without an order

Last Reviewed On Date

Related Documents

Article(s)
A23660 - Canes and Crutches - Policy Article - Effective May 2005

LCD Attachments

There are no attachments for this LCD

Article for Canes and Crutches - Policy Article - Effective May 2005 (A23660)

Contractor Information

Contractor Name, Number, and Type

DME PSC: TriCenturion (77011)
DME MAC: AdminaStar Federal, Inc (17003) , National Heritage Insurance Company (16003)

Article Information

Article ID Number

A23660

Article Type

Article

Key Article

Yes

Article Title

Canes and Crutches - Policy Article - Effective May 2005

AMA CPT / ADA CDT Copyright Statement

Primary Geographic Jurisdiction

DME Region Article Covers

Jurisdiction A/B

Original Article Effective Date

01/01/2005

Article Revision Effective Date

03/01/2006

Article Text

NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:

A white cane for a blind person is noncovered since it is a “self help” item.

CODING GUIDELINES

Code A9270 must be used for a white cane for a blind person.

All canes and crutches are billed using the specific codes listed in the Local Coverage Determination regardless of their stated weight capacity. Do not use code E1399 (DME, miscellaneous) to code any type of cane or crutch regardless of special features or weight capacity.

Suppliers should contact the Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC) for guidance on the correct coding of these items.

Coverage Topic

Canes and Crutches
Durable Medical Equipment

Coding Information

No Coding Information has been entered in this section of the article.

Other Information

Revision History Explanation
Revision Effective Date: 05/05/2005 CODING GUIDELINES Clarified coding instructions for canes and crutches with special features or weight capacity. Effective Date: 01/01/2005 LMRP converted to LCD and Policy Article 03/01/2006 - In accordance with Section 911 of the Medicare Modernization Act of 2003, this article was transitioned to DME PSC TriCenturion (77011) from DMERC Tricenturion (77011).
Related Documents
LCD(s) L11496 - Canes and Crutches