Benefits for DME are provided in accordance with the benefit provisions of each specific member’s benefit plan. Benefits will be provided if the DME is covered by the member’s benefit plan and the prescribed equipment meets our DME and medical necessity requirements. Most member benefit plans provide for the rental of DME not to exceed the purchase allowance.
Deductible, Coinsurance, Copay and Non-covered Services
After the member’s deductible has been met, Blue Cross will pay a specified benefit for the remaining rental or purchase allowance for covered DME. The deductible and benefit amounts will vary according to the member’s contract.
The member is responsible for payment of any deductible, coinsurance and non-covered services.
However, the DME provider cannot bill the member for any amount that exceeds the Blue Cross allowable charge for rented or purchased DME pursuant to your contractual agreement with Blue Cross.
Sales tax on DME is considered a non-covered charge and the member’s responsibility according to most Blue Cross and HMO Louisiana member benefit plans.
Payment Allowance
Benefit payment for the rental of DME is based on the Blue Cross monthly rental allowance (not to exceed the purchase allowance). Benefit payment for the purchase of DME is based on the Blue Cross purchase allowance.
Rented DME is considered purchased once the monthly rental allowance equals the purchase allowance. The patient then owns the DME and neither the member nor Blue Cross can be billed for additional rental or purchase of the equipment.
Rental vs. Purchase
Blue Cross has the option of approving either rental or purchase of DME. Based on medical necessity, rental may be approved for a specified number of months, rental may be approved up to the purchase allowance, or purchase may be approved.
Billing Guidelines
DME must be billed using the most appropriate HCPCS code and appropriate modifiers in effect for the date of service. Claims billed with an inappropriate code/modifier combination will be returned to the Provider for submission of a corrected claim and will cause a delay of reimbursement.
Purchase
For purchased items, the appropriate HCPCS code must be billed with the NU modifier. See specific guidelines for insulin infusion pump billing and modifiers.
Rentals
Daily Rental Codes
E0202 - PHOTOTHERAPY LIGHT WITH PHOTOMETER
E0935 - CONT PSV MOT EXER DEVC KNEE ONLY
E0936 - CONT PASS MOTION EXER DEVC NOT KNEE
Miscellaneous, unlisted, non-specific and Not Otherwise Classified (NOC) codes should only be used when a more specific Procedure or HCPCS code is not available. Components of the primary equipment should be billed with the most specific Procedure or HCPCS code or the most specific unlisted or miscellaneous code. DME billed with unlisted, miscellaneous, non-specific, and Not Otherwise Classified (NOC) codes must be billed with the name of the manufacturer, product number, and quantity.
Codes for durable medical equipment, medical supplies, orthotics, and prosthetics without an established allowable may require submission of the manufacturer name, product name, product number, and quantity.
Charges for rental equipment accessories should be included in the rental price of the equipment with no separate or itemized billing when submitting claims for consideration to Blue Cross. All DME requests for special or customized features should be submitted to the Blue Cross Medical Review Department for prior approval using the Medical Certification Form.
All DME/HME claims for supplies that exceed the usual and customary utilization may result in a request for medical records to determine medical necessity.
All supplies must be requested by an eligible member or caregiver. Supplies are not to be automatically dispensed on a predetermined regular basis.
Maintenance and Service Fees
Oxford allows for reimbursement of maintenance and service once every six months to the Same Specialty Physician Hospital, Ambulatory Surgical Center or Other Health Care Professional. The appropriate HCPCS code appended with modifier MS (maintenance/service fee) is required to identify such services. The Maintenance and Service modifier (MS), must be reported on a separate line in order to be considered for separate reimbursement from the rental or purchase of the equipment.
Maintenance and Service agreements include the following:
Regular routine maintenance and performance checks as required to maintain the warranty or performance standards
Re-education
Compliance with alerts and recalls
necessary supplies in accordance with the applicable agreement
Back-up equipment
Emergency availability and replacement equipment when out-of-service for repair
For the purposes of this policy, maintenance and servicing does not apply to Orthotics or Prosthetics. HCPCS Codes A9900, A9901 and L9900 Delivery, set-up and supplies are included in the payment rates associated with a DME, Orthotic, or Prosthetic item.
They are not reimbursable services when submitted alone or with another service.
