Article Detail - JD DME

Article retired on 7/1/2018. Please refer to the updated article titled, "Billing Instruction - Hospital Beds and Pressure Reducing Support Surfaces."

Posted August 05, 2011

When the beneficiary owns or is renting a medically necessary group I (E0184, E0186, E0187, E0196) or group II support mattress (E0277, E0373) and a hospital bed becomes medically necessary, Medicare will deny the hospital bed if the item provided to the beneficiary includes a mattress (Healthcare Common Procedure Coding System (HCPCS) Codes E0250, E0255, E0260, E0265, E0290, E0292, E0294, E0296, E0303, E0304, E0328, and E0290).

Jurisdiction A DME MAC will begin issuing an American National Standards Institute (ANSI) 150 same/similar denial on claims for hospital beds with mattresses when the patient is currently renting or owns a medically necessary group I or II support mattress.

If there is a change in the beneficiary's condition which results in the need for a different item (i.e., a hospital bed and a group II support surface), Medicare would consider payment. However, at no time will Medicare allow for a hospital bed with mattress and a support surface classified as a mattress (i.e., group I support mattress [E0184, E0186] or group II support mattress [E0277, E0373]) at the same time.

Helpful Tips

Suppliers should verify if the beneficiary is renting or owns a medically necessary group I or II support mattress, or a hospital bed with mattress, by checking Option 7 Same or Similar on the Interactive Voice Response (IVR).

If the supplier determines the beneficiary is renting or owns a medically necessary group I or II support surface mattress, they should deliver the appropriate hospital bed without mattress (HCPCS Codes E0251, E0291, E0256, E0293, 0261, E0295, E0266, E0297, E0301, or E0302) and bill the appropriate corresponding HCPCS code to the DME MAC.

Medicare considers a group I or II support surface same or similar to a hospital bed mattress. If the beneficiary is renting or owns a medically necessary hospital bed with mattress and their condition changes and they require and receive a group I or group II support mattress (E0184, E0186, E0277, E0373) they must notify the supplier so that billing can be modified for the hospital bed. At that time, suppliers may pick up the hospital bed mattress that the patient is no longer using or can opt to leave the hospital bed mattress in the patient's home.

If the hospital bed mattress is picked up, suppliers should bill using a hospital bed HCPCS code where the narrative indicates that a mattress is not included (E0251, E0256, E0261, E0266, E0291, E0293, E0295, E0297, E0301, and E0302).

If the beneficiary requests to keep the hospital bed mattress, suppliers may execute an Advance Beneficiary Notice of Noncoverage (ABN). In that situation the supplier should bill using the upgrade modifiers.

Line 1: Bill the appropriate HCPCS code for the upgraded item the supplier actually provided to the beneficiary (hospital bed with mattress) with the dollar amount of the upgraded item. If the supplier has a properly obtained ABN on file signed by the beneficiary, report modifier GA; if the supplier did not properly obtain an ABN signed by the beneficiary, report modifier GZ.

Line 2: Bill the appropriate HCPCS code for the reasonable and necessary item (hospital bed without mattress) with the actual charge for the item; report modifier GK.

The following examples explain how to file claims with an ABN and without an ABN.

Example 1

Example 2