A commode chair is a device that serves as a toilet, usually outside the bathroom setting.

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 commode is covered when the patient is physically incapable of utilizing regular toilet facilities. This would occur in the following situations:

1. The patient is confined to a single room, or
2. The patient is confined to one level of the home environment and there is no toilet on that level, or
3. 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. 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.

A 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 Medical Policy Bulletin E-49, 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.

Reasons for Noncoverage

A raised toilet seat (E0244) is non-covered; therefore, a commode chair that is used as a raised toilet seat by positioning it over the toilet is also non-covered. When a commode chair is provided for use in this manner, modifier GY must be added to the code for the commode chair and the KX modifier must not be used. The provider can bill the member for the non-covered service.

Toilet seat lift mechanisms (E0172) are not primarily medical in nature, therefore do not meet the statutory definition of durable medical equipment. They are non-covered. The provider can bill the member for the non-covered service.

A footrest (E0175) is non-covered because it is not medical in nature. 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.

GA, GY, GZ, and KX Modifiers
For all commodes (E0163-E0171), if it is used as a raised toilet seat by positioning it over the toilet, the GY modifier must be added to the code and the GA, GZ, or KX modifier must not be used. Commodes submitted with the GY modifier will be denied as non-covered. The provider can bill the member for the non-covered service.

For all commodes (E0163-E0171), if it is not used as a raised toilet seat, the KX modifier must be added to the code only if all of the coverage criteria as described in the "Indication and Limitations of Coverage" section have been met.

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

If all of the criteria in the "Indications and Limitations of Coverage" section have not been met and the commode is not used as a raised toilet seat, the GA or GZ modifier must be added to the code. When there is an expectation of a medical necessity denial, suppliers must enter a GA modifier on the claim line if they have obtained a properly executed Pre-Service Denial Notice or a 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 GA, GY, GZ, or KX modifier will be rejected as missing information.

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 commode with seat lift mechanism (E0170, E0171) is a free-standing device that has a commode pan and that has an integrated seat that can be raised with or without a forward tilt while the patient is seated. An integrated device is one which is sold as a unit by the manufacturer and in which the lift and the commode cannot be separated without the use of tools.

A toilet seat lift mechanism is a device with a seat that can be raised with or without a forward tilt while the patient is seated, allowing the patient to stand and ambulate once he/she is in an upright position. It may be manually operated or electric. It is attached to the toilet. These devices are coded as E0172.

A raised toilet seat (E0244) is a device that adds height to the toilet seat. It is either fixed height or adjustable. It is either attached to the toilet or is unattached, resting on the bowl. (Note: A freestanding raised toilet seat supported by legs on the floor is coded as a commode.)

Extra wide/heavy duty commode chairs (E0168) have a width of greater than or equal to 23 inches and are also capable of supporting a patient who weighs 300 pounds or more.

A Column II code is included in the allowance for the corresponding Column I code when provided at the same time. Modifier 59 may be reported with a non-E/M service, to identify it as distinct or independent from other non-E/M services performed on the same day. When modifier 59 is reported, the patient’s records must support its use in accordance with CPT guidelines.

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