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24.5.23 Hospital Beds and Equipment
Hospital beds are defined as medical beds that are used by a client who has a medical condition that requires positioning the body in ways that are not feasible with an ordinary bed. Head/upper body elevation of less than 30 degrees does not require use of a hospital bed. Hospital beds and related equipment are considered for reimbursement for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Note: If the client is not eligible for home health services, hospital beds may be provided under THSteps-CCP for clients younger than 21 years of age.
Hospital beds require prior authorization.
Hospital beds may be considered for those clients who cannot safely use a regular bed. To request prior authorization for a hospital bed, the following documentation must be submitted:
• Accurate diagnostic information pertaining to the underlying medical diagnoses/conditions (e.g., gastrostomy feeding, suctioning, ventilator dependent, other respiratory equipment/ventilation assistance devices) to include the client's overall health status.
•The client's height and weight.
•The client's functional mobility status.
•The client's use of any pressure-reducing support surfaces, if applicable.
A hospital bed without side rails and/or mattress is not a benefit of Home Health Services. Side rails or mattresses may be considered for reimbursement for replacement only. A replacement mattress or side rails may be considered if a client's condition requires a replacement of an innerspring mattress or side rails and it is a client-owned hospital bed. A determination will be made by HHSC or its designee as to whether the equipment will be rented, purchased, repaired, or modified based on the client's needs, duration of use, and age of the equipment.
The following types of hospital beds are addressed in this policy:
•A fixed height hospital bed with manual head and leg elevation adjustments but no height adjustment.
•A variable height hospital bed with manual head and leg elevation adjustments and manual height adjustment.
•A semielectric bed with manual height adjustment and with electric head and leg elevation adjustments.
•A full electric bed has an electric head and leg adjustment, plus electric height adjustment.
•Heavy-duty hospital beds:
•A heavy-duty, extra wide hospital bed is capable of supporting a client who weighs more than 350 pounds, but no more than 600 pounds or
•A extra heavy-duty, extra wide hospital bed is capable of supporting a client who weighs more than 600 pounds.
A hospital bed is not one that is typically sold as furniture. A home furniture bed may consist of a frame, box spring and mattress. It is a fixed height and has no head or leg elevation adjustments.
A fixed height bed may be considered for prior authorization if the client requires the head of the bed to be elevated more than 30 degrees most of the time because of conditions such as congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have been used and found to be ineffective.
Use procedure code J/L-E0250 when billing for a fixed height bed.
A variable height hospital bed may be considered for prior authorization if the client meets the criteria for a fixed height hospital bed and requires a bed height different than a fixed height hospital bed to permit transfers to chair, wheelchair, or standing position.
Use procedure code J/L-E0255 when billing for a variable height hospital bed.
A semi-electric hospital bed may be considered for prior authorization if the client meets the criteria for a variable height bed and requires frequent changes in body position and/or has an immediate need for a change in body position.
Use procedure code J/L-E0260 when billing for a semi-electric hospital bed.
A fully electric hospital bed may be considered if the manufacturer's product information and MSRP for manually priced items documentation is included for clients who cannot function without a fully electric bed. A fully electric bed may be considered for prior authorization if it is found to increase the client's ability to self-care and will not be authorized for the convenience of the caregiver.
Use procedure code J/L-E0265 when billing for a fully electric hospital bed.
A heavy-duty, extra wide hospital bed is capable of supporting a client who weighs more than 350 pounds, but no more than 600 pounds. A heavy-duty, extra wide hospital bed may be considered for prior authorization if the client meets the criteria for one of the other hospital beds.
Use procedure code J/L-E0303 when billing for a heavy-duty, extra wide hospital bed.
An extra heavy-duty, extra wide hospital bed is capable of supporting a client who weighs more than 600 pounds. An extra heavy-duty, extra wide hospital bed may be considered for prior authorization if the client meets the criteria for one of the other hospital beds and whose weight meets the description of a heavy-duty hospital bed.
Use procedure code J/L-E0304 when billing for an extra heavy-duty, extra wide hospital bed.
Equipment
All equipment must be prior authorized.
A trapeze bar attached to a bed may be considered for reimbursement if the client needs this device to sit up, to change body position, for other medical reasons, or to get in or out of bed with documentation of medical necessity. Use procedure code J/L-E0910 or J/L-E0911 when billing for a trapeze bar attached to a bed.
Free standing trapeze equipment may be considered for reimbursement if the client does not have a covered hospital bed but the client needs this device to sit up to change body position for other medical reasons, or to get in or out of bed. Use procedure codes J/L-E0912 or J/L-E0940 when billing for free standing trapeze equipment.
An over-bed table may be considered for reimbursement if client is bed bound and needs the equipment for treatments. Use procedure code J-E0315 when billing for an over-bed table.
A safety enclosure (J/L-E0316) used to prevent a client from leaving the bed is not a benefit of the Home Health Services. A safety enclosure may be considered through THSteps-CCP.
Traction equipment, such as procedure codes J/L-E0890, J/L-E0947, and J/L-E0948, (excluding procedure codes J/L-E0910 and J/L-E0940 trapeze devices) are not a benefit of Home Health Services.
Pressure-Reducing Support Surfaces
Pressure-reducing support surfaces must be prior authorized.
A pressure-reducing support surface includes three separate groups of mattress/mattress-like equipment designed to assist in the healing of wounds. These devices are used in conjunction with conventional wound care therapy and/or to prevent the occurrence of said wounds in susceptible clients. Pressure-reducing support surfaces are designed to prevent skin breakdown or promote the healing of pressure ulcers by reducing or eliminating tissue interface pressure. Most of these devices reduce interface pressure by conforming to the contours of the body so that pressure is distributed over a larger surface area rather than concentrated on a more circumscribed location.
Pressure-reducing support surfaces are a benefit of Home Health Services on a case-by-case basis. To request prior authorization for a pressure-reducing support surface the following documentation must be provided:
•Client's overall health status and all other medical diagnosis/condition (e.g., history of decubitus).
•Documentation of the client's limited mobility or confinement to a bed.
•Previous use of pressure-reducing support surfaces with client outcome, (e.g., wound improvement, stasis, or degradation).
•Current wound therapy if any.
•Wound measurements to include location, length, width, depth, any undermining and/or tunneling, and odor if applicable.
Pressure-reducing support surfaces containing multiple components are categorized according to the clinically predominant component (usually the topmost layer of a multilayer product).
A support surface that does not meet the characteristics specified in the pressure-reducing support surface policy may be denied as not medically necessary.
Home Health Services will only cover alternating air mattresses and low-air-loss beds when they meet the definition of DME. Air mattresses that are not durable or made to withstand prolonged use do not meet the definition of DME.
For all types of pressure-reducing support surfaces, the support surface provided for the client should be one in which the client does not bottom out. The Centers for Medicare & Medicaid Services (CMS) defines "bottoming out" as when an outstretched hand, palm up, between the undersurface of the overlay or mattress and in an area under the bony prominence can readily palpate the bony prominence (coccyx or lateral trochanter). This bottoming out criterion should be tested with the client in the supine position with their head flat, in the supine position with their head slightly elevated (no more than 30 degrees), and in the sidelying position.
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