Therefore, Oxford will not separately reimburse the following codes:
A9900 - Miscellaneous DME supply, accessory, and/or service component of another HCPCS code
A9901 - DME delivery, set up, and/or dispensing service component of another HCPCS code
L9900 - Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS "L" code
QUESTIONS AND ANSWERS
1 Q: Why is a rental month defined as a calendar month when months vary as to their number of days
A: The rationale for reimbursing rental once per Calendar Month rather than once per 30 day period is due to the fact that some months are less or greater than 30 days. Billing trends indicate that rentals are reported on a cycle billing method; i.e., item dispensed on 1/9/13, and rented for 3 continuous months. Resulting bills will be submitted with 1/9/13 and 2/9/13 and 3/9/13 dates of service.
2 Q: How should monthly rental of DME items be reported ?
A: According to the National Uniform Billing Committee (NUBC) and the National Uniform Claim Committee (NUCC), monthly rental of an item should be reported on a single claim line with one unit and a single calendar month date span - that is, for one month, enter the rental initiation date in the From field and the end date of that month’s rental in the To field. Rental charges for multiple months should not be reported on the same line. If two claims are submitted that show From dates in the same month for the same item from the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional, only one claim will be allowed and the second claim for the same month will not be covered. See the policy section titled Reporting Monthly Rental for an example of how to report more than one month’s rental for the same item. Note that each line in the example has a From date in a different month.
ANKLE-FOOT ORTHOSES
Ankle-foot orthoses extend well above the ankle (usually to near the top of the calf) and are fastened around the lower leg above the ankle. These features distinguish them from foot orthotics, which are shoe inserts that do not extend above the ankle.
CUSTOM FABRICATED ORTHOSIS
Custom fabricated orthosis is one which is individually made for a specific patient starting with basic materials including, but not limited to, plastic, metal, leather, or cloth in the form of sheets, parts, etc. It involves substantial work such as cutting, bending, molding, sewing, etc. It may involve the incorporation of some prefabricated components. It involves more than trimming, bending, or making other modifications to a substantially prefabricated item.
DISPOSABLE MEDICAL SUPPLIES
Disposable medical supplies are those items which are not reusable, and are primarily and customarily used to serve a medical purpose, and generally are not useful to a person in the absence of an illness or injury.
DURABLE MEDICAL EQUIPMENT (DME)
DME is defined as equipment which can withstand repeated use, and is primarily and customarily used to serve a medical purpose, and generally is not useful to a person in the absence of illness or injury and is appropriate for use in the home.
DURABLE MEDICAL EQUIPMENT MEDICARE ADMINISTRATIVE CONTRACTOR (DME MAC)
The Centers for Medicare and Medicaid Services (CMS) utilize four insurance companies to process durable medical equipment, prosthetic, orthotic, and disposable medical supply claims for Medicare in four distinct jurisdictions. Nevada is in Jurisdiction D. This was formerly referred to as Durable Medical Equipment Regional Carrier (DMERC).
DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS, AND SUPPLIES (DMEPOS)
Aggregate term used under the Medicare program and by some Medicaid programs, which incorporates all durable medical equipment, prosthetics, orthotics, and disposable medical supplies. The acronym is pronounced “demipose”.
MEDICAL DOCUMENTATION
For the purposes of obtaining DMEPOS through Nevada Medicaid and Nevada Check Up (NCU), medical documentation used to support medical necessity is part of a medical record which is completed, signed and dated by a licensed medical professional. Clinical reports or assessments required to support medical necessity must be from a licensed/certified professional performing within their scope of practice. Information used as medical documentation cannot be compiled or composed by the recipient, their relatives or representatives.
MISUSE
To use in a manner in which an item is not intended, excessive use, or to use incorrectly.
MOLDED TO PATIENT MODEL ORTHOSIS
A molded-to-patient-model orthosis is a particular type of custom fabricated orthosis in which an impression of the specific body part is made (by means of a plaster cast, CAD-CAM technology, etc.) and this impression is then used to make a positive model (of plaster or other material) of the body part. The orthosis is then molded on this positive model.
ORTHOSIS
An orthosis (brace) is a rigid or semi-rigid device which is used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body. An orthosis can be either prefabricated or custom-fabricated.
PREFABRICATED ORTHOSIS
Pre-fabricated orthosis is one which is manufactured in quantity without a specific patient in mind. A prefabricated orthosis may be trimmed, bent, molded (with or without heat), or otherwise modified for use by a specific patient (i.e., custom fitted). An orthosis that is assembled from prefabricated components is considered prefabricated. Any orthosis that does not meet the definition of a custom-fabricated orthosis is considered prefabricated.
