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Date Printed: June 23, 2017: 06:31 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

09-E0000-15

Original Effective Date: 12/15/02

Reviewed: 08/25/16

Revised: 09/15/16

Subject: Continuous Passive Motion Device

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates  
           

DESCRIPTION:

The restoration of joint range of motion following surgery or trauma is dependent upon rehabilitation. Delay in rehabilitation may subsequently result in poor joint function or immobility. Passive motion, a treatment component of joint rehabilitation, may be performed by a physical therapist or accomplished with a continuous passive motion (CPM) device. It is thought that CPM can improve recovery by stimulating the healing or articular tissues and circulation of synovial fluid, reduce local edema and prevent adhesions, joint stiffness or contractures or cartilage degeneration. CPM has been most thoroughly investigated in the knee, particularly after total knee arthroplasty or ligamentous or cartilage repair, but its acceptance of its use in the knee joint has created interest in other joints such as the hip, ankle, metatarsal, shoulder, elbow, metacarpals, and interphalangeal joints.

The device used for the knee moves the joint (eg, flexion/extension), without patient assistance, continuously for extended periods of time (ie, up to 24 hours per day). An electrical power unit is used to set the variable range of motion (ROM) and speed. The initial settings for ROM are based on a patient’s level of comfort and other factors that are assessed intraoperatively. The ROM is increased by 3 to 5 degrees per day, as tolerated. The speed and ROM can be varied, depending on joint stability. The use of the device may be initiated in the immediate postoperative period and then continued at home for a variable period of time.

POSITION STATEMENT:

The rental of a continuous passive motion (CPM) exercise device for home use meets the definition of medical necessity as an adjunct to physical therapy for ONE the following situations:

Under conditions of low postoperative mobility or inability to comply with rehabilitation exercises following a total knee arthroplasty (TKA) or TKA revision. This may include members with complex regional pain syndrome (reflex sympathetic dystrophy); extensive arthrofibrosis or tendon fibrosis; or physical, mental, or behavioral inability to participate in active physical therapy.

During the non-weight-bearing rehabilitation period following intra-articular cartilage repair procedures of the knee (eg, microfracture, osteochondral grafting, autologous chondrocyte implantation, treatment of osteochondritis dissecans, repair of tibial plateau fractures).

The use of a continuous passive motion (CPM) device is considered experimental or investigational for all other indications. The evidence is insufficient to determine the effects of the technology on health outcomes.

Refer to section entitled DECISION TREE.

BILLING/CODING INFORMATION:

The following code(s) may be used to describe continuous passive motion devices:

HCPCS Coding:

E0935

Continuous passive motion exercise device for use on knee only

E0936

Continuous passive motion exercise device for use other than knee (Investigational)

REIMBURSEMENT INFORMATION:

Reimbursement for the rental of a CPM device is limited to a 14-day post-operative period (beginning immediately after surgery, i.e. within 48 hours). The use of a CPM device beyond 14-days post-operatively is subject to medical review for medical necessity. The following information may be required documentation to support medical necessity: physician operative reports and physician progress notes.

LOINC Codes:

DOCUMENTATION TABLE

LOINC CODES

LOINC TIME FRAME MODIFIER CODE

LOINC TIME FRAME MODIFIER CODES NARRATIVE

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Physician operative note

28573-4

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

In situations where bilateral total knee arthroplasty or anterior cruciate ligament reconstruction has occurred, rental for only one (1) CPM device is allowed.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Durable Medical Equipment, (280.1) located at cms.gov.

DEFINITIONS:

Total knee arthroplasty (TKA): surgical procedure that involves replacement of the joint surfaces with an artificial knee joint.

RELATED GUIDELINES:

None applicable.

OTHER:

None applicable.

REFERENCES:

  1. American Academy of Orthopaedic Surgeons, Arthroscopic Treatment for Elbow Osteoarthritis Reduces Pain, Improves Motion, 06/07.
  2. American Academy of Orthopaedic Surgeons. Surgical managment of osteoarthritis of the knee. Evidence-based clinical practice guideline. 2015; accessed at aaos.org 07/25/16.
  3. Blue Cross Blue Shield Association Medical Policy – Continuous Passive Motion in the Home Setting 1.01.10, 07/16.
  4. Blue Cross Blue Shield Association TEC Assessments – (1996, Tab # 20).
  5. Blue Cross Blue Shield Association TEC Evaluations (1993, Tab # 6).
  6. Centers for Medicare & Medicaid Services, National Coverage Determination (NCD) for Durable Medical Equipment Reference List (280.1), accessed at cms.gov 07/25/16.
  7. ECRI Institute, Continuous Passive Motion Devices Following Orthopedic Surgery, updated 03/07.
  8. Harvey LA, Brosseau L, Herbert RD. Continuous passive motion following total knee arthroplasty in people with arthritis. Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD004260. DOI: 10.1002/14651858.CD004260.pub3.
  9. HAYES Medical Technology Directory: Continuous Passive Motion (CONT0701.25 11/04/99, updated 07/31/03).
  10. Hayes, Inc., Mechanical Stretching Devices and Continuous Passive Motion for Joints of the Extremities, updated 06/06.
  11. Milne S, Brosseau L, Robinson V, et al, Continuous Passive Motion Following Total Knee Arthroplasty, 04/03.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 08/25/16.

GUIDELINE UPDATE INFORMATION:

12/15/02

Medical Coverage Guideline Reformatted; limitations revised.

10/15/04

Scheduled review; no change in coverage statement.

01/01/06

Annual HCPCS coding update: revise E0935.

01/01/07

Annual HCPCS coding update: add E0936.

09/15/07

Review, coverage statements maintained, guideline reformatted, references updated.

07/01/11

Revision; formatting changes.

05/11/14

Revision: Program Exceptions section updated.

09/15/16

Revision; description, position statements, and references updated; formatting changes.

Date Printed: June 23, 2017: 06:31 PM