CODING, COVERAGE AND REIMBURSEMENT

This section currently focuses primarily on Medicare. It may be expanded in the future to include information on private insurers as well.

General

• Overall, Canes and Crutches are covered under the Durable Medical Equipment benefit (Social Security Act §1861(s)(6)) = place of service , patient's home
• Medicare coverage of Canes and Crutches is managed by Medicare and Medicare Administrative Contractors (MAC). Coverage is explained by the:
• Local Coverage Determination (LCD):  Canes and Crutches (L33733) https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33733&ContrID=140
• Local Coverage Article: Canes and Crutches - Policy Article (A52459) https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52459&ContrID=140
• The following items are covered by Medicare Part B when requirements are met:

Canes

• HCPCS: 
• 
  
• E0100 CANE, INCLUDES CANES OF ALL MATERIALS, ADJUSTABLE OR FIXED, WITH TIP
• E0105 CANE, QUAD OR THREE PRONG, INCLUDES CANES OF ALL MATERIALS, ADJUSTABLE OR FIXED, WITH TIPS
• E0110 CRUTCHES, FOREARM, INCLUDES CRUTCHES OF VARIOUS MATERIALS, ADJUSTABLE OR FIXED, PAIR, COMPLETE WITH TIPS AND HANDGRIPS
• E0111 CRUTCH FOREARM, INCLUDES CRUTCHES OF VARIOUS MATERIALS, ADJUSTABLE OR FIXED, EACH, WITH TIP AND HANDGRIPS
• E0112 CRUTCHES UNDERARM, WOOD, ADJUSTABLE OR FIXED, PAIR, WITH PADS, TIPS AND HANDGRIPS
• E0113 CRUTCH UNDERARM, WOOD, ADJUSTABLE OR FIXED, EACH, WITH PAD, TIP AND HANDGRIP
• E0114 CRUTCHES UNDERARM, OTHER THAN WOOD, ADJUSTABLE OR FIXED, PAIR, WITH PADS, TIPS AND HANDGRIPS
• E0116 CRUTCH, UNDERARM, OTHER THAN WOOD, ADJUSTABLE OR FIXED, WITH PAD, TIP, HANDGRIP, WITH OR WITHOUT SHOCK ABSORBER, EACH
• 
  
• Coverage requirements:
• Canes (E0100, E0105) and crutches (E0110 - E0116) are covered if all of the following criteria (1-3) are met:
• The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADL) in the home.
• The MRADLs to be considered in this and all other statements in this policy are toileting, feeding, dressing, grooming, and bathing performed in customary locations in the home.
• A mobility limitation is one that:
• Prevents the beneficiary from accomplishing the MRADL entirely, or,
• Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or,
• Prevents the beneficiary from completing the MRADL within a reasonable time frame;
• And,
• The beneficiary is able to safely use the cane or crutch; and,
• The functional mobility deficit can be sufficiently resolved by use of a cane or crutch.
• Frequency of replacement allowed by Medicare:
• 
  
• Non-covered conditions:
• A white cane for a blind person is noncovered since it is a "self help" item.
•  underarm, articulating, spring assisted crutch (E0117)
• hcpcs outside Canes (E0100, E0105) and crutches (E0110 - E0116)
• Code E0117 describes an articulating crutch which has two crutch legs connected by a bar between them which helps propel the beneficiary forward
• Code E0118 describes a crutch substitute which can be either a device strapped to the lower leg with a platform or a device with wheels and a platform the beneficiary propels with their sound limb.
• A4635 UNDERARM PAD, CRUTCH, REPLACEMENT, EACH
• A4636 REPLACEMENT, HANDGRIP, CANE, CRUTCH, OR WALKER, EACH
• A4637 REPLACEMENT, TIP, CANE, CRUTCH, WALKER, EACH.
• A9270 NON-COVERED ITEM OR SERVICE
• E0117 CRUTCH, UNDERARM, ARTICULATING, SPRING ASSISTED, EACH
• E0118 CRUTCH SUBSTITUTE, LOWER LEG PLATFORM, WITH OR WITHOUT WHEELS, EACH
• E0153 PLATFORM ATTACHMENT, FOREARM CRUTCH, EACH
• Billing reminders:
• 
  
• Billable unit: each or pair, depending on the HCPCS
• Code A9270 must be used for a white cane for a blind person.
• All canes and crutches are billed using the specific codes listed in the Local Coverage Determination regardless of their stated weight capacity.
• Do not use code E1399 (DME, miscellaneous) to code any type of cane or crutch regardless of special features or weight capacity.
• Code E0117 describes an articulating crutch which has two crutch legs connected by a bar between them which helps propel the beneficiary forward.
• Code E0118 describes a crutch substitute which can be either a device strapped to the lower leg with a platform or a device with wheels and a platform the beneficiary propels with their sound limb.
• Canes or crutches which contain a spring that reduces impact and vibration against the ground should not be billed with E1399. These types of canes or crutches should be coded with the existing codes for canes or crutches.

HCPCS Modifiers 

• EY NO PHYSICIAN OR OTHER LICENSED HEALTH CARE PROVIDER ORDER FOR THIS ITEM OR SERVICE