Term
Definition
Why is this important?
HCPCS
“hick-pics” stands for Healthcare Common Procedure Coding System. This system is used by Centers for Medicare and Medicaid Services.
All insurance companies require this for billing. It’s important to obtain this billing code from your doctor or equipment provider for your best chance at determining coverage as well as reimbursement qualifications.
Level 1 HCPCS Code: CPT Code
These codes are assigned by your Doctor are set by the American Medical Association.
This numeric code identifies your specific surgery or injury type and is provided to you by your Doctor’s office.
Level 2 HCPCS Code
Alphanumeric code sets used by medical suppliers such as DME providers for non-physician products, supplies, and procedures not included in CPT.
The code of E0118 is what all knee walkers are categorized under. This classifies it as a “Crutch Substitute, lower leg platform, with or without wheels.”
DME
Durable Medical Equipment:
For an item to be considered DME it must meet these requirements.
It must be able to withstand repeated use.
It must be primarily and customarily used to serve a medical purpose.
It must be generally not useful to a person in the absence of an illness or injury.
It must be appropriate for use in the home.
A knee walker is classified as DME. Their billing codes are classified as “E-codes” (because their codes start with an E) within the HCPCS code set.
CMS
Centers for Medicare and Medicaid Services. Administers these two programs among other programs.
Most insurance companies base their billing coding systems using CMS’ established codes. Any changes in coverage by the CMS normally affect insurance coverages.
Medicare
The Federal government program that provides health coverage for people that are 65 or older or certain younger people with disabilities. The system is comprised of different “parts” to help cover specific services. “Medicare Part B” covers medical supplies.
Medicare determines the pricing and coverage of most medical costs, which private insurance companies in turn follow their guidelines for their own coverage options. Knee walkers are seen by Medicare as being a luxury item in most cases, so they are not initially covered in most insurance plans.
Billing Code E0118
This HCPSC code stands for: Crutch Substitute, lower leg platform, with or without wheels.
All Knee walkers are under this code. A modifier may be required by your insurance company for clarification. They include: new purchase (E0118-NU), rental (E0118-RR) or purchase of a used product (E0118-UE).
DME Provider
A company that supplies Durable Medical Equipment.
In some cases, DME Providers are exclusive to some insurance plans. In most cases concerning knee walkers, these DME providers are considered “out-of-network providers” due to not having initial coverage abilities. Insurance plans have differing policies on reimbursement through in-network and out-of-network DME providers which is why it’s important to call and find out your individual policy.
FLEX/HSA Plans
Flexible Spending Plans and Health Savings Plans are employer provider plans for various health costs.
These plans traditionally issue debit cards that can be used to purchase DME. Not all providers accept these payments, and you may need to speak with them before hand to authorize the charge if it’s a large amount. These plans and coverages also differ so it’s in best practice to find out if your knee walker will be accepted or reimbursed in payment.
Letter of Medical Necessity (LMN)
This document is written, or signed, by a healthcare professional relevant to the service requested. It states why the equipment is medically necessary to your condition or recovery.
In terms of reimbursement and insurance coverage, a LMN combined with a prescription are most commonly needed for obtaining coverage or reimbursement. Some companies provide blank letters of medical necessity to be filled out by your doctor before submitting your claim.
Prescription from Your Doctor
A prescription from your doctor tells the insurance company what recommended equipment or supplies are needed to aid in your recovery. On the form, they may also list the HCPCS diagnosis codes that assist insurance/healthcare providers with billing and coverage.
A prescription for a knee walker is your almost always required for obtaining coverage or reimbursed. If not initially provided this by your doctor, you can always request one. This is the responsibility of the individual looking for a knee walker.