PROSTHETIC DEVICES
Prosthetic devices are replacement, corrective, or supportive devices prescribed by a physician (or other licensed practitioner of the healing arts within the scope of his practice as defined by state xlaw) to:
a. Artificially replace a missing portion of the body;
b. Prevent or correct physical deformity or malfunction; or
c. Support a weak or deformed portion of the body (as defined by CFR at 42 CFR 440.120(c)).
For Nevada Medicaid’s DMEPOS program purposes, dentures and eyeglasses are not included as a prosthetic device.
SPEECH GENERATING DEVICE (SGD)
SGDs, also commonly known as “Augmentative and Alternative Communication” (AAC) devices are electronic aids, devices, or systems that correct expressive communication disabilities that preclude an individual from meaningfully participating in activities of daily living. SGDs are covered as DME. Requests for SGDs must provide the information required in Appendix B to this Chapter of the Medicaid Services Manual (MSM).
Reimbursement Guidelines
Rental or Purchase Modifiers
Some DME items are eligible for rental as well as for purchase. The codes representing these items are listed in Modifier Required Code List in the Attachments section below and must be reported with the appropriate rental or purchase modifier in order to be considered for reimbursement.
Rental guidelines are explained further in the sections titled Monthly Rental and Daily Rental.
Rental Modifiers (Medicaid)** The vendor must specify monthly rental of equipment using one or more of the following modifiers:
** RR Rental
** KH Initial Claim, purchase or first month rental
** KI Second or third monthly rental
** KJ Capped rental months four to fifteen
** KR Partial month
** LL Lease/rental (use the LL modifier when DME equipment rental is to be applied against the purchase price. Rental Modifiers (Medicare):
** RR Rental
** KH Initial Claim, purchase or first month rental
** KI Second or third monthly rental
** KJ Capped rental months four to fifteen
** KR Partial month
Purchase Modifiers (Medicaid and Medicare)** The following modifiers indicate that an item has been purchased:
** NU New Equipment (use the NR modifier when DME which was new at the time of rental is subsequently purchased)
** UE Used Equipment
** NR New when rented
** KM Replacement of facial prosthesis including new impression/moulage
** KN Replacement of facial prosthesis using previous master model
Other Allowable DME Modifiers
** MS Six month maintenance and servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warranty
Monthly Rental
Monthly Rental Monthly rental of DME, orthotics, or prosthetics identified by the applicable code with a rental modifier RR and/or modifiers KH, KI, KJ, KR, LL appended will be reimbursed once per Calendar Month to the Same Specialty Physician or Other Health Care Professional. A Calendar Month is the period of duration from a day of one month to the corresponding day of the next month (please see Definitions) and is determined based on the “From” date reported on the claim. If a code is submitted with modifier RR and/or modifiers KH, KI, KJ, KR, LL with units greater than 1, or multiple times during the same Calendar Month, UnitedHealthcare Community Plan will only reimburse one monthly rate per Calendar Month to the Same Specialty Physician or Other Health Care Professional except where noted below.
Modifiers RT and LT
** An additional rental rate will be allowed in the same Calendar Month for codes with a rental modifier when both modifiers RT and LT are submitted for the same HCPCS code on separate
lines. Modifiers RT and LT may be used to report an item for the right or left side of the body and convey that multiples of that item are being utilized.
Backup Ventilator
** One additional rental rate will be allowed in the same Calendar Month for a backup ventilator reported with a rental modifier plus modifier TW (backup equipment), appended to HCPCS codes E0465 or E0466.
Codes with Extension/Flexion, Supination/Pronation, or Each in the Description
** Up to two rental rates will be allowed in the same Calendar Month for codes with "extension/flexion," "supination/pronation" or "each" in the description. These codes describe services where multiple devices may be reported. If these codes are reported with modifiers RT and LT and multiple units, UnitedHealthcare Community Plan will consider for separate reimbursement up to two units for each side for a total of up to four rental rates in the same Calendar Month. For additional information, refer to the Questions and Answers section, Q&A #4, and the Attachments section.
Reporting Monthly Rental
Monthly rental of DME, Orthotics, or Prosthetics should be reported on a 1500 Health Insurance Claim Form (a/k/a CMS-1500) or its electronic equivalent or its successor form according to the National Uniform Billing Committee (NUBC) and the National Uniform Claim Committee (NUCC) guidelines. The appropriate HCPCS code and rental modifier are submitted with one unit for each Calendar Month time span. The rental initiation date is entered in the "From" field, and the end date in the "To" field. In the following example, the rental for HCPCS code E1130 (Standard wheelchair, fixed full-length arms, fixed or swing-away detachable footrests), is initiated on 1/10/2013, and the item is rented for 3 months. The claim should be submitted as follows:
Code Modifier Units From Date To Date E1130 RR
11/10/2013 2/9/2013 E1130 RR 1
2/10/2013 3/9/2013 E1130 RR 1 3/10/2013 4/9/2013 E1130-RR reported with 3 units, a From Date of 1/10/2013 and a To Date of /9/2013 on one line will result in reimbursement of only 1 unit.
