HCPCS E0265: Hospital Bed, electric, with type side rails with mattress

## **HCPCS code E0265 documentation requirements** To justify any hospital bed (the base item), the beneficiary must meet one of the criteria demonstrating that a hospital bed is medically necessary, as an ordinary bed will not suffice. ### **General hospital bed medical necessity criteria** The treating practitioner's medical records must document that at least one of the following is true: - The beneficiary has a medical condition that requires positioning of the body in ways not feasible with an ordinary bed. - The beneficiary requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain. - The beneficiary requires the head of the bed to be elevated more than 30 degrees most of the time due to conditions like congestive heart failure, chronic pulmonary disease, or problems with aspiration. - The beneficiary requires traction equipment that can only be attached to a hospital bed. ### **Specific documentation for the total electric feature** Because the total electric feature (height adjustment) is often denied as a convenience, some payers (non-Medicare or specific state Medicaid programs) may have limited coverage criteria for it. Medicare, however, generally does not cover the height adjustment feature. When coverage is possible, the documentation must support that the total electric feature is reasonable and necessary beyond the medical necessity for a semi-electric bed. This typically involves: - The beneficiary meets all criteria for a lower-level (semi-electric or fixed-height) hospital bed. - The specific need for the height adjustment (total electric feature) is documented, usually to facilitate safe transfers to a chair, wheelchair, or standing position, or to assist a caregiver with the beneficiary's care due to the caregiver's inability to manually adjust the bed. ### **Required supplier documentation** The DME supplier must maintain: - **Standard Written Order (SWO)**: A complete, signed, and dated order from the treating practitioner. - **Medical record information**: Records from the practitioner that support the medical necessity criteria. - **Proof of Delivery (POD)**: Documentation showing the item was delivered to and received by the beneficiary.

## **E0265 billing requirements** For Medicare beneficiaries, the height adjustment feature that makes a bed "total electric" is generally not covered as it's viewed as a convenience. If the beneficiary or caregiver chooses a total electric bed, the supplier must: - Inform the beneficiary that the total electric feature is an upgrade and is not medically necessary and that the patient will be financially responsible for the difference in cost. - Have the beneficiary sign an Advance Beneficiary Notice of Non-coverage (ABN), outlining their financial responsibility for the non-covered portion of the upgrade. - The supplier must bill the full E0265 code. The claim will be paid at the allowed amount for the medically necessary component (e.g., E0260), and the patient will be responsible for the difference in cost. The supplier should use the GK modifier to denote the upgrade. Billing modifiers such as the following may also be used, depending on the need: - **RR**: Used when the bed is being rented (Capped Rental item) - **NU**: Used when the bed is being purchased (Lump Sum Purchase) - **KX**: Indicates that specific required documentation for medical necessity, as set forth in the policy, is on file. This modifier is crucial for payment. - **GA**: Waiver of liability statement (ABN) on file. Used when the supplier expects the item to be denied as not reasonable/necessary, but an ABN was signed. - **GZ**: Item or service expected to be denied as not reasonable/necessary (no ABN signed).

## **Other relevant codes** Relevant HCPCS codes for comparative or accessory equipment include: - **E0271**: Mattress, innerspring - **E0272**: Mattress, foam rubber - **E0305**: Bedside rails, half-length - **E0310**: Bedside rails, full-length - **E0250**: Hospital bed, fixed height, with any type of side rails, with a mattress. - **E0260**: Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress. - **E0261**: Semi-electric hospital bed (head and foot adjustment), with any type side rails, without mattress. - **E0266**: Hospital bed, total electric (head, foot and height adjustments), with any type side rails, without mattress. - **E0296**: Hospital bed, total electric (head, foot and height adjustments), without side rails, with mattress. - **E0255**: Variable height hospital bed, hi-lo, with any type side rails, with mattress - **E0301**: Extra wide hospital bed heavy duty, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, without mattress - **E0272**: Foam rubber mattress Note: When mattress or bedside rails are furnished concurrently with a hospital bed, billing must use the single combined code.