SUPERCEDED LCD: Centers for Medicare & Medicaid Services

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Contractor Information

Contractor Name, Number, and Type ^{back to top}

DME PSC: Electronic Data Systems Corp. (77006) DME MAC: Noridian Administrative Services (19003)
Contractor's Affiliation ^{back to top}
This LCD has been adopted by DME MAC Noridian Administrative Services who is affiliated with DME PSC Electronic Data Systems Corp..

LCD Information

LCD ID Number ^{back to top}

L11486

LCD Title ^{back to top}
Commodes

Contractor's Determination Number ^{back to top}
COM

AMA CPT / ADA CDT Copyright Statement ^{back to top}
CPT codes, descriptions and other data only are copyright 2009 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 ^{back to top}
CMS Manual System, Pub. 100-3, Medicare National Coverage Determinations Manual, Chapter 1, Section 280.1

Primary Geographic Jurisdiction ^{back to top}
Alaska American Samoa Arizona California - Entire State Guam Hawaii Iowa Idaho Kansas Missouri - Entire State Montana North Dakota Nebraska Nevada Oregon South Dakota Utah Washington Wyoming Northern Mariana Islands

Oversight Region ^{back to top}
Region X


DME Region LCD Covers ^{back to top}
Jurisdiction D

Original Determination Effective Date ^{back to top}
For services performed on or after 10/01/1993

Original Determination Ending Date ^{back to top}


Revision Effective Date ^{back to top}
For services performed on or after 01/01/2007

Revision Ending Date ^{back to top}


Indications and Limitations of Coverage and/or Medical Necessity ^{back to top}
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 an 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 commode is covered when the patient is physically incapable of utilizing regular toilet facilities. This would occur in the following situations: The patient is confined to a single room, or The patient is confined to one level of the home environment and there is no toilet on that level, or The patient is confined to the home and there are no toilet facilities in the home. An extra wide/heavy duty commode chair (E0168) is covered for a patient who weighs 300 pounds or more. If the patient weighs less than 300 pounds but the basic coverage criteria for a commode chair are met, payment will be based on the least costly medically appropriate alternative, E0163. A commode chair with detachable arms (E0165) is covered if the detachable arms feature is necessary to facilitate transferring the patient or if the patient has a body configuration that requires extra width. If coverage criteria are not met payment will be denied as not medically necessary. Commode chair with seat lift mechanism (E0170, E0171) is covered if the patient has medical necessity for a commode and meets the coverage criteria for a seat lift mechanism (see Local Coverage Determination [LCD and Policy Article] on Seat Lift Mechanisms). However, a commode with seat lift mechanism is intended to allow the patient to walk after standing. If the patient can ambulate, he/she would rarely meet the coverage criterion for a commode. Therefore, if the patient is capable of walking from the bed to the bathroom, a KX modifier must not be added to the code for the commode with seat lift mechanism.

Coding Information

Bill Type Codes: ^{back to top}

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.

Revenue Codes: ^{back to top}

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.

CPT/HCPCS Codes ^{back to top}

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.
GY - Item or service statutorily excluded or does not meet the definition of any Medicare benefit.
KX - Specific required documentation on file.

E0163	COMMODE CHAIR, MOBILE OR STATIONARY, WITH FIXED ARMS
E0165	COMMODE CHAIR, MOBILE OR STATIONARY, WITH DETACHABLE ARMS
E0167	PAIL OR PAN FOR USE WITH COMMODE CHAIR, REPLACEMENT ONLY
E0168	COMMODE CHAIR, EXTRA WIDE AND/OR HEAVY DUTY, STATIONARY OR MOBILE, WITH OR WITHOUT ARMS, ANY TYPE, EACH
E0170	COMMODE CHAIR WITH INTEGRATED SEAT LIFT MECHANISM, ELECTRIC, ANY TYPE
E0171	COMMODE CHAIR WITH INTEGRATED SEAT LIFT MECHANISM, NON-ELECTRIC, ANY TYPE
E0172	SEAT LIFT MECHANISM PLACED OVER OR ON TOP OF TOILET, ANY TYPE
E0175	FOOT REST, FOR USE WITH COMMODE CHAIR, EACH
E0244	RAISED TOILET SEAT

ICD-9 Codes that Support Medical Necessity ^{back to top}

Not specified.

