The following are considered examples of hospital beds: variable height hospital bed, semi-electric hospital bed, heavy duty extra wide hospital bed, heavy duty extra wide hospital bed, and extra heavy-duty hospital bed.

For any item to be covered, 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 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.

For an item to be covered, 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 fixed height hospital bed (E0250, E0251, E0290, E0291, and E0328) is covered if one or more of the following criteria (1-4) are met:

1. The patient has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed. Elevation of the head/upper body less than 30 degrees does not usually require the use of a hospital bed; or
   
   
2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain; or
   
   
3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have been considered and ruled out; or
   
   
4. The patient requires traction equipment, which can only be attached to a hospital bed.

A variable height hospital bed (E0255, E0256, E0292, and E0293) is covered if the patient meets one of the criteria for a fixed height hospital bed and requires a bed height different than a fixed height hospital bed to permit transfers to chair, wheelchair or standing position.

A semi-electric hospital bed (E0260, E0261, E0294, E0295, and E0329) is covered if the patient meets one of the criteria for a fixed height bed and requires frequent changes in body position and/or has an immediate need for a change in body position.

A heavy duty extra wide hospital bed (E0301, E0303) is covered if the patient meets one of the criteria for a fixed height hospital bed and the patient's weight is more than 350 pounds, but does not exceed 600 pounds.

An extra heavy-duty hospital bed (E0302, E0304) is covered if the patient meets one of the criteria for a hospital bed and the patient's weight exceeds 600 pounds.

A total electric hospital bed (E0265, E0266, E0296, and E0297) is not covered; the height adjustment feature is a convenience feature. Total electric beds will be paid as the least costly medically appropriate alternative for the comparable semi-electric bed (E0260, E0261, E0294, and E0295).

For any of the above hospital beds (plus those coded E1399 – see Coding Guidelines), if documentation does not support the medical necessity of the type of bed billed, payment will be based on the allowance for the least costly medically appropriate alternative.

If the patient does not meet any of the coverage criteria for any type of hospital bed, it will be denied as not medically necessary. 

A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

Accessories
Trapeze equipment (E0910, E0940) is covered if the patient needs this device to sit up because of a respiratory condition, to change body position for other medical reasons, or to get in or out of bed.

Heavy duty trapeze equipment (E0911, E0912) is covered if the patient meets the criteria for regular trapeze equipment and the patient's weight is more than 250 pounds.

A bed cradle (E0280) is covered when it is necessary to prevent contact with the bed coverings.

Side rails (E0305, E0310) or safety enclosures (E0316) are covered when they are required by the patient's condition and they are an integral part of, or an accessory to, a covered hospital bed.

If a patient's condition requires a replacement innerspring mattress (E0271) or foam rubber mattress (E0272), it will be covered for a patient owned hospital bed.

Reasons for Noncoverage

A bed board (E0273, E0315) is non-covered since it is not primarily medical in nature. The provider can bill the member for the non-covered service.

An over bed table (E0274, E0315) is non-covered because it is not primarily medical in nature. The provider can bill the member for the non-covered service.

Trapeze bars attached to a bed (E0910, E0911) are non-covered when used on an ordinary bed. The provider can bill the member for the non-covered service.

Documentation Requirements

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 procedure code. Items submitted with an EY modifier will be denied as not medically necessary.

KX, GA, and GZ Modifiers
Suppliers must add a KX modifier to a hospital bed code only if all of the criteria in the “Indications and Limitations of Coverage” section of this policy have been met. The KX modifier should also be added for an accessory when the applicable accessory criteria are met. If the requirements for the KX modifier are not met, the KX modifier must not be used.

If all of the coverage criteria have not been met, the GA or GZ modifier must be added to a claim line for a hospital bed and accessories. When there is an expectation of a medical necessity denial, suppliers must enter the GA modifier on the claim line if they have obtained a properly executed Pre-Service Denial Notice or the GZ modifier if they have not obtained a valid Pre-Service Denial Notice. Services submitted with a GA modifier will be denied as not medically necessary and are billable to the member. Services submitted with a GZ modifier will be denied as not medically necessary and are not billable to the member.

Claim lines billed without a KX, GA or GZ modifier will be rejected as missing information.

Upgrade Modifiers
When a hospital bed upgrade is provided, the GA, GK, GL and/or GZ modifiers must be used to indicate the upgrade. Fully electric hospital beds must always be billed with these modifiers.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

A fixed height hospital bed is one with manual head and leg elevation adjustments but no height adjustment.

A variable height hospital bed is one with manual height adjustment and with manual head and leg elevation adjustments.

A semi-electric bed is one with manual height adjustment and with electric head and leg elevation adjustments.

A total electric bed is one with electric height adjustment and with electric head and leg elevation adjustments.

An ordinary bed is one which is typically sold as furniture. It may consist of a frame, box spring and mattress. It is a fixed height and may or may not have head or leg elevation adjustments.

E0301 and E0303 are hospital beds that are capable of supporting a patient who weighs more than 350 pounds, but no more than 600 pounds.

E0302 and E0304 are hospital beds that are capable of supporting a patient who weighs more than 600 pounds.

E0316 is a safety enclosure used to prevent a patient from leaving the bed.

E1399 should be used for products not described by the specific procedure codes above.

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.

When mattress or bedside rails are provided at the same time as a hospital bed, use the single code that combines these items.

E0271, E0272: Mattress, innerspring/foam rubber

- When combined with E0251, bill as E0250
- When combined with E0291, bill as E0290
- When combined with E0293, bill as E0292
- When combined with E0295, bill as E0294
- When combined with E0266, bill as E0265
- When combined with E0297, bill as E0296
- When combined with E0301, bill as E0303
- When combined with E0302, bill as E0304

E0305, E0310: Bedside rails, half-length/full-length

- When combined with E0290, bill as E0250
- When combined with E0291, bill as E0251
- When combined with E0292, bill as E0255
- When combined with E0293, bill as E0256
- When combined with E0294, bill as E0260
- When combined with E0295, bill as E0261
- When combined with E0296, bill as E0265
- When combined with E0297, bill as E0266

E0271, E0272: Mattress, innerspring/foam rubber plus
E0305, E0310: Bedside rails, half-length/full-length

- When combined with E0291, bill as E0250
- When combined with E0293, bill as E0255
- When combined with E0295, bill as E0260
- When combined with E0297, bill as E0265

Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items. https://www.dmepdac.com/

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.

CMS Publication 100-3, Medicare National Coverage Determinations Manual, Chapter 1, Section 280.1, 280.7

Fixed Height Beds

Variable Height Beds

Semi-electric Beds

Total Electric Beds

Heavy Duty Beds

Accessories

Miscellaneous