Procedure code E0603, E0784, K0740

Breast Pumps

 Blue Cross provides the durable medical equipment (DME) benefit for the standard manual breast pump model (E0602) covered for purchase at 100 percent of the allowable charge. However, unless prior authorized for medically necessity, a hospital-grade breast pump (E0603), is considered a deluxe/ luxury item and reimbursed at the same rate as the electric breast pump (E0603), with the member being responsible for any amount above the allowable charge. (Please refer to the special instructions for deluxe/luxury items). Only when prior authorization is approved, Blue Cross will allow for special processing of hospital grade breast pumps, and these authorizations are subject to periodic review.



Infusion Pumps

In an effort to appropriate align reimbursement to the types and cost of equipment provided modifier(s) are required on infusion pump code E0784 effective for dates of service beginning July 1, 2015. These items are for purchase only.

For Omnipod pumps, bill Modifier NU in the first position; for Medtronic pumps, bill Modifier SC in the  first position and NU in the second position; for pumps other than Omnipod and Medtronics bill Modifier KD in the first position and NU in the second position.

Coding Examples for Infusion Pumps

E0784NU – Omnipod infusion pump purchase

E0784SCNU – Medtronic infusion pump purchase

E0784KDNU – Infusion Pump purchase other than Omnipod or Medtronic brand/model Orthotics

Evaluation, measurement and/or casting, and fitting of the orthosis are included in the allowance for the orthosis and are not separately billable.

Repairs to an orthosis are billable when they are necessary to make the orthosis functional. The reason for the repair must be documented in the supplier’s record. If the expense for repairs is greater than providing another entire orthosis, no payment will be made for the amount in excess.

Replacement of a complete orthosis or component is billable if Medically Necessary.


Labor for replacing an orthosis component that is coded with a specific “L” HCPCS code is included in the allowance for that component.

Billable orthosis components and labor must be billed on the same claim form.



Oxygen Concentrator

Oxygen Concentrators can be rented or purchased. The rental amount will be allowed for 15 months at which time, the item will be considered purchased. Maintenance and servicing charges can be billed using HCPCS code K0740 every six months after the end of 15 months of continuous use or the end of the manufacturer’s warranty.


Prosthetics

The following items are not separately billable and are included in the reimbursement for a prosthesis:

• Evaluation of the residual limb and gain;

• Cost of component parts and labor contained in the HCPCS codes;

• Fitting of the prosthesis to include adjustments of the prosthesis or prosthetic component; and

• Routine periodic servicing to include testing, cleaning, and checking of the prosthesis.

Repair or Maintenance other than Prosthetic and Orthotic DME The repair or maintenance of rented DME/HME is the responsibility of the participating DME/HME supplier at no additional charge to the member. Rental rates include reimbursement for repair, adjustment, maintenance, and replacement of equipment and its components related to normal wear and tear, defects, or aging. If the expense for repairs is greater than the estimated expense of purchasing another entire item, no payments can be made for the amount of the excess.



Repairs to Memberowned

DME are billable using the appropriate code (K0739 or K0740) when necessary to make the item functional. For ventilators see section below.

For facial prostheses codes L8040 thru L8047, providers must bill using modifiers KM or KN when the prosthesis is being replaced.

• KM Replacement of facial prosthesis including new impression/moulage

• KN Replacement of facial prosthesis using previous master model



Ventilators

Effective January 1, 2016, Ventilator HCPCS codes are to be billed and reimbursed as rental using the RR modifier, which includes  maintenance. One additional rental rate at 50 percent (upon prior authorization) will be allowed in the same calendar month for a backup ventilator reported with a rental modifier (RR) plus modifier TW (backup equipment), appended to HCPCS codes. Note: Members may be allowed to purchase the ventilators if authorized. Maintenance fees may be allowed for this purchased/member owned equipment using code K0740.