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Medicare Commode LCD Coverage

For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this local coverage determination, the criteria for “reasonable and necessary”, based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following indications and limitations of coverage and/or medical necessity.

For an item to be covered by Medicare, a detailed written order (DWO) must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed DWO, the item will be denied as not reasonable and necessary.

A commode is covered when the beneficiary is physically incapable of utilizing regular toilet facilities. This would occur in the following situations:

  1. The beneficiary is confined to a single room, or
  2. The beneficiary is confined to one level of the home environment and there is no toilet on that level, or
  3. The beneficiary is confined to the home and there are no toilet facilities in the home.
    An extra wide/heavy duty commode chair (E0168) is covered for a beneficiary who weighs 300 pounds or more. If an E0168 commode is ordered and the beneficiary does not weigh more than 300 pounds, it will be denied as not reasonable and necessary.

    A commode chair with detachable arms (E0165) is covered if the detachable arms feature is necessary to facilitate transferring the beneficiary or if the beneficiary has a body configuration that requires extra width. If coverage criteria are not met payment will be denied as not reasonable and necessary.

Commode chair with seat lift mechanism (E0170, E0171) is covered if the beneficiary has medical necessity for a commode and meets the coverage criteria for a seat lift mechanism (see Local Coverage Determination [LCD] and Policy Article on Seat Lift Mechanisms). However, a commode with seat lift mechanism is intended to allow the beneficiary to walk after standing. If the beneficiary can ambulate, he/she would rarely meet the coverage criterion for a commode. Therefore, if the beneficiary is capable of walking from the bed to the bathroom, a KX modifier must not be added to the code for the commode with seat lift mechanism.

ALL OF THIS MUST BE DOCUMENTED BY THE DOCTOR IN THE OFFICE NOTES