The Centers for Medicare & Medicaid Services (CMS) addresses numerous items that it terms “mobility assistive equipment” (MAE) and includes within that category canes, crutches, walkers, manual wheelchairs, power wheelchairs, and scooters. This list, however, is not exhaustive.

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

1. 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:

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

   and

2. The patient is able to safely use the walker; and
   
   
3. 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.

Services that do not meet the medical necessity criteria on this policy will be considered 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.

Reasons for Noncoverage

Enhancement accessories of walkers will be denied as non-covered. 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). Code A9270 should be used when an enhancement accessory of a walker is billed. The provider cannot 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.

When code 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 and the product name/number.

KX, GA, AND GZ MODIFIERS
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 all of the criteria on this policy have not been met, the GA or GZ modifier must be added to the code. 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 with codes E0148-E0149 without a KX, GA, or GZ 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 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 Pricing, Data Analysis and Coding (PDAC) Contractor website.

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).

Codes 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 procedure 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. 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 Pub. 100-3, Medicare National Coverage Determinations Manual, Chapter 1, Section 280.3