LCD for Cold Therapy (L5038)

 

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 

L5038 

LCD Title 

Cold Therapy 

Contractor's Determination Number 

COLD20070701 

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 

None 

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 04/01/1997  

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.

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

Coverage Topic 

Durable Medical Equipment
 

 

Coding Information

CPT/HCPCS Codes 

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

HCPCS MODIFIERS:

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

A9270

NON-COVERED ITEM OR SERVICE

E0218

WATER CIRCULATING COLD PAD WITH PUMP

 

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 

Reserved for future use. 

Advisory Committee Meeting Notes 

 

Start Date of Comment Period 

12/01/1996 

End Date of Comment Period 

03/01/1997 

Start Date of Notice Period 

01/01/1997 

Revision History Number 

COLD003 

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: 07/01/2004
LMRP converted to LCD and Policy Article

Revision effective date: 04/01/2003
HCPCS CODES AND MODIFIERS:
Added: EY modifier
INDICATIONS AND LIMITATIONS OF COVERAGE:
Adds standard language concerning coverage of items without an order
DOCUMENTATION REQUIREMENTS:
Adds standard language concerning use of EY modifier for items without an order 

Last Reviewed On Date 

04/30/2004 

Related Documents 

Article(s)
A19799 - Cold Therapy – Policy Article – Effective July 2007

 

LCD Attachments 

There are no attachments for this LCD

 

 

 

Article for Cold Therapy – Policy Article – Effective July 2007 (A19799)

 

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 

A19799 

Article Type 

Article

Key Article 

Yes

Article Title 

Cold Therapy – Policy Article – Effective July 2007 

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.

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

DME Region Article Covers 

Jurisdiction A/B 

Original Article Effective Date 

06/01/2004

Article Revision Effective Date 

07/01/2007

Article Text 

Coding Guidelines

A device in which ice water is put in a reservoir and then circulated through a pad by means of gravity is not considered durable medical equipment (DME). Other devices (not all-inclusive) which are also not considered to be DME are: single use packs which generate cold temperature by a chemical reaction; packs which contain gel or other material which can be repeatedly frozen; simple containers into which ice water can be placed. All of these types of devices must be coded A9270 if claims are submitted.

Code E0218 describes a device which has an electric pump that circulates cold water through a pad.

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

Coverage Topic 

Durable Medical Equipment
 

 

 

Other Information

Revision History Explanation 

Revision Effective Date: 07/01/2007
CODING GUIDELINES:
Removed DMERC references

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).

Revision effective date: 07/01/2004
LMRP converted to LCD and Policy Article

 

Related Documents 

 

LCD(s)
L5038 - Cold Therapy