Daily Rental
UnitedHealthcare Community Plan will allow a daily rental for the following items to the Same Specialty Physician or Other Health Care Professional. HCPCS codes E0935 (Continuous passive motion exercise device for use on knee only), and E0936 (Continuous passive motion exercise device for use other than knee) are reimbursed on a daily basis consistent with CMS guidelines.
The following HCPCS codes are also reimbursed on a daily basis:
** E0193, Powered air flotation bed (low air loss therapy)
** E0194, Air fluidized bed
** E0277, Powered pressure-reducing air mattress
** E0304, Hospital bed, extra heavy-duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, with mattress
** E0371, Nonpowered advanced pressure reducing overlay for mattress, standard mattress length and width
** E0372, Powered air overlay for mattress, standard mattress length and width
** E0373, Nonpowered advanced pressure reducing mattress
** E1639, Scale, each
** E2402, Negative pressure wound therapy electrical pump, stationary or portable
Rental to Purchase
Rental fees from a single vendor are payable up to either the purchase price of an item or a maximum number of rental months, whichever is less. The maximum number of rental months for comparison to the purchase price varies according to the vendor’s contract. Once the Rent-to-Purchase maximum (or Rental Cap) specified in the contract is reached, the item is considered purchased and is not reimbursable. Daily rental items may also be subject to rental limits, depending on the vendor’s contract. These rental limits do not apply to oxygen equipment or to ventilators.
The vendor is responsible for complying with all the terms of their contract with UnitedHealthcare Community Plan, including the provision that requires the vendor to stop billing for rental of items when the maximum rental amount for those items specified in their contract has been reached.
Identification of whether the equipment was rented or purchased must be documented by the use of the applicable modifier referenced in the Rental or Purchase Modifiers section above.
Maintenance and Service Fees
The UnitedHealthcare Community Plan allows for reimbursement of maintenance and service once every six months to the Same Specialty Physician or Other Health Care Professional. The appropriate HCPCS code appended with modifier MS (maintenance/service fee) is required to identify such services. The Maintenance and Service modifier (MS) must be reported on a separate line in order to be considered for separate reimbursement from the rental or purchase of the equipment.
Maintenance and Service includes the following:
** regular routine maintenance and performance checks as required to maintain the warranty or performance standards
** re-education
** compliance with alerts and recalls
** necessary supplies in accordance with the applicable agreement
** back-up equipment
** emergency availability and replacement equipment when out-of-service for repair.
For the purposes of this policy, maintenance and servicing does not apply to Orthotics or Prosthetics.
HCPCS Codes A9900, A9901 and L9900
Delivery, set-up and supplies are included in the payment rates associated with a DME, Orthotic, or Prosthetic item. They are not reimbursable services when submitted alone or with another service. Therefore, UnitedHealthcare Community Plan will not separately reimburse the following codes:
** A9900 (Miscellaneous DME supply, accessory, and/or service component of another HCPCS code)
** A9901 (DME delivery, set up, and/or dispensing service component of another HCPCS code)
** L9900 (Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS L code)
Arizona
Arizona has separately designated code and modifier lists.
Arizona Medicaid is exempt from monthly rental limit due to State requirements. Iowa
Per state regulations, Iowa requires the use of the RB modifier and not the MS modifier for the maintenance of purchased equipment.
Kansas
** The State of Kansas allows an RR modifier for 1 month rental (when appropriate) on the following hearing aid codes: V5030, V5040, V5050, V5060, V5120, V5130, V5140, V5160, V5210, V5220, V5242, V5243, V5244, V5245, V5246, V5246, V5247, V5248, V5249, V5250, V5251, V5252, V5253, V5254, V5255, V5256, V5257, V5258, V5259, V5260, V5261, V5264, V5266.
** The State of Kansas allows code E0202 to be billed as daily rental.
** The State of Kansas allows ventilators to be reimbursed at a daily rate.
** The State of Kansas allows a monthly limit of 6 boxes of test strips (HCPC A4253) for insulin dependent diabetics and 2 box of test strips for non-insulin dependent diabetics.
