The need for bariatric HME products has been increasing, and questions have cropped up about the proper coding for these products. For example, heavy duty walkers have codes such as E0147 for heavy duty multiple braking systems and variable wheel resistance. This type of walker would be covered if:

A regular heavy duty walker (E0148 or E0149) must support more than 300 pounds (these require a KX modifier). If these are provided and additional documentation is sent, they will be considered just as an E1399 would be. You would not use the KX modifier unless the weight is greater than 300 pounds.

Over 500 Pounds?
What if the patient weighs more than 500 pounds and there is no walker that truly fits under any of the three codes above? We face these coding and descriptor problems almost daily. Too often, the allowable is set at a level comparable with most “heavy” duty walkers, but would not even cover the cost for a really obese patient.

When in doubt, use E1399 for an item not identified with a specific code. State first that the patient has the potential for ambulation (criteria required for a walker), then give the name, make, model, and manufacturer’s suggested retail price (MSRP) of the item you are providing.

You will have to give a detailed description of the item, as well as why the other “heavy” duty walkers will not meet the specific patient’s needs. You will have to state what type of other walkers you looked at within the existing codes, the weight and measurements of the patient, and why the standard or heavy duty item would not meet the needs as described. Manufacturers’ information is always helpful.

Peggy Walker

I suggest using an advance beneficiary notice (ABN) as well and explaining to the patient that Medicare may not think this item medically necessary since there is a code that states heavy duty supports weight greater than 300 pounds. This situation relates to all items in the bariatric category.

Another example would be a bariatric trapeze. This again would have to be billed using an E1399 with a full explanation of the weight capacity that most manufacturers give for the standard trapeze bar, then the weight of the patient, and finally a statement that the patient might be injured using a standard trapeze. Include the name, make, and model of the heavy duty trapeze and state that the criteria have been met. You must meet the same criteria for the bariatric item that are required for a standard item (a certificate of medical necessity [CMN] for the standard item if a CMN is required).

Hospital Beds
Hospital beds have “heavy duty” codes as well. For example:

• E0301 is for heavy duty extra wide weight capacity greater than 350 pounds, less than or equal to 600 pounds, with any type of side rails, and without a mattress (E0303 is for beds with a mattress).

• E0302 is for extra heavy duty, extra wide weight capacity greater than 600 pounds, with any side rails, and without a mattress (E0304 denotes inclusion of a mattress). You will need an order for the bed, a standard hospital bed CMN—making sure you write the patient’s weight on the CMN.

Power Wheelchairs and More
Bariatric power wheelchairs have to be billed using the K0014 code for the base at this time (new codes will be in effect on January 1, 2006). Make sure you have the patient’s height and weight on the CMN and a full explanation of why the K0014 is needed over the K0011 (or lower level base).

First address the criteria for a power chair. Give the name, make, model, and MSRP of the base for pricing (and a power wheelchair CMN). Remember, there must be a good reason that the patient will not fit in any lower level power base.

New Stuff in 2006
The following codes will be modified and broken out in 2006.

• Manual wheelchairs: Heavy duty chairs are K0006 (greater than 250 pounds) for acute spasticity.

• You will need correctly completed CMNs. Remember, patients may not be able to self-propel this base, but if weight is greater than 250 pounds, they can get this base. However, when asked on CMN question #8 whether they can self-propel in a standard manual wheelchair, the answer must be N or D because patients can not self-propel in wheelchairs they can not fit in.

K0007 is for extra heavy duty, greater than 300 pounds, capped rental only, and does not specifically meet the weight capacity. Therefore, it will down code to a standard wheelchair (K0001) with a CMN required along with an N or D response to question #8.

If you have an exceptionally large patient who requires a bariatric manual base, you would use the K0009 code (other wheelchair base) and again fully explain why a K0007 or lower level chair would not meet needs. You will need height and weight on the CMN and the name, make, model, and MSRP of the base you are providing—and a specific statement as to why no other chair would meet the needs of the patient. Complete measurements are required.

Bedside Commodes
Bedside commodes: E0168 is for extra wide/heavy duty—and greater than 300 pounds. Bariatric cushions are now addressed in policy to some extent (width and depth codes are given).

The bariatric tilt-in-space is coded with the standard tilt code, and the DMERC/SADMERC has stated that they have decided not to pay for a bariatric tilt. Remember, as long as documentation is appropriate and all information is sent with the claim, these will be considered individually.

Peggy Walker, RN, is a billing and reimbursement advisor for US Rehab/Van G. Miller Group, Waterloo, Iowa. She can be reached via e-mail: walkerp321@aol.com.