Medi-Cal Coverage Criteria for Hospital Beds and Accessories

November 7th, 2018 - Raquel Shumway
Categories:   DME|Supplies|Equipment   Medicare   Insurance   Billing   Documentation Guidelines   CPT® Coding  
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Medi-Cal covers Pediatric Cribs, Pediatric Beds and Adult Hospital Beds and accessories when documentation clearly shows medical necessity.

Examples of hospital bed accessories listed:

  • trapeze equipment
  • bed cradle
  • side rails
  • safety enclosures

Billing:

Medi-Cal states, "If any combination of the mattress and/or bedrail codes (E0271, E0272, E0305, and E0310 is billed separately, no more than the allowed amount for bed codes E0303, E0304, E0328, or E0329 will be paid. (parenthesis added)

NOTE: HCPCS codes E0303 and E0304 are semi-electric, as are all heavy duty beds. Semi-electric beds electronically control the head and knee sections and manually adjust the height.

Coverage Criteria for Hospital Beds for Adults

Bed Type Requirements:
Fixed Height Recipient must meet at least one of the following:
  1. positioning of body is not feasible in non-hospital beds
  2. needs one of the following

    1. promotion of body alignment to prevent contractures and has a history of contractures or a documented medical condition that causes risk of contractures.

    2. more than 30 degrees elevation of the bed’s head due to certain medical conditions such as congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) or has a documented history of aspiration. Pillows and wedges must have been ruled out as an option

    3. use of special attachments or traction equipment or

  3. has a documented history of

    1. pain related to positioning needs alleviation of such pain 

    2. respiratory infection needs avoidance of respiratory infections related to positioning 
  Requirements: Must meet the requirements in both columns
Variable Height Fixed Height  requires height adjustment to transfer to
  • chair
  • wheelchair 
  • stand up
Semi-Electric Fixed Height requires
  • frequent body position change and/or
  • immediate body position change
Heavy-Duty Extra-Wide Fixed Height  Weight is 351-600 pounds
Extra
Heavy-Duty
Fixed Height  Weight is 601+ pounds
Total Electric This type is for convenience purposes only and not covered by Medi-Cal

Documentation Requirements:

  • Documentation must be completed by licensed practitioner
  • Treatment Authorization Request (TAR) accompanied by the prescription signed by physician or an electronic equivalent
  • Clinical documentation must:
    • describe medical condition
    • severity
    • frequency of symptoms necessitating the bed
    • therapeutic outcome expected
    • availability of a caregiver
    • recipient's level of independence to operate the bed

Criteria for Pediatric Crib:

E0316 and E0300 will not be be reimbursed if billed for the same recipient

E0316  safety enclosure frame/canopy for use with hospital bed, any type

E0300  pediatric crib, hospital grade, fully enclosed

Criteria for Pediatric Beds:

Medi-Cal states:

Most pediatric medical conditions do not require specialized home furnishings as prescribed medical treatment.  It is reasonable to expect parents or legal caregivers of infants and children to provide an appropriate bed and bed care items necessary for comfort and positioning.  However, a hospital or specialized bed and related accessories may be medically necessary for pediatric recipients when the nature and severity of their illness, injury, or disease meets all of the following medical criteria:

  • The hospital bed is necessary to treat the medical condition as documented in the medical record.

  • The hospital bed is expected to produce a positive medical outcome which would not occur without the bed, or will prevent complications or worsening of the medical condition for which it is prescribed.

  • The desired medical benefit is not attainable by use of an ordinary bed.

  • An ordinary bed cannot be modified or adapted by commercially available items to meet the medical need.

Enclosed cribs or enclosed pediatric beds may be medically necessary for recipients with diagnosis of developmental delay when the nature and severity of their illness, injury, or disease meets all of the following medical criteria:

  • The behavioral necessity for an enclosed bed is documented and described in the medical record.
  • There is clinical documentation that underlying behavioral issues have been proactively addressed with appropriate behavioral interventions and modification without success.
  • Other less restrictive forms of bed restraint/accommodations have been employed without adequate success (such as increased caregiver monitoring, alarm systems, padding bed rails or placing mattress on the floor).
  • An ordinary bed cannot be modified or adapted by commercially available items to meet the child’s needs.
  • There is no other appropriate and reasonably feasible alternative method for providing safe bed/sleep care.
  • The request for the enclosed bed is not for caregiver convenience or due to lack of caregiver monitoring of recipient’s safety.

Requests for hospital beds and accessories for children case managed by California Children’s Services (CCS) are reviewed by CCS for medical necessity for treatment of a CCS-eligible medical condition per California Code of Regulations, Title 22, Sections 41515.1 – 41518.9.

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