LCD for Walkers (L11472)

LCD for Walkers (L11472)

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

L11472

LCD Title

Walkers

Contractor's Determination Number

WALK20070701

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 280.3

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.

A standard walker (E0130, E0135, E0141, E0143) and related accessories are covered if all of the following criteria (1-3) are met:

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.
- A mobility limitation is one that:

Prevents the patient from accomplishing the MRADL entirely, or
Places the patient at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform the MRADL, or
Prevents the patient from completing the MRADL within a reasonable time frame;

and

The patient is able to safely use the walker; and
The functional mobility deficit can be sufficiently resolved with use of a walker.

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

A heavy duty walker (E0148, E0149) is covered for patients who meet coverage criteria for a standard walker and who weigh more than 300 pounds. If a E0148 or E0149 walker is provided and the patient does not weigh more than 300 pounds (i.e., KX modifier is absent - see Documentation section) but does meet coverage criteria for a standard walker, payment will be based on the allowance for the least costly medically appropriate alternative, E0135 or E0143 respectively.

A heavy duty, multiple braking system, variable wheel resistance walker (E0147) is covered for patients who meet coverage criteria for a standard walker and who are unable to use a standard walker due to a severe neurologic disorder or other condition causing the restricted use of one hand. Obesity, by itself, is not a sufficient reason for an E0147 walker. If an E0147 walker is provided and the coverage criteria for a standard walker are met but the additional coverage criteria for an E0147 are not met, payment will be based on the allowance for the least costly medically appropriate alternative, E0143 or E0149 depending on the patient’s weight.

The medical necessity for a walker with an enclosed frame (E0144) compared to a standard folding wheeled walker, E0143, has not been established. Therefore, if the basic coverage criteria for a walker are met and code E0144 is billed, payment will be based on the allowance for the least costly medically appropriate alternative, E0143.

A walker with trunk support (E0140) is covered for patients who meet coverage criteria for a standard walker and who have documentation in the medical record justifying the medical necessity for the special features. If an E0140 walker is provided and the special features are not justified, but the patient does meet the coverage criteria for a standard walker, payment will be based on the allowance for the least costly medically appropriate alternative.

Leg extensions (E0158) are covered only for patients 6 feet tall or more.

Coverage Topic

Durable Medical Equipment
Walkers

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

KX - Specific required documentation on file

A4636	REPLACEMENT, HANDGRIP, CANE, CRUTCH, OR WALKER, EACH
A4637	REPLACEMENT, TIP, CANE, CRUTCH, WALKER, EACH.
A9270	NON-COVERED ITEM OR SERVICE
A9900	MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS CODE
E0130	WALKER, RIGID (PICKUP), ADJUSTABLE OR FIXED HEIGHT
E0135	WALKER, FOLDING (PICKUP), ADJUSTABLE OR FIXED HEIGHT
E0140	WALKER, WITH TRUNK SUPPORT, ADJUSTABLE OR FIXED HEIGHT, ANY TYPE
E0141	WALKER, RIGID, WHEELED, ADJUSTABLE OR FIXED HEIGHT
E0143	WALKER, FOLDING, WHEELED, ADJUSTABLE OR FIXED HEIGHT
E0144	WALKER, ENCLOSED, FOUR SIDED FRAMED, RIGID OR FOLDING, WHEELED WITH POSTERIOR SEAT
E0147	WALKER, HEAVY DUTY, MULTIPLE BRAKING SYSTEM, VARIABLE WHEEL RESISTANCE
E0148	WALKER, HEAVY DUTY, WITHOUT WHEELS, RIGID OR FOLDING, ANY TYPE, EACH
E0149	WALKER, HEAVY DUTY, WHEELED, RIGID OR FOLDING, ANY TYPE
E0154	PLATFORM ATTACHMENT, WALKER, EACH
E0155	WHEEL ATTACHMENT, RIGID PICK-UP WALKER, PER PAIR
E0156	SEAT ATTACHMENT, WALKER
E0157	CRUTCH ATTACHMENT, WALKER, EACH
E0158	LEG EXTENSIONS FOR WALKER, PER SET OF FOUR (4)
E0159	BRAKE ATTACHMENT FOR WHEELED WALKER, REPLACEMENT, EACH
E1399	DURABLE MEDICAL EQUIPMENT, MISCELLANEOUS

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.

If a heavy duty walker (E0148, E0149) is provided and if the supplier has documentation in their records that the patient’s weight (within one month of providing the walker) is greater than 300 pounds, the KX modifier should be added to the code. If the requirements for the KX modifier are not met, the KX modifier must not be used.

If E0147 is billed, the claim must include the manufacturer’s name and the product name/number

When code E1399 is billed, the claim must include the manufacturer's name amd the product name/number.

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

03/30/1993

End Date of Comment Period

05/14/1993

Start Date of Notice Period

08/01/1993

Revision History Number

WALK005

Revision History Explanation

Revision Effective Date: 06/01/2007
INDICATIONS AND LIMITATIONS OF COVERAGE:
Removed: DMERC references
DOCUMENTATION REQUIREMENTS:
Removed: DMERC references
Revised: Requirements for billing E0147
Revised: Requirements for billing E1399

Revision Effective Date: 05/05/2005
LMRP converted to LCD and Policy Article
INDICATIONS AND LIMITATIONS OF COVERAGE:
Incorporated coverage criteria from new NCD.
Added coverage statement for E0140.

Revision effective date: 04/01/2004
HCPCS CODES:
Added: A9900, E0140
Revised: E0141, E0143, E0144, E0147, E0149
CODING GUIDELINES:
Eliminates paragraph mentioning codes E0142, E0145, and E0146 because those codes have been discontinued.
Adds coding guidelines for gait trainers.
Adds code E0140 to the correct coding table.

