Medicaid DME billing guidelines

DME Policy

The DME program covers medically necessary durable medical equipment, prosthetics, orthotics, and disposable medical supplies (DMEPOS); which includes oxygen and related supplies, parenteral and enteral nutrition and medical foods. Medicaid Services Manual (MSM) Chapter 1300 contains Nevada Medicaid DME policy, including but not limited to: documentation requirements, dispensing and
delivery of items, recipient qualifications, coverage and limitations.

Durable Medical Equipment (DME) is medical equipment that:

• Can withstand repeated use;
• Is primarily and customarily used to serve a medical purpose;
• Is generally not useful to a person in the absence of illness or injury; and

• Is appropriate for use in the home.

Products and services must be medically necessary, safe and appropriate for the course and
severity of the condition using the least costly and equally effective alternative to meet the recipient’s
needs.

Remember to check http://nevada.fhsc.com at least weekly for updates, policy changes, and Web Announcements!

DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS AND SUPPLIES (DMEPOS) 

DATE(S) OF SERVICE

Medical Supplies For medical supplies, the date supplied must be reported as the date of service.

Diaper and Incontinent Supplier

For the Diaper and Incontinent Supplier Contract, the date the order is transmitted by the contractor to the fulfillment house is the date of service.


DME/Prosthetics/ Orthotics

For both custom and noncustom durable medical equipment (DME) and prosthetics and orthotics (P&O), the date of delivery must be reported as the date of service. For subsequent rental months, if applicable, the DOS must be the first day of the service
month based on the original date of delivery.

Custom-Fabricated DME or P&O Appliances

For custom-fabricated DME or P&O appliances when there is a loss of eligibility or a change in eligibility status (e.g., from FFS to health plan enrollment or vice versa) between the time the item is ordered and is delivered, the order date rather than the delivery date must be reported as the date of service. For payment, the item must be delivered within 30 days after loss or change in eligibility.

Rented DMEPOS For all rented DMEPOS, if a beneficiary's death occurs during a specific month in which payment has already been made, the prorating of actual days the items were used is not required.

6.8.B. DAYS OR UNITS Continuous Passive Motion Device

For a passive motion device, the rental must be billed as a daily rate by reporting total number of days used as units. (Up to 21 days of rental may be considered for payment.)

Enteral Formula For enteral formula (administered orally or by tube), the appropriate formula HCPCS code should be billed on a monthly basis with total caloric units reported as the quantity. To determine the number of caloric units, divide the total number of calories of all cans to be used by 100.

Gradient Compression Stockings/Surgical Stockings

Gradient compression stockings are considered a "one item" service. The right (RT) and left (LT) modifiers must be used for these items when reporting HCPCS codes A6530 – A6549. When a gradient compression stocking is provided bilaterally, the
same code is reported for both garments on one service line using modifiers LTRT with a quantity of "2".

Surgical stockings and most gradient compression stockings are packaged by a pair and are billed with a quantity of "1" for each stocking. No RT or LT modifier is required for billing surgical stockings.

Home Intravenous Infusion Therapy

For home intravenous infusion therapy, HCPCS "S" codes must be reported as a daily rate by reporting the total number of days used as units unless otherwise noted in the code description. A home infusion therapy code may be billed with modifier "SH" or "SJ" if multiple drugs are being administered concurrently (e.g., SH – 2 drugs, SJ – 3drugs). Routine catheter care is included with the daily rate for the active infusion. For chemotherapy and pain management, the specific HCPCS code will designate either continuous or intermittent administration. If the therapy is provided withoutinterruption for 24 hours or more, report the continuous therapy code. For less than 24 hours of therapy, use the intermittent code. For antibiotic, antiviral or antifungal therapy, report the code that best describes the frequency of administration. Only one therapy code of this series may be reported on the same date of service.

Parenteral Intravenous InfusionTherapy

For parenteral intravenous infusion therapy, the appropriate HCPCS "B" codes must be billed as a daily rate by reporting total number of days used as units. The parenteral lipids, the parenteral pre-mix solution, the infusion pump, supply kit, and the administration kit may be billed in combination with each other.


Powered Air Flotation Bed/Airfluidized Bed

For a powered air flotation bed or air-fluidized bed, the rental must be billed as a daily rate by reporting total number of days used as units. (Up to 10 months of rental may be considered for payment.)

For a powered air flotation bed or air-fluidized bed, the "MS" modifier is reported only after 10 months of rental have occurred and an additional six months of continued maintenance and servicing of the item has been provided. A quantity of "1" must be reported for the entire six-month period of service.

6.8.C. HOSPITAL DISCHARGE WAIVER SERVICES 

To bypass the PA requirement when billing for standard DME covered under the hospital discharge waiver service, report the discharge date in item 18. (The discharge date must be entered in the eight-digit MMDDCCYY format.)

6.8.D. CONVERTING RENTAL TO PURCHASE

 If the purchase of an item is requested after a previous rental month(s) has been paid, the provider must subtract all amounts previously paid from the total purchase price. Enter this amount in the charge field. Enter in the Remarks section that the item is converting from rental to a purchase. Do not enter any payment made by Medicaid in field 24k.