When we could purchase new equipment in DME billing

PURCHASE

1. Purchase New Equipment Option:

a. Certain products are identified by Nevada Medicaid in the DMEPOS Fee Schedule with a purchase option for new equipment, or can only be purchased, such as disposable supplies and custom-made items which can only be used by that recipient. These will be considered for purchase when, in addition to all other requirements and qualifications for a specific item/device:

1. the anticipated length of need (per physician’s order) is long term (more than six months); and 2. the provider will be supplying a new device/item to the recipient; or 3. the item is only available for purchase.

2. Purchase Used Equipment Option:

a. Certain products are identified by Nevada Medicaid with a purchase option for used equipment. When an item was new at the time it was dispensed to a recipient for rental purposes, and prior to billing the third month of rental, it is determined the item will be needed indefinitely, the DHCFP may purchase the item for the recipient for ongoing use. The DHCFP does not purchase used equipment from the provider’s inventory of rental items used for re-issuance to same or multiple persons over time (rental fleets, etc.).

b. The DHCFP will only purchase used equipment when, in addition to all other requirements and qualifications for the item:

1. the recipient meets the criteria for purchase of new equipment;

2. the item was new when placed in the recipient’s use and has been used for less than three months; and

3. the item is currently being used by the same recipient during a trial period and it has been determined the length of need will now be
indefinite.

c. A prior authorization must be submitted to request purchase of a used item, with all supportive medical documentation to show the date the item was initially issued to the recipient and that the recipient continues to have an ongoing need for the item.


Rental and Purchase Modifiers

Some DME items are eligible for rental as well as for purchase. The codes representing these items are listed in Items

Eligible for Rental or Purchase in the Attachments section below and must be reported with the appropriate rental or purchase modifier in order to be considered for reimbursement.

Some DME items are eligible for rental only. The codes representing these items are listed in Items Eligible for Rental Only in the Attachments section below and must be reported with the appropriate rental modifier in order to be considered for reimbursement.

Rental fees fr om a single vendor are payable up to either the purchase price of an item or a maximum number of rental months, whichever is less. These rental limits do not apply to oxygen equipment or to ventilators. Rental guidelines are explained further in the sections titled Monthly Rental and Daily Rental.


Rental Modifiers

The following modifiers indicate that an item has been rented:

 RR - Rental

 KH - Initial Claim, purchase or first month rental

 KI - Second or third monthly rental

 KJ - Capped rental months four to fourteen

 KR - Partial month

Purchase Modifiers

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



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 appended will be reimbursed once per Calendar month to the Same Specialty Physician, Hospital, Ambulatory Surgical Center 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 with units greater than 1, or multiple times during the same Calendar Month, Oxford will only reimburse one monthly rate per Calendar Month to the Same Specialty Physician Hospital, Ambulatory Surgical Center 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. Use of these modifiers may convey that multiples of that item are being utilized.