| NHIC, Corp.DME MAC A ListServe | For Immediate Release |
January 13, 2009
Billing Reminder: Pneumatic Compression Devices (PCD) Coverage and Documentation Requirements
PCDs are only covered for beneficiaries who suffer from lymphedema or chronic venous insufficiency with venous stasis ulcers. Unnecessary denials may be avoided by close attention to the coverage and documentation requirements.
LYMPHEDEMA:
Lymphedema is the swelling of subcutaneous tissues due to the accumulation of excessive lymph fluid. The accumulation of lymph fluid results from impairment to the normal clearing function of the lymphatic system and/or from an excessive production of lymph. Lymphedema is divided into two broad classes according to etiology. Primary lymphedema is a relatively uncommon, chronic condition which may be due to such causes as Milroy's Disease or congenital anomalies. Secondary lymphedema, which is much more common, results from the destruction of or damage to formerly functioning lymphatic channels, such as radical surgical procedures with removal of regional groups of lymph nodes (for example, after radical mastectomy), post-radiation fibrosis, and spread of malignant tumors to regional lymph nodes with lymphatic obstruction, among other causes.
Lymphedema is the swelling of subcutaneous tissues due to the accumulation of excessive lymph fluid. The accumulation of lymph fluid results from impairment to the normal clearing function of the lymphatic system and/or from an excessive production of lymph. Lymphedema is divided into two broad classes according to etiology. Primary lymphedema is a relatively uncommon, chronic condition which may be due to such causes as Milroy's Disease or congenital anomalies. Secondary lymphedema, which is much more common, results from the destruction of or damage to formerly functioning lymphatic channels, such as radical surgical procedures with removal of regional groups of lymph nodes (for example, after radical mastectomy), post-radiation fibrosis, and spread of malignant tumors to regional lymph nodes with lymphatic obstruction, among other causes.
Pneumatic compression devices are covered in the home setting for the treatment of lymphedema if the patient has undergone a four-week trial of conservative therapy and the treating physician determines that there has been no significant improvement or if significant symptoms remain after the trial. The trial of conservative therapy must include use of an appropriate compression bandage system or compression garment, exercise, and elevation of the limb. The garment may be prefabricated or custom-fabricated but must provide adequate graduated compression.
CHRONIC VENOUS INSUFFICIENCY WITH VENOUS STASIS ULCERS:
Chronic venous insufficiency (CVI) of the lower extremities is a condition caused by abnormalities of the venous wall and valves, leading to obstruction or reflux of blood flow in the veins. Signs of CVI include hyperpigmentation, stasis dermatitis, chronic edema, and venous ulcers.
Chronic venous insufficiency (CVI) of the lower extremities is a condition caused by abnormalities of the venous wall and valves, leading to obstruction or reflux of blood flow in the veins. Signs of CVI include hyperpigmentation, stasis dermatitis, chronic edema, and venous ulcers.
Pneumatic compression devices are covered in the home setting for the treatment of CVI of the lower extremities only if the patient has one or more venous stasis ulcer(s) which have failed to heal after a six month trial of conservative therapy directed by the treating physician. The trial of conservative therapy must include a compression bandage system or compression garment, appropriate dressings for the wound, exercise, and elevation of the limb.
DEVICES:
There are four types of devices currently available.
There are four types of devices currently available.
| E0650 | PNEUMATIC COMPRESSOR, NON-SEGMENTAL HOME MODEL | E0651 | PNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL WITHOUT CALIBRATED GRADIENT PRESSURE | E0652 | PNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL WITH CALIBRATED GRADIENT PRESSURE | E0675 | PNEUMATIC COMPRESSION DEVICE, HIGH PRESSURE, RAPID INFLATION/DEFLATION CYCLE,FOR ARTERIAL INSUFFICIENCY (UNILATERAL OR BILATERAL SYSTEM) |
When a pneumatic compression device is covered, a non-segmented device (E0650) or segmented device without manual control of the pressure in each chamber (E0651) is generally sufficient to meet the clinical needs of the patient. A non-segmented compressor (E0650) with a segmented appliance/sleeve (E0671-E0673) is considered functionally equivalent to an E0651 compressor with a segmented appliance/sleeve (E0667-E0669).
When a segmented device with manual control of the pressure in each chamber (E0652) is ordered and provided, payment will be based on the allowance for the least costly medically appropriate alternative, E0651, unless there is clear documentation of medical necessity in the individual case. Full payment for code E0652 will be made only when there is documentation that the individual has unique characteristics that prevent satisfactory pneumatic compression treatment using a non-segmented device (E0650) with a segmented appliance/sleeve (E0671-E0673) or a segmented device without manual control of the pressure in each chamber (E0651).
A high pressure device (E0675) in not indicated for the treatment of lymphedema or venous insufficiency with stasis ulcers.
DOCUMENTATION:
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.
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.
A Certificate of Medical Necessity (CMN) which has been completed, signed, and dated by the treating physician must be kept on file by the supplier and made available upon request. The CMN may act as a substitute for a written order if it contains all of the required elements of an order. The CMN for pneumatic compression pumps is CMS Form 846 (DME form 04.04B). The initial claim must include an electronic copy of the CMN.
For all devices, the determination by the physician of the medical necessity of a pneumatic compression device must include:
- the patient's diagnosis and prognosis;
- symptoms and objective findings, including measurements which establish the severity of the condition;
- the reason the device is required, including the treatments which have been tried and failed (prior conservative therapy); and
- the clinical response to an initial treatment with the device. The clinical response includes the change in pre-treatment measurements, ability to tolerate the treatment session and parameters, and ability of the patient (or caregiver) to apply the device for continued use in the home.
- the location of venous stasis ulcer(s),
- how long each ulcer has been continuously present,
- previous treatment with a compression bandage system or compression garment, appropriate dressings for the ulcer(s), exercise and limb elevation for at least the past 6 months,
- evidence of regular physician visits for treatment of venous stasis ulcer(s) during the past 6 months.
- the treatment plan including the pressure in each chamber, and the frequency and duration of each treatment episode,
- whether a segmented compressor without calibrated gradient pressure (E0651) or a non-segmented compressor (E0650) with a segmented appliance (E0671-E0673) had been tried and the results,
- why the features of the device that was provided are needed for this patient,
- the name, model number, and manufacturer of the device.
This information should be recorded in the beneficiary's medical record.
If the patient has chronic venous insufficiency with venous stasis ulcers documentation reflecting all of the following must be in the patient's medical record and made available upon request:
If E0652 is billed, the following additional documentation supporting the medical necessity for this device must be substantiated by information in the patient's medical records and available upon request:
Questions pertaining to medical necessity on any form used to gather the above information may not be completed by the supplier or anyone in a financial relationship with the supplier. The information on the form must be supported by documentation in the patient's medical record and made available to the DME MAC upon request.
Refer to the Local Coverage Determination, associated Policy Article and Supplier Manual for additional information on coverage and documentation. This article should not be considered a complete substitute for the information contained in those sources.
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