TPL and Medicare
Providers must meet any provider criteria, including accreditation, for third party insurance or for Medicare to assist members for whom Minnesota Health Care Programs (MHCP) is not the primary payer.

MHCP quantity limits and thresholds apply to all members unless only Medicare coinsurance or deductible is requested.

Refer to the Medicare and Other Insurance section of the MHCP Provider Manual for more information.

Eligible Members

Bath and toilet equipment is covered for eligible Medical Assistance and MinnesotaCare members who meet medical necessity criteria. Bath and toilet equipment is included in the nursing facility per diem and is not separately reimbursable. Most bath and toilet equipment is included in the long-term care facility (LTC) and intermediate care facility for people with developmental disabilities (ICF/DD) per diem. Seat lift mechanisms and rehab shower or toileting systems may be covered outside the ICF/DD and LTC per diem for members who meet medical necessity criteria.

Covered Services

Codes: E0163, E0165, E0167, E0168, E0170-E0172, E0240, E0244, E0245, E0247, E0248, E0625

MHCP covers the following products:

· Commodes (E0163, E0165, E0167, E0168)

· Seat lifts for commodes (E0170 to E0172)

· Bath or shower chairs (E0240)

· Raised toilet seats (E0244)

· Tub stools or benches (E0245)

· Transfer benches (E0247, E0248)

· Bath lifts (E0625)

Commodes
Commodes are covered for members who are unable to safely and promptly access the toilet in the bathroom in their homes due to a medical condition. MHCP does not require members to be confined to their beds or to their rooms.

Toilet Seat Lift Mechanism or Commode Chair with Integrated Seat Lift Mechanism
Commode chairs with nonelectric seat lift mechanisms (E0171) are covered for members who meet criteria for a commode but are unable to safely raise or lower themselves to use the commode. Commode chairs with integrated electric seat lift mechanisms (E0170) or seat lift mechanisms to be placed over the toilet (E0172) are covered with authorization.

Documentation must establish all of the following:

· The member is unable to safely and promptly access the toilet in the bathroom in the home because of a medical condition

· The member is unable to safely raise or lower themselves to use the toilet or commode

· A trial has shown that the seat lift mechanism will allow the member to independently use the toilet or commode, and that the item fits in the member’s home

· Other less costly ways to meet the member’s needs (raised toilet seat, non-electric seat lift mechanism) have been considered

· The member has acknowledged that the increased independence offered by the seat lift mechanism may affect future requests for PCA or home care services

· Requests for authorization must address the member’s ability to transfer onto or off of other furniture, caregiver availability to assist with transfers and transfer method used for toileting in the community

Bath or Shower Chairs, Tub Stools or Benches
Bath or shower chairs (E0240) or tub stools or benches (E0245) are covered for members who are unable to safely use the bathtub or shower in their homes.

Raised Toilet Seats
Raised toilet seats (E0244) are covered for members who are unable to safely raise or lower themselves to use a standard-height toilet.

Transfer Benches
Transfer benches (E0247 and E0248) are covered for members who are unable to safely transfer to the toilet, bath, or shower chair without the use of the transfer bench. Authorization is required if the submitted charge is more than $400. Documentation must establish that the requested item is the least costly appropriate way to meet the member’s medical needs. A transfer bench is considered a duplication of equipment if the member has a patient lift that can be used in the bathroom unless the transfer bench allows the member to transfer without assistance.

Rehab Shower and Toileting Systems
Rehab shower and toileting systems are covered with authorization for members who are unable to safely and promptly access the toilet or shower in the bathroom of their homes due to a medical condition, and who require significantly more positioning assistance than is available from a commode or shower chair. Providers should use HCPCS code E0240 with modifier U3 when the equipment will be used in the shower or bath in the member’s bathroom. Providers should use HCPCS code E1399 when the equipment will not be used for bath or shower. Authorization requests must include U3 when requesting payment above the fee schedule rate for E0240. Review the information under Billing in this MHCP Provider Manual section for how to bill with U3 modifier.

Documentation must establish all of the following:

· The member is unable to safely and promptly access the toilet or shower in the bathroom in the home because of a medical condition; and

· The specific medical conditions that make a commode or shower chair unsafe, and how the requested item will address the member’s medical conditions; and

· The amount of time the member will use the equipment daily; and

· The member’s living arrangement and caregiver status; and

· The requested equipment is appropriate to the member’s height and weight; and

· A trial has shown that the requested equipment will fit in all necessary areas of the member’s home; and

· Details about the member’s current equipment or how the member is currently bathing, and specific and detailed information about why it is no longer meeting the member’s needs or cannot be repaired; and

· Other related equipment in use (mobility device, patient lift, or similar); and

· Other less-costly ways to meet the member’s needs have been considered and why they will not meet the member’s needs. Include make and model of multiple less-costly items considered and rejected; and

· Evaluation by a physical therapist or occupational therapist or other professional with experience evaluating bath and toilet equipment; and

· When tilt-in-space shower commode chairs or custom-molded seating is requested, additional documentation is required to support these options. The amount of time the member uses the equipment daily will be considered when evaluating the need for these options.

