DME Billing Guidelines and tips from BCBS

DME/HME Providers


Durable Medical Equipment/Home Medical Equipment (DME/HME) providers are expected to provide services only within the scope of their license. DME/HME is subject to review and reimbursement determination based on appropriateness, criteria, and the member’s benefits. Therefore, in addition to the physician’s order, supporting documentation may be required.

Items that do not require a physician’s written order or prescription are generally non-reimbursable. Examples of non-reimbursable items include, but are not limited to, dispensing fees, sales tax (S9999), alcohol prep wipes and over-the-counter and disposable, one-time use items.

Note: Florida Blue applies Medical Policies (Medical Coverage Guidelines) to DME medical coverage requests.

General DME/HME-

• Date ranges are acceptable as long as they do not exceed a 31-day period in any billing cycle.

• All DME HCPCS codes must be submitted with the appropriate modifier (e.g., NU, RR or UE) that represents rental or purchase.

• Use specific and inclusive codes, when available, to prevent over utilization of miscellaneous codes (such as E1399) and inappropriate “unbundling.”

• The member’s benefits, medical coverage guidelines and your applicable Agreement(s) will determine the frequency to submit claims. Example: Continuous passive motion equipment (E0935) may be reimbursed daily for 14-days.


Medical Supply Companies

Medical supplies are items for health use, other than drugs, prosthetic or orthotic appliances, and/or durable medical equipment, that have been ordered by a qualified practitioner in the treatment of a specific medical condition and are consumable, non-reusable, disposable, for a specific (not incidental) purpose and generally have no salvageable value.

Medical supplies include, but are not limited to:

• Diabetic testing supplies (strips, lancets)

• Ostomy supplies

• Oxygen supplies

• Specialty dressings

• Urinary retention supplies


Billing Requirements


• Include a specific and inclusive codes, when available, to prevent over utilization of miscellaneous codes and inappropriate “unbundling.”

• Medical supplies are not reusable and should be submitted with the NU modifier.

• Date ranges are acceptable, as long as they do not include dates of service in the future (e.g., diabetic testing supplies).

• For unlisted codes, include an itemized description with an invoice showing the MSRP for each unlisted code.


Non-Reimbursable Items

Items used in the course of professional treatment, given as take-home supplies or do not require a prescription are non-reimbursable.
Examples of non-reimbursable items include, but are not limited to:

• Dispensing fees (e.g., E0590, S9537);

• Implantable prosthetics (L8600-L8699), which are included in the facility or physician reimbursement;

• Sales tax (S9999) and

• Over-the-counter, disposable or one-time use items.


Respiratory Services

• Refer to the Medical Policies (Medical Coverage Guidelines) for specific coverage and documentation requirements,

• Oxygen equipment rentals include oxygen and are reimbursed as a monthly supply. Providers should bill each monthly supply as one unit (e.g. E0424, E0431, E0434, E0439, and E1390).

• CPAP/BiPAP must be billed with the appropriate modifier. Typical coverage of a positive airway pressure device is limited to a three month trial period that requires billing with the rental modifier (RR) for the first three months.



General DME/HME Billing for:

Purchase

Used equipment is reimbursed at 75 percent of the purchase allowance, Rental (short-term), Continuous or Perpetual Rental

Rental is only covered up to the purchase price. When the rental payments total up to the purchase allowance (usually at 10 months), a DME/HME item is considered purchased and no more payment is to be made. However, some DME/HME items are not purchased, but are rented perpetually, such as oxygen equipment and ventilators. DME/HME rental fees will cover the cost of maintenance, repairs, replacements, adjustments, supplies, and accessories. Reimbursement will begin the day the device is delivered to the member.


Hearing Aid Dealers

Depending on the terms and conditions of the member benefits, hearing aid benefits exist for BlueCare, BlueChoice, BlueMedicare PPO, BlueOptions, and Traditional members.

Routine hearing exams

• Conformity evaluations

• Hearing aids

• Hearing aid repairs

• Dispensing


Commonly billed codes include the following:

• Audiometric Tests

o 92541-92568

• Auditory Functions

o 92620-92621

• Conformity evaluations, hearings aids, hearing aid repairs, and dispensing fees

o S0618

o V5008-V5275


Hearing Aid Dealers

Depending on the terms and conditions of the member benefits, hearing aid benefits exist for BlueCare, BlueChoice, BlueMedicare PPO, BlueOptions, and Traditional members.


Routine hearing exams

• Conformity evaluations

• Hearing aids

• Hearing aid repairs

• Dispensing


Commonly billed codes include the following:

• Audiometric Tests

o 92541-92568

• Auditory Functions

o 92620-92621

• Conformity evaluations, hearings aids, hearing aid repairs, and dispensing fees

o S0618

o V5008-V5275