Revision effective date: 04/01/2003
HCPCS CODES AND MODIFIERS:
Added: EY
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.
Revises statements concerning use of KX modifier

The revision dates listed below are the dates the revisions were published and not necessarily the effective dates for the revisions.

07/01/2002 - Replaced the ZX modifier with KX. Instructed
suppliers to check the SADMERC Web site to identify products that are correctly coded as E0147 and revised the documentation requirements for this code.

01/01/2002 - The revision incorporates the new codes for heavy duty walkers which were established in January 2001.

01/01/2000 - A new code has been established for a special type of walker: E0144 - Enclosed, framed folding walker, wheeled, with posterior seat. This code is effective for claims with dates of service on or after January 1, 2000, and will be in the Inexpensive or Routinely Purchased (IRP) payment category. This code describes a folding wheeled walker which has a frame that completely surrounds the patient and an attached seat in the back. The medical necessity of this type of walker compared to a standard folding wheeled walker, E0143, has not been established. Therefore, if the basic coverage criteria for a walker are met and code E0144 is billed, payment will be based on the allowance for the least costly medically appropriate alternative, E0143.

03/01/1999 - The major change is a revision of the definition and documentation for code E0147. As of the effective dates of the revised policy, the only products that may be billed as code E0147 are those products for which a written coding determination has been made by the Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC). This coding determination must be dated on or after April 1, 1998, and specify use of code E0147 for that product. If a claim for E0147 is received and appropriate use of the code for the product is not substantiated, the claim will be denied as an invalid code. If a supplier or manufacturer deems a certain product meets the definition of this code in the revised policy, contact the SADMERC for a coding determination. Region D DMERC regrets the policy revision was inadvertently omitted from the Fall publication.

03/01/1998 – Incorporated Indications section into Coverage and Payment Rules section. Revised Coding Guidelines and added unbundling table.

This LCD was converted from an LMRP on 8/8/2005

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).

Last Reviewed On Date

Related Documents

Article(s)
A35351 - Walkers - Policy Article - Effective May 2005

LCD Attachments

There are no attachments for this LCD

Article for Walkers - Policy Article - Effective May 2005 (A35351)

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

A35351

Article Type

Article

Key Article

Yes

Article Title

Walkers - Policy Article - Effective May 2005

Primary Geographic Jurisdiction

DME Region Article Covers

Jurisdiction A/B

Original Article Effective Date

05/05/2005

Article Revision Effective Date

03/01/2006

Article Text

NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES

Enhancement accessories of walkers will be denied as noncovered.

CODING GUIDELINES

A wheeled walker (E0141, E0143, E0149) is one with either 2, 3, or 4 wheels. It may be fixed height or adjustable height. It may or may not include glide-type brakes (or equivalent). The wheels may be fixed or swivel.

A glide-type brake consists of a spring mechanism (or equivalent) which raises the leg post of the walker off the ground when the patient is not pushing down on the frame.

Code E0144 describes a folding wheeled walker which has a frame that completely surrounds the patient and an attached seat in the back.

A heavy duty walker (E0148, E0149) is one which is labeled as capable of supporting patients who weigh more than 300 pounds. It may be fixed height or adjustable height. It may be rigid or folding.

Code E0147 describes a 4-wheeled, adjustable height, folding-walker that has all of the following characteristics:

1) Capable of supporting patients who weigh greater than 350 pounds,

2) Hand operated brakes that cause the wheels to lock when the hand levers are released,

3) The hand brakes can be set so that either or both can lock both wheels,

4) The pressure required to operate each hand brake is individually adjustable,

5) There is an additional braking mechanism on the front crossbar,

6) At least two wheels have brakes that can be independently set through tension adjustability to give varying resistance.

The only walkers that may be billed using code E0147 are those products listed in the Product Classification List on the SADMERC Web site.

An enhancement accessory is one which does not contribute significantly to the therapeutic function of the walker. It may include, but is not limited to style, color, hand operated brakes (other than those described in code E0147), or basket (or equivalent).

A4636, A4637, and E0159 are only used to bill for replacement items for covered, patient-owned walkers. Codes E0154, E0156, E0157, and E0158 can be used for accessories provided with the initial issue of a walker or for replacement components. Code E0155 can be used for replacements on covered, patient-owned wheeled walkers or when wheels are subsequently added to a covered, patient-owned nonwheeled walker (E0130, E0135). Code E0155 cannot be used for wheels provided at the time of, or within one month of, the initial issue of a nonwheeled walker.

Hemi-walkers must be billed using code E0130 or E0135, not E1399.

Use code A9270 when an enhancement accessory of a walker is billed.

A gait trainer is a term used to describe certain devices that are used to support a patient during ambulation. Gait trainers are billed using one of the codes for walkers. If a gait trainer has a feature described by one of the walker attachment codes (E0154-E0157) that code may be separately billed. Other unique features of gait trainers are not separately payable and may not be billed with code E1399. If a supplier chooses to bill separately for a feature of a gait trainer that is not described by a specific HCPCS code, then code A9900 must be used.

A Column II code is included in the allowance for the corresponding Column I code when provided at the same time and must not be billed separately at the time of billing the Column I code.

Column I (Column II)
E0130 (A4636, A4637)
E0135 (A4636, A4637)
E0140 (A4636, A4637, E0155, E0159)
E0141 (A4636, A4637, E0155, E0159)
E0143 (A4636, A4637, E0155, E0159)
E0144 (A4636, A4637, E0155, E0156, E0159)
E0147 (A4636, E0155, E0159)
E0148 (A4636, A4637)
E0149 (A4636, A4637, E0155, E0159)

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
Walkers

Other Information

Revision History Explanation
Effective Date: 05/05/2005 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) L11472 - Walkers