Bath Lift Equipment
Bath chairs that lower the member into the bathtub are covered with authorization for members who are unable to safely access the bathtub in their home due to a medical condition. Providers should use HCPCS code E0625 when the equipment will lower into the water in the bathtub. Only use E0625 for patient lifts for use in the bathtub. Providers should use HCPCS code E0245 with modifier U3 when the equipment will not lower into the water in the bathtub. Authorization requests must include U3 when requesting payment above the fee schedule rate for E0245.

Documentation must establish all of the following:

· The member is unable to safely access the bathtub in the home due to a medical condition; and

· The specific medical conditions that require the member to be lowered into the bathtub to soak in the water rather than using a bath or shower chair for a shower; and

· The member’s living arrangement and caregiver status; and

· The requested equipment is appropriate to the member’s height and weight; and

· A trial has shown that the requested equipment will fit in the member’s bathtub and can safely meet all of the member’s bathing needs; and

· Details about the member’s current equipment, and why it is no longer meeting the member’s needs; and

· Other related equipment in use (mobility device, patient lift, or similar). Bath lift equipment may be considered a duplication of equipment if the member has a member lift that can be used in the bathroom; and

· Other less-costly ways to meet the member’s needs that have been considered and why they will not meet the member’s needs. Include details including make and model of multiple less-costly items considered and rejected; and

· Evaluation by a physical therapist or an occupational therapist, or another professional with experience evaluating bath and toilet equipment.

Noncovered Services

MHCP does not cover the following:

· Bathtub wall rails (E0241)

· Bathtub floor base rails (E0242)

· Toilet rails (E0243)

· Grab bars

· Hand-held shower units

· Modifications to bathrooms

· “Potty” chairs or seats for toilet training children

Authorization

Authorization is required for the following:

· Rehab shower and toileting systems (E0240 U3, E1399)

· Commodes with electric seat lift mechanisms (E0170)

· Seat lift mechanisms to be used with a toilet (E0172)

· Bath lifts (E0245 U3, E0625)

· Transfer benches (E0247, E0248) if the submitted charge is more than $400

· Repairs if the submitted charge is more than $400

When authorization is required, list all requested parts or accessories on the authorization request. If approved, the approved rate will include all requested and approved parts or accessories.

Submit authorizations and required documentation to the Medical Review Agent. All requests must include either an invoice or documentation of Manufacturer’s Suggested Retail Price (MSRP) as pricing documentation.

Billing

Use MN–ITS 837P Professional. Refer to the MN–ITS User Guide Billing for Durable Medical Equipment, Medical Supplies, Prosthetics and Orthotics, and Augmentative Devices for billing instructions.

· Bill rehab shower and toileting systems using E0240 U3 or E1399 when appropriate.

· If the member has Third Party Liability (TPL) that does not cover custom shower chairs, bill the custom shower chair with the U3 modifier, without Coordination of Benefits (COB) information, and include an attachment with TPL information. Also add a cover sheet stating, “policy needs to review as this is a specialty item that is not covered by the primary payer.”

· Bill bath lift equipment using E0245 U3 or E0625 when appropriate.

· Bill miscellaneous accessories that are not included in payment of customized equipment using HCPCS code A9999.

· Bill miscellaneous components that are not included in payment of customized equipment using HCPCS code A9900. For miscellaneous accessories or components that are included in payment, list these items in the notes of the authorization request. Providers do not need to bill bundled components under HCPCS code A9900 if there is no allowed amount.

· Bill repairs using the HCPCS code of the item being repaired and modifier RB. The submitted charge must include all materials. Labor for repairs may be billed on a separate line.

· The HCPCS code and modifiers must match the authorization.

· It is not necessary to submit a claim to Medicare for denial if authorization was approved for purchase or repair of bath or toilet equipment that Medicare is known not to cover. If a claim for approved equipment is denied because it was not submitted to Medicare, contact the MHCP Provider Resource Center to request a work order for review and possible payment.

Legal References

Minnesota Statutes, 256B.0625, subdivision 31
Minnesota Rules, 9505.0310 (Medical Supplies and Equipment)
Minnesota Rules, 9505.0210 (Covered Services; General Requirements)

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