A Practical Guide for Clinicians and Staff
Important Notes for Prescribing Clinicians
Hospital beds are a frequently prescribed DME item, but Medicare has specific coverage criteria that must be documented. A regular bed in a home setting may be perfectly adequate – the need for a hospital bed must be clearly documented based on medical necessity.
Important Notes for Prescribing Clinicians
Basic Coverage Requirements (Fixed Height)
Patient must have ONE of these conditions that requires positioning:
- Medical condition requiring head of bed elevation >30 degrees (e.g., CHF, COPD, aspiration risk) AND standard pillows/wedges are insufficient
- Positioning for pain relief
- Positioning to alleviate respiratory conditions
- Need for traction equipment
Semi-Electric Bed Coverage (Additional Criteria)
- Meets criteria for fixed height bed AND
- Patient requires frequent changes in body position OR
- Immediate position changes for medical condition management
Full Electric Bed Coverage
- Always considered a “luxury item”
- Height adjustment feature is considered convenience
- Must be billed with upgrade modifiers
- Patient responsible for additional cost above semi-electric
Required Documentation Elements
- Initial Face-to-Face Evaluation Note Must Include:
- Specific medical condition requiring bed
- Why regular bed is inadequate
- Which bed features are required
- Duration of need
- Other attempted positioning methods
- For Head Elevation Requirements:
- Document specific angle needed
- Why this angle is required
- Why pillows/wedges are insufficient
- Related diagnosis
- For Frequent Position Changes:
- Document frequency needed
- Medical reason for changes
- Why manual adjustment is inadequate
- Caregiver situation if relevant
Common Documentation Mistakes to Avoid
- Insufficient Medical Necessity:
- Just stating “needs hospital bed”
- Not explaining why regular bed inadequate
- Missing specific required features
- No documentation of failed alternatives
- Vague Clinical Information:
- Non-specific symptoms
- Missing required angles
- Unclear positioning needs
- Duration not specified
- Missing Required Elements:
- No face-to-face evaluation
- Incomplete written order
- Missing measurements if bariatric
- No documentation of caregiver ability
Special Scenarios
- Bariatric Beds:
- Document weight and BMI
- Specify weight capacity needed
- Include measurements
- Note any skin issues
- Side Rails:
- Document specific medical need
- Safety assessment
- Cognitive status
- Caregiver training
- Mattress/Support Surface:
- If needed, requires separate documentation
- Must meet separate coverage criteria
- Cannot be billed together with certain beds
- See Support Surface guide for details
Documentation Checklist
- Face-to-face evaluation completed
- Medical condition clearly documented
- Specific features needed and why
- Failed alternatives noted
- Duration of need specified
- Measurements if bariatric
- Side rail assessment if needed
- Caregiver ability addressed
- Written order completed with all required elements
Billing Tips
- Fixed Height Bed (E0250-E0251):
- Basic documentation only
- No special modifiers
- Semi-Electric (E0260):
- Add documentation for frequent changes
- Must justify electric features
- Full Electric (E0265):
- Use upgrade modifiers
- Patient responsibility notice
- ABN if required
Best Practices
-
- Initial Documentation:
- Use specific measurements
- Include objective findings
- Document failed alternatives
- Note caregiver situation
- Orders:
- Include all required elements
- Specify accessories needed
- Note duration of need
- Include diagnosis codes
- Follow-up:
- Document continued need
- Note any complications
- Update if needs change
- Regular reassessment
Remember: Medicare contractors may request documentation at any time. Keep detailed records readily available in the patient’s chart.
- Initial Documentation:
