what is DMEPOS program - Guidelines

DURABLE MEDICAL EQUIPMENT, PROSTHETIC DEVICES, ORTHOTIC DEVICES, DISPOSABLE MEDICAL SUPPLIES (DMEPOS) PROGRAM 

A. GENERAL INFORMATION

1. DMEPOS Program coverage areas include parenteral and enteral nutrition (PEN), medical foods and oxygen and oxygen equipment; all of which must meet the
definition of durable medical equipment, a prosthetic device, an orthotic device, or disposable medical supply.

2. Durable Medical Equipment (DME) of a medical nature, needed as a result of a medical condition, and which lasts a considerable time without significant deterioration and appropriate for use within the home, is covered by the Division of Health Care Financing and Policy (DHCFP) and Nevada Check Up (NCU) for eligible recipients. Equipment repairs, or replacement requires medical documentation and is subject to limitations of model, cost and frequency, which
are deemed reasonable by the program.

3. Disposable medical supplies are covered by the DHCFP and NCU for eligible recipients only if they are necessary for the treatment of a medical condition and
would not generally be useful to a person in the absence of an illness, disability or injury.

4. All DMEPOS 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 medical needs.

5. Deluxe equipment will not be authorized when it is determined a standard model will meet the basic medical needs of the recipient. The recipient must have a
medical need for each component of the item(s) requested. This includes accessory items and features not included in the standard models of the product.

6. Equipment which the program determines is principally for education or rehabilitation will not be approved.

7. Refer to Appendix A of this Chapter for non-covered services, and for special coverage considerations that are based on medical necessity outside of the
DMEPOS Program or that is considered under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Healthy Kids Program.

8. Refer to Appendix B of this Chapter, for Coverage and Limitation Policies regarding specific coverage information, qualifications, documentation requirements, and miscellaneous information.

9. Refer to the Provider Type 33 DMEPOS Fee Schedule for specific item coverage under the DMEPOS program. Access http://dhcfp.nv.gov/Ratesunit.htm.

10. The DHCFP does not reimburse for items that are the same or similar to items that the recipient has already acquired, such as but not limited to back-up equipment,
unless allowed in the specific policy for that item. Duplicate items intended to be used within the same span of time are not considered medically necessary.

11. Individuals deemed eligible for Nevada Medicaid or NCU and who have ownership of existing equipment from any prior resource must continue using that
equipment. Existing equipment, regardless of who purchased it, must be identified, including the estimated date of purchase or age of equipment, and medical
documentation showing evidence of need for replacement. All documentation must be submitted with a prior authorization request.

12. Some items not covered under the DMEPOS Program may be covered under other Medicaid programs such as Pharmacy, Audiology, or Ocular programs. Additional
resources may be available through other agencies or through waiver programs for items not covered under the DMEPOS Program or by the Medicaid State Plan.

Power Mobility Devices, Power Operated Vehicle, power wheelchair billing in DME

Power Mobility Devices (PMD)

Prescribing physician/practitioners may bill an additional fee using HCPCS code G0372 on the claim for the office visit (CPT 99211) during which the Medicare required face-to-face examination/evaluation was completed.

Power Operated Vehicle (POV), Basic Equipment Package

Upon initial issue, a POV must include all items below; separate billing/payment is not acceptable.
• Battery or batteries required for operation
• Battery charger, single mode
• Weight appropriate upholstery and seating system
• Tiller steering
• Non-expandable controller with proportional response to input
• Complete set of tires
• All accessories needed for safe operation

Power Mobility Devices (PMD)

Prescribing physician/practitioners may bill an additional fee using HCPCS code G0372 on
the claim for the office visit (CPT 99211) during which the Medicare required face-to-face
examination/evaluation was completed.

Power Operated Vehicle (POV),Basic Equipment Package

Upon initial issue, a POV must include all
items below; separate billing/payment is not
acceptable.
• Battery or batteries required for operation
• Battery charger, single mode
• Weight appropriate upholstery and seating
system
• Tiller steering
• Non-expandable controller with
proportional response to input
• Complete set of tires
• All accessories needed for safe operation

Power Wheelchair, Basic Equipment Package

Upon initial issue, a power wheelchair must include all items below unless otherwise noted;
separate billing/payment is not acceptable.

Inclusion of a code below does not indicate coverage. See the DMEPOS Fee Schedule for
coverage and limitations.

• Lap belt or safety belt (E0978)

• Battery charger, single mode (E2366)
• Complete set of tires and casters any type
(K0090, K0091, K0092, K0093, K0094,
K0095, K0096, K0097, K0099)
• Legrests. Separate billing is not allowed
when swingaway, detachable, nonelevating
legrests with/without calf pad
(K0051, K0052, E0995) are provided.
Elevating leg rests may be billed
separately.

