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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:

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:

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:

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:

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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