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

Traction equipment is covered for eligible Medical Assistance and MinnesotaCare members to treat musculoskeletal or neurological conditions of the spine or other body parts.

Covered Services

Codes: E0830, E0840, E0849, E0850, E0855, E0856, E0860, E0870, E0880, E0890, E0900, E0910-E0912, E0920, E0930, E0935, E0936, E0940-E0942, E0944-E0948

MHCP covers the following equipment:

· Ambulatory traction devices (E0830)

· Cervical traction equipment, including:

· Traction frame, attached to headboard (E0840)

· Freestanding stand or frame and pneumatic pump (E0849)

· Freestanding traction stands (E0850)

· Overdoor traction equipment (E0860)

· Cervical head harnesses and halters (E0942)

· Extremity traction equipment (E0870, E0880)

· Pelvic traction equipment (E0890, E0900)

· Fracture frames (E0920, E0930, E0946 through E0948)

· Trapeze bars (E0910 through E0912, E0940)

· Continuous passive motion exercise devices (E0935, E0936)

· Pelvic belts, harnesses, and boots (E0944)

· Extremity belts and harnesses (E0945)

Traction equipment is covered for members with conditions that require traction equipment to relieve pain. Traction equipment must be ordered by a physician and medically necessary to relieve pain due to a musculoskeletal or neurological condition of the member. Documentation must detail the member’s condition, description of the member’s impairment, failure of conservative treatment, the member’s ability and willingness to use the device, and why the item is necessary for the member’s medical condition. Conservative treatment includes cervical collars, medical management, and physical therapy.

Ambulatory traction devices (E0830) are covered for members with orthopedic impairment and require traction equipment to move. Authorization is required if the submitted charge is over $400.

Cervical traction equipment extends neck muscles, ligaments, and tissue of the upper spine through a gentle pulling action. Cervical traction equipment includes attached-to-headboard frames (E0840), freestanding stands (E0849, E0850), and overdoor equipment (E0860). MHCP covers one cervical traction frame or stand per five years.

Traction equipment for extremities is covered for members who require extremity traction. This equipment includes attached-to-footboard frames (E0870) and freestanding stands (E0880).

Pelvic traction equipment is covered for members who require pelvic traction. This equipment includes attached-to-footboard frames (E0890) and freestanding stands (E0900).

Fracture frames (E0920, E0930, E0946 through E0948) are covered for treatment of serious fractures.

Trapeze bars (E0910 through E0912, E0940) are covered for members who require assistance with movement due to medical conditions. HCPCS code E0940 represents a freestanding trapeze bar. MHCP covers one trapeze bar per five years.

Continuous passive motion exercise devices (E0935, E0936) are covered for members during post-operative periods following joint or knee replacement surgery. HCPCS codes E0935 and E0936 represent one day as one unit of service. MHCP covers continuous passive motion exercise devices as short-term rentals for up to 30 consecutive days.

Cervical head harnesses and halters (E0942) are covered for members who require harnesses for rehabilitative therapy. Pelvic belts, harnesses, and boots (E0944) are covered for members with lumbosacral pain. Extremity belts and harnesses (E0945) are covered for members who require traction of the extremities.

MHCP does not cover cervical collars with inflatable air bladders (E0856), cervical traction equipment not requiring additional stand or frame (E0855), and gravity-assisted traction devices (E0941) as they are not standard in community care and substantive research is lacking.

Noncovered Services

MHCP does not cover the following:

· Continuous passive-motion exercise devices for indications not listed in this policy

· Rentals of continuous passive-motion exercise devices lasting longer than 30 consecutive days

· The following devices for any indication because they are not standard in community care and substantive research is lacking:

· Cervical collars with inflatable air bladders (E0856)

· Cervical traction equipment not requiring additional stand or frame (E0855)

· Gravity-assisted traction devices (E0941)

Authorization

Authorization is required for the following:

· Quantities over MHCP quantity limits

· Ambulatory traction devices (E0830) if the submitted charge is over $400

· Repairs if the submitted charge is over $400

Billing

Providers are responsible to coordinate services. Refer to the Billing Policy Overview section of the MHCP Provider Manual for general billing information.

Bill traction equipment using MN–ITS 837P Professional. Refer to the Billing for Durable Medical Equipment, Medical Supplies, Prosthetics, Orthotics, and Augmentative Devices MN–ITS user manual for general billing requirements and guidance when submitting claims.

· Use modifier NU for purchases.

· Use modifier RR for rentals.

· Use modifiers KH, KI, KJ, and RR as appropriate for capped rentals.

· Bill HCPCS codes E0935 and E0936 as a date span with one unit as one date of service.

Documentation must include:

· Member’s diagnosis and clinical history; and

· Order; and

· History of conservative treatments; and

· Description of pain, including pain intensity and impacted area of the body; and

· Item to be dispensed; and

· Anticipated duration of need; and

· Trial of the member successfully using the equipment.

Continuous passive-motion exercise devices are rental items only.

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