** The State of Kansas reimburses code E0463 as a daily rental.
** Kansas uses a customized, state identified DME Modifier Required list
Michigan
Michigan excludes codes E0202, E0604, E0619, E2000, K0606, and S9001 from rental to purchase.
Mississippi
The Division of Medicaid (MS CAN) covers rental of equipment up to ten (10) months, or up to the purchase price, whichever is less.
Nebraska
** Nebraska allows multiple units to be reimbursed as a daily rental when the KR modifier is billed with a specific list of codes. The codes that are included can be found on the Nebraska KR List in the Attachment Section.
** NE allows A9900 to be billed as a supply kit with Breast Pumps and Apnea Monitors.
** The state of NE does not cover a purchase of HCPCS code E0604. There is a 12 month rental cap for this code. Purchase is not allowed; therefore, claim should not deny for purchase price.
Ohio
Ohio does not require modifiers on all codes in the policy. The codes that are excluded can be found on the Ohio DME Modifier Bypass List in the Attachment Section.
Texas
** For code A4253 Texas allows 2 units per month for insulin dependent diabetics and 1 unit per month for noninsulin dependent diabetics.
** For codes A4253 and A9275 Texas allows a combined total of 2 units per month for insulin dependent diabetics and a combined total of 1 unit per month for noninsulin dependent diabetics.
Wisconsin
Exempt from the monthly rental unit limit due to State requirements. Wisconsin bills in daily rather than monthly units.
Definitions
Calendar Month
The period from a day of one month to the corresponding day of the next month. Durable Medical Equipment
Medical equipment which: *Can withstand repeated use *Is not disposable *Is used to serve a medical purpose
*Is generally not useful to a person in the absence of sickness or injury *Is appropriate for use in the home
Orthotic
An external appliance such as a brace or splint that prevents or assists movement of the spine or limbs. A brace is used for the purpose of supporting a weak or deformed body part of a Customer or restricting or eliminating motion in a diseased or injured part of the body.
Prosthetic
A device that replaces all or part of an external body organ or all or part of the function of a permanently inoperative or malfunctioning external body organ.
Same Specialty Physician or Other Health Care Professional
Physicians and/or other health care professionals of the same group and same specialty reporting the same Federal Tax Identification number.
Questions and Answers
1 Q: Why is a rental month defined as a Calendar Month when months vary as to their number of days ?
A: The rationale for reimbursing rental once per Calendar Month rather than once per 30 day period is due to the fact that some months are less or greater than 30 days. Vendor billing trends indicate that rentals are reported on a cycle billing method; i.e., item dispensed on 1/9/13, and rented for 3 continuous months. Resulting bills will be submitted with 1/9/13 and 2/9/13 and 3/9/13 dates of service.
2 Q: How should monthly rental of DME items be reported ?
A: According to the National Uniform Billing Committee (NUBC) and the National Uniform Claim Committee (NUCC), monthly rental of an item should be reported on a single claim line with one unit and a single calendar month date span—that is, for one month, enter the rental initiation date in the From field and the end date of that month’s rental in the To field. Rental charges for multiple months should not be reported on the same line. If two claims are submitted that show From dates in the same month for the same item from the Same Specialty Physician or Other Health Care Professional, only one claim will be allowed and the second claim for the same month will not be covered. See the policy section titled Reporting Monthly Rental for an example of how to report more than one month’s rental for the same item. Note that each line in the example has a From date in a different month.
3 Q: Why does UnitedHealthcare Community Plan pay a full Calendar Month rental rate when modifier KR is used, which indicates the item is only rented for a partial Calendar Month ?
A: Regardless of whether the item is used for a full Calendar Month or only a few days within a Calendar Month, UnitedHealthcare's Community Plan contracted rental rates will be allowed once per Calendar Month to the same vendor. For example, E0202 (Phototherapy (bilirubin) light with photometer) is reported with modifier KR and 7 units to indicate the number of days it was used in a Calendar Month. Regardless of the number of days it is used within that Calendar Month, UnitedHealthcare Community Plan pays a single monthly rate to the same vendor and does not prorate the services to allow a daily rate. This is consistent with the terms of our participating agreements. The exceptions to the above are the items listed in the section titled Daily Rental.
4 Q: How should a vendor report a device that has been provided for extension and flexion on both sides of the body, e.g., code E1800 (Dynamic adjustable elbow extension/flexion device, includes soft interface material) ?
A: Because two devices were used on both sides of the body, it is appropriate to report this as E1800-RR-RT with two units for the right side, and E1800-RR-LT with two units for the left side.
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