Hospital Beds & Accessories

5 Element Order obtained prior to Delivery 

The date of the order is on or after a face-to-face encounter between the ordering physician and the beneficiary.

The 5EO was obtained prior to delivery.

Any changes or corrections have been initialed/signed and dated by the ordering physician.

Beneficiary’s name

Prescribing practitioner’s name

Detailed description of each option/accessory that will be separately billed

The prescribing practitioner’s signature

The date the prescribing practitioner signed the order

The date of the order

Any changes or corrections have been initialed/signed and dated by the prescribing practitioner.

The practitioner’s signature on the written order meets CMS Signature Requirements

Beneficiary’s name

Delivery address

Delivery date

Quantity delivered

Detailed description of item(s) 

Brand

Serial Number

Signature of the person accepting delivery

Relationship to beneficiary

Delivery date

Medical records include documentation of a face-to-face encounter between the beneficiary and the ordering practitioner that occurred within 6 months prior to completion of the detailed written order.

The notes of the face-to-face encounter record that the encounter occurred specifically to document that the beneficiary was evaluated and/or treated for a condition that supports the need for a hospital bed.

The practitioner’s signature on the medical records meets CMS Signature Requirements:

The beneficiary has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed. Elevation of the head/upper body less than 30 degrees does not usually require the use of a hospital bed.

The beneficiary requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain.

The beneficiary requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration, 

The beneficiary requires traction equipment, which can only be attached to a hospital bed.

The beneficiary meets coverage criteria for a fixed height hospital bed (see above), 

The beneficiary requires a bed height different than a fixed height hospital bed to permit transfers to chair, wheelchair or standing position.

The beneficiary meets coverage criteria for a fixed height hospital bed (see above)

The beneficiary requires frequent changes in body position and/or has an immediate need for a change in body position.

The beneficiary meets coverage criteria for a fixed height hospital bed (see above)

The beneficiary’s weight is more then 350 pounds but does not exceed 600 pounds.

The beneficiary meets coverage criteria for a fixed height hospital bed (see above);

The beneficiary’s weight exceeds 600 pounds.

Total electric hospital beds are not covered since the height adjustment feature is a convenience feature. Claims for total electric beds will be denied as not reasonable and necessary.

Trapeze Equipment (E0910 and E0940)

Heavy Duty Trapeze Equipment (E0911 and E0912)

Bed Cradle (E0280)

Side Rails (E0305 or E0310) or Safety Enclosures (E0316)

Replacement Innerspring Mattress (E0271) or Foam Rubber Mattress (E0272)

A change in prescription dated within 12 months of the date of service under review; 

A medical record, dated within 12 months of the date of service under review, which shows usage of the item.

Items delivered before a signed and dated detailed written order has been received must be submitted with modifier EY added to each affected HCPCS code.

Suppliers must add a KX modifier to a hospital bed code only if all of the coverage criteria in the Indications and Limitations of Coverage section of this policy have been met.

If all of the coverage criteria have not been met, the GA or GZ modifier must be added to the code. 

Claim lines billed without a KX, GA, GY, or GZ modifier will be rejected as missing information.

When a hospital bed upgrade is provided, the GA, GK, GL and/or GZ modifiers must be used to indicate the upgrade