Subject: Durable Medical Equipment NY Policy: 0022 Effective: 12/01/2014 07/31/2015 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and policy criteria listed below. DESCRIPTION The definition of durable medical equipment (DME) is based on the member s contract definition of DME. DME may be purchased, continuously rented, or rented until the purchase allowance has been met. There are also times when a purchased DME item may need maintenance, repair, or replacement. Generally a DME item must: Be able to withstand repeated use Be appropriate for use in the home Be medically necessary for the treatment of an illness or injury Be primarily used to serve a medical condition Not be generally useful to a person in the absence of illness or injury This policy applies to providers /suppliers claims submitted on a Form CMS 1500 and applies to DME only. DME may be purchased, rented, or rented until the purchase price has been paid. Occasionally, a purchased DME item may need maintenance, repair, or replacement. This policy documents the Health Plan s reporting and reimbursement guidelines for durable medical equipment (DME). Policy The Health Plan requires that all claims submitted by a provider/supplier for purchased or rented DME, and for DME repair, maintenance, or replacement must be coded with the applicable Health Care Procedure Coding System (HCPCS Level II) code(s) and must have the applicable modifier appended. MS: Six month maintenance and servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warranty NR: New when rented (use the NR modifier when DME which was new at the time of rental is subsequently purchased) NU: New equipment RR: Rental (use the RR modifier when DME is to be rented) UE: Used durable medical equipment The Health Plan considers the following services not eligible for separate reimbursement: NY 0022 Page 1 of [6]
Sales tax Shipping and handling fees Equipment delivery services, and set-up fees Education and/or training for a member/family member. Repair and replacement fees for rented DME items The Health Plan uses the Centers for Medicare & Medicaid Services (CMS s) Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) payment classes as a general for the Health Plan s reimbursement classifications for DME items only. The type of reimbursement classifications for DME the Health Plan uses are: Purchase (new or used), Purchase and Rent to Purchase (P/RTP), Continuous Rental, and Daily Rental as descrbied below. The nature of the DME item, its cost, and its assigned payment class is considered in determining when a covered item will be eligible for reimbursement as a purchase, P/RTP, continuous rental, or daily rental. The Health Plan may apply frequency maximums per day and/or per date span to DME items (usually based on the CMS s MUEs, industry standards, and/or HCPCS description). (See also our Frequency Editing policy.) I. Purchase (new or used): a. Items assigned to this classification are eligible for reimbursement when purchased. These items generally are not reusable (such as supplies), or are available for long-term use, and/or are customized. b. Reimbursement for the purchase of an eligible DME item is at the Health Plan s allowed amount for the purchase price. To designate that a DME item was purchased, the applicable HCPCS code must be reported with the appropriate modifier. Modifier NR is to be appended when the DME was new at the time of rental and is subsequently purchased. Modