A patient lift is a device that assists in transferring the patient between bed and a chair, wheelchair, or commode.

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 patient lift is covered if transfer between bed and a chair, wheelchair, or commode is required and, without the use of a lift, the patient would be bed confined.

A patient lift described by codes E0630 or E0635, E0639, or E0640 is covered if the basic coverage criteria are met. If the coverage criteria are not met, the lift will be denied as not medically necessary. 

A multi-positional patient transfer system (E0636, E1035, E1036) is covered if both of the following criteria 1 and 2 are met:

1. The basic coverage criteria for a lift are met; and
2. The patient requires supine positioning for transfers.

If criterion 1 is not met, codes E0636, E1035, and E1036 will be denied as not medically necessary. 

If criterion 1 is met but criterion 2 is not met, payment will be made for the least costly medically appropriate alternative, E0630.

If coverage is provided for code E1035 or E1036, payment will be discontinued for any other mobility assistive equipment, including but not limited to: canes, crutches, walkers, rollabout chairs, transfer chairs, manual wheelchairs, power-operated vehicles, or power wheelchairs.

Code E0621 is covered as an accessory when ordered as a replacement for a covered patient lift.

Services that do not meet the medical necessity guidelines 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.

Reasons for Noncoverage

E0625 is non-covered; not primarily medical in nature. The provider can bill the member for this non-covered item.

Home modifications are non-covered. Therefore suppliers must not submit claims for any structural changes or remodeling necessitated by the installation of a lift system.

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.

The patient’s medical record must contain information demonstrating that all of the applicable coverage criteria are met. This information must be available upon request.

When an upgrade is provided, the GA, GK, GL, and/or GZ modifiers must be used to indicate the upgrade.

KX, GA and GZ Modifiers
Suppliers must add a KX modifier to codes E0636, E1035 and E1036 only if all of the coverage criteria in the “Indications and Limitations of Coverage” section of this policy have been met and evidence of such is retained in the supplier’s files and available upon request.

If all of the criteria in the Indications and Limitations of Coverage section 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.

Claims lines billed with codes 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.

Heavy duty and bariatric lifts are included in the codes for patient lifts, E0630-E0640.

A patient lift for a toilet/tub, any type (E0625), describes a device with which the patient can be transferred from the toilet/tub to another seat (e.g., wheelchair). It is used for a patient who is unable to ambulate. Devices included in this code may be attached to the toilet, ceiling, floor, or wall of the bathroom or may be freestanding. Some items may be placed in a tub for lifting the patient in and out of the tub but may not necessarily be attached to the toilet, ceiling, floor, or wall of the bathroom.

A multi-positional patient support system, with integrated lift, patient accessible controls (E0636) describes a device that can be used to transfer the bed-bound patient in either a sitting or supine position. It has electric controls of the lift function.

Code E0639 describes a device in which the lift mechanism is part of a floor-to-ceiling pole system that is not permanently attached to the floor and ceiling and which is used in a room other than the bathroom. The lift/transport mechanisms may be mechanical or electric. No separate payment is made for installation. All costs associated with installation are included in the payment for the device. When a device is only used in a bathroom, it is coded E0625.

Code E0640 describes a device in which the lift mechanism is attached to permanent ceiling tracks or a wall mounting system and which is used in a room other than the bathroom. The lift/transport mechanisms may be mechanical or electric. No separate payment is made for installation. All costs associated with installation are included in the payment for the device. When a device is only used in a bathroom, it is coded E0625.

A multi-positional patient transfer system, with integrated seat, operated by caregiver (E1035, E1036) describes a device that can be positioned and adjusted such that the bed-bound patient can be transferred onto the device in the supine position. Once positioned on the device, it can then be adjusted to a chair-like position with multiple degrees of recline and leg elevation. It has small, castor wheels that are not accessible by the patient for mobility. It has no electric controls.

The only products that may be billed with codes E0636, E0639, E0640, E1035, or E1036 are those which have received a written Coding Verification Review from the Pricing, Data Analysis, and Coding (PDAC) contractor and that are listed in the Product Classification List on the PDAC web site.

A Column II code is included in the allowance for the corresponding Column I code when provided at the same time.

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. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Section 280.1