Diagnoses that Support Medical Necessity ^{back to top}

Not specified.

ICD-9 Codes that DO NOT Support Medical Necessity ^{back to top}

Not specified.

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation ^{back to top}

Diagnoses that DO NOT Support Medical Necessity ^{back to top}

Not specified.

General Information

Documentation Requirements ^{back to top}

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 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.

For all commodes (E0163-E0171), modifier KX must be added to the code only if all of the coverage criteria as described in the Indications and Limitations of Coverage and/or Medical Necessity section have been met.

In addition, for a commode chair with seat lift mechanism (E0170 and E0171), modifier KX must only be used if the patient meets all of the criteria for a seat lift mechanism.

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

Appendices ^{back to top}

Utilization Guidelines ^{back to top}

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

Sources of Information and Basis for Decision ^{back to top}

Reserved for future use.

Advisory Committee Meeting Notes ^{back to top}

Start Date of Comment Period ^{back to top}

03/30/1993

End Date of Comment Period ^{back to top}

05/14/1993

Start Date of Notice Period ^{back to top}

08/01/1993

Revision History Number ^{back to top}

COM008

Revision History Explanation ^{back to top}

Revision Effective Date: 01/01/2007
INDICATIONS AND LIMITATIONS OF COVERAGE AND/OR MEDICAL NECESSITY:
Removed downcoding paragraph for E0164 and E0166.
HCPCS CODES:
Added: E0172, E0244
Removed: E0164 and E0166
Revised: E0163, E0165 and E0167
DOCUMENTATION REQUIREMENTS:
Removed references to the DMERC.

Revision Effective Date: 03/01/2006
In accordance with Section 911 of the Medicare Modernization Act of 2003, this policy was transitioned to DME PSC Electronic Data Systems Corp. (77006) from DMERC CIGNA Government Services (05655).

Revised Effective Date: 01/01/2006
INDICATIONS AND LIMITATIONS OF COVERAGE AND/OR MEDICAL NECESSITY:
Removed LCA statement for E0165.
Revised statements related to E0165.
Revised statements for commodes E0170 and E0171.
HCPCS CODES:
Added: E0170 and E0171
Deleted: E0169
DOCUMENTATION REQUIREMENTS:
Added: E0170, E0171 as requiring the KX modifier if criteria for seat lift mechanism is met.
Removed requirement for documentation of weight to be submitted on claim with E0168.

Revision Effective Date: 04/01/2005
DOCUMENTATION REQUIREMENTS:
Corrected E0169 definition.

Revision Effective Date: 04/01/2005
LMRP converted to LCD and Policy Article.
HCPCS CODES AND MODIFIERS:
Added: GY modifer
DOCUMENTATION REQUIREMENTS:
All codes now require the KX modifier.

Revision Effective Date: 04/01/2003
HCPCS CODES AND MODIFIERS:
Added: EY modifier to HCPCS Modifier array.
INDICATIONS AND LIMITATIONS OF COVERAGE:
Added standard language concerning coverage of items without an order. Added standard language concerning EY modifier.
CODING GUIDELINES:
Moved definition of extra wide/heavy duty commode chair (E0168) to Coding Guidelines section.
DOCUMENTATION REQUIREMENTS:
Added standard language concerning an order requirement.
Added standard language concerning use of the EY 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 SADMERC reference with paragraph referring to SADMERC Web site.

04/01/2002 - Added new HCPCS E code replacing K code for extra wide, heavy-duty commodes. Added new HCPCS code for commode with seat lift mechanism and coverage criteria allowing for its reimbursement. Added a new KX modifier to be used with a commode with seat lift mechanism if coverage and payment rules have been fulfilled.

09/01/1999 – Added HCPCS code K0457 (extra wide/heavy duty commode chair). Added definition for extra wide/heavy duty commode chair. Revised Coverage and Payment Rules section. Added K0457 to bundling table in Coding Guidelines section. Added information for K0457 in Documentation section.

Reason for Change ^{back to top}

Last Reviewed On Date ^{back to top}

Medicare Coverage Database

LCD for Commodes (L11486)