• Fixed/swing-away detachable footrests
with/without angle adjustment
footplate/platform (K0037, K0040,
K0041, K0042, K0043, K0044, K0045,
K0052)
• Armrests. Separate billing is not allowed
when fixed/swingaway, detachable, nonadjustable
armrests with arm pad (K0015,
K0019, K0020) are provided. Adjustable
height armrests may be billed separately.
• Upholstery for seat and back of proper
strength and type for recipient weight
capacity of the power wheelchair (E0981,
E0982)

• Weight specific components per recipient
weight capacity

• Controller and Input Device. Separate
billing is not allowed when a nonexpandable
controller and proportional
input device (integrated or remote) is
provided. If a code specifies an
expandable controller as an option (but not
a requirement) at the time of initial issue,
it may be billed separately.

Billing Intravenous Therapy Supplies & Orthotic and Prosthetic Devices in DME setup

Intravenous Therapy Supplies

Intravenous therapy supplies including all HCPCS “S” codes listed on the DMEPOS Fee Schedule are billed through the DME program (provider type 33), not provider type 37

Medications added to TPN Solution immediately prior to administration are billed through Point of Sale (POS) using provider type 37. See the Provider Type 37 Billing Guidelines and MSM Chapter 1200 for coverage and limitations.

Orthotic and Prosthetic Devices
With the exception of “repair” codes, DME providers (provider type 33) are not required to request prior authorization for “L codes” with a reimbursement rate of less than $250.00. This does not negate the provider or supplier’s responsibility to practice within their scope and to follow DHCFP policy in MSM Chapter 1300.

DME - Incontinent Products BILLING - T4521, T4528, T4533, T4534, T4543

Incontinent Products


Providers must use the appropriate HCPCS code for the size of the recipient.

• Codes T4521 – T4528 small, medium, large, or extra large adult-sized products;

• Codes T4529 – T4532 small/medium, or large pediatric-sized products;

• Codes T4533 and T4534 youth-sized products;

• Code T4543 is only to be used for bariatric-sized adult recipients with waist
size 60” to 90”.

Refer to a HCPCS book for exact sizing (small, med, large, etc.) for each code. If an alternate
size product is medically necessary for a recipient, supportive medical documentation must be obtained and maintained by the provider for audit purposes. Example: a child who needs
an adult-sized diaper.

The use of codes A4520, A4335, and T4535 for incontinent products should only be used
when there is not a more appropriate T code. For underpads, use code T4542 for small-sized
underpads and T4521 for large-sized underpads; or code A4554 for any size underpad.
Medicaid does not pay for products used for menses.

Billing Enteral / Gastrostomy & Gloves, nos sterile - CPT A4927, B4149 - B4162

Enteral / Gastrostomy

The Enteral Feeding Supply Kit, Pump fed (code B4035) is limited to 31 units per month (1 unit equals 1 day). The Enteral Feeding Supply Kit, Gravity fed (code B4036) is limited to 30 units per month.

To bill a partial month for an Enteral Feeding Supply Kit, enter the first date of the billing cycle in the “from” date (Field 24A). Enter the same date for the “To” date (Field 24A also). Enter one unit for each day Field 24G. For example, to bill for March 12–31, enter a “From” date of March 12, a “To” date of March 12, and a “20” in Field 24G.

The following scenario shows how to bill continued services (rolling months) for code B4035 (a 31-day billing frequency). The same instructions would apply to code B4036, except a 30-day billing frequency would be used.


a) You begin your billing cycle on February 3. February has 28 days in it, and 31 days from February 3 is March 5. Therefore, March 5 will be the last day of your billing cycle. On the claim form, enter “February 3” (the first day of the billing cycle) as the From date and as the To date (Field 24A). Enter “31” in Field 24G.

b) The next 31-day billing cycle would start on March 6. March has 31 days in it, and 31 days from March 6 is April 5. Therefore, April 5 will be the last day of your billing cycle. On the claim form, enter “March 6” as the From date and as the To date (Field 24A). Enter “31” in Field 24G.

c) The next 31-day billing cycle would start on April 6. April has 30 days in it, and 31 days from April 6 is May 6. Therefore, May 6 will be the last day of your billing cycle. On the claim form, enter “April 6” as the From date and as the To date (Field 24A). Enter “31” in Field 24G.

Enteral Nutrition/Formula does not require prior authorization when the recipient has a feeding tube through which enteral feeding is administered.

If the recipient’s diagnosis is gastrostomy or other artificial opening of gastrointestinal tract, such as jejunostomy or attention to one of these sites (ICD-9 code V44.1, V44.4 V55.1 or V55.4), prior authorization is not required. Enter the appropriate ICD-9 code in Field 21 on the CMS-1500 claim form.

Leave blank Field 23. This bypass of the prior authorization requirement does not pertain to recipients in an institutional setting (e.g., acute care, NF or ICF/MR).

Refer to MSM Chapter 1300 for covered and non-covered services.

Bill enteral formulas monthly as prior authorized. On the claim form, enter the begin date of the billing cycle in both the “From” and “To” date fields (Field 24A). If the recipient has Medicare coverage and you billed Medicare more than one month on a claim line, bill Medicaid the same way. In all other instances (e.g., private insurance), you may need to bill Medicaid differently than the
primary insurance.

For the following Enteral Formula codes, 100 calories equals 1 unit. Enter the units in Field 24G on the CMS-1500 claim form.

• B4149 • B4157
• B4150 • B4158
• B4152 • B4159
• B4153 • B4160
• B4154 • B4161
• B4155 • B4162

For Feeding Tubes, use code B4087 to bill for standard gastrostomy/jejunostomy tubes and code B4088 without a modifier to bill for a low-profile gastrostomy/jejunostomy feeding tube. For the Low Profile Gastrostomy Feeding Tube, MIC-KEY® Button only, use B4088 with modifier BA. Use  B9998 to bill for Extension Sets. Prior authorization is required to exceed 1 unit every 3 months

Percutaneous Catheter/Tube Anchoring Devices (code A5200) and dressing holders (A4461 or A4463) used in conjunction with a gastrostomy or enterostomy tube are included in supply kit codes B4034-B4036 and may not be billed separately.

Gloves, Non-sterile, per 100 (Code A4927) One box contains 100 gloves. Therefore, one box of 100 gloves equals one unit for billing.

Billing BIPAP, CPAP & Diabetic supply DME billing - A4223,A4230, K0552

BIPAP Devices

Use OPAS or submit form FH-1A to request continued services for BIPAP devices no sooner than 61 days and no later than 120 days after initiation of therapy. Form FH-1A or an attached physician’s note must contain a signed and dated statement declaring that the
recipient is:

• Compliantly using the device an average of 4 hours per 24 hour period; and
• Benefiting from its use

CPAP Devices

Use OPAS or submit form FH-1A to request continued services for CPAP devices no sooner than 61 days and no later than 120 days after initiation of therapy. The request must include all of the following:

• The number of hours a day the machine is used;
• The number of months the recipient has used the machine;
• Whether the recipient will continue to use the machine; and
• The name of the person who answered these questions (it can not be the DME
supplier).

Diabetic Supplies
Diabetic supplies are billed through the pharmacy program (provider type 28), not DME provider type 33.

The exceptions to this are as follows: insulin pumps (E0784) and insulin pump-related supplies (A4223, A4230, A4231 and K0552) or diabetic shoes/fittings/modifications (A5500 – A5513) which need to be billed through DME.

DME claims submission guideline and tips

Claims/Billing

• Provider must submit claims in accordance with the Healthcare Common Procedure Coding System (HCPCS) and national industry standards.

• Providers can only bill for the actual number of medically necessary units dispensed/delivered to a recipient, regardless of the number of units allowed by policy and/or prior authorization.

• Providers must bill their usual and customary charges.

Rental Items
Rates identified in the DMEPOS Fee Schedule for rental items (modifier code RR) are calculated as a monthly rate and are to be billed at monthly intervals beginning with the date item was dispensed/delivered to recipient. The exceptions to this are for codes E0202 and E0935, which are daily rates.

Special Instructions for Common Products and Services

For all DME items, refer to Nevada Medicaid DME policy in MSM Chapter 1300. Claims
must include the appropriate physician’s diagnosis code in accordance with policy.

Bundled Services

For any HCPCS code description in which various components are identified, the components may not be billed separately. The Nevada Medicaid rate includes all items in the description.

DME services required pre - authorization

Prior Authorization

Some DMEPOS services/items require prior authorization. Requests maybe submitted through the Online Prior Authorization System (OPAS) or by fax using form FH-1 (use form FH-1A for continuing usage of BIPAP and CPAP devices).

It is critical to submit complete and accurate clinical documentation on prior authorization requests. Documentation must include the prescription and fully support medical necessity of the item. When submitting supporting medical documentation online, the name and credentials of the provider who supplied the information are required. Failure to provide this information may result in a denied request and/or may delay the determination.

MSM Chapter 1300, including Appendix B lists specific prior authorization and documentation
requirements. If you have any questions, please contact the Prior Authorization Department at (800)
525-2395.

All items dispensed to recipients in an institutional setting (e.g., Nursing Facility (NF) or Intermediate Care Facility for the Mentally Retarded (ICF/MR)), require prior authorization for exception to inclusive facility rates.

Medicaid DMEPOS Fee Schedule

DMEPOS Fee Schedule 

The Provider Type 33 DMEPOS Fee Schedule is online at
http://dhcfp.nv.gov/Rates/PT/PT%2033%20DME%20Fee%20Sched%2005-06-09%20ds.pdf


 Services/Products are listed according to their Healthcare Common Procedure Coding System (HCPCS), Level II alpha/numeric code.

The DMEPOS fee schedule provides coverage information and more.

• Non-covered codes show “999” in the “Flag Code” column; all other listed codes are covered.
• Service limits (if applicable) are shown in the “Limits” column.
• Prior authorization requirements are shown in the “PA Type” column on the fee schedule. In the “PA Type” column:
• “00” means that PA is not required.
• “01” means that PA is always required.
• “02” means that PA is required to exceed the
service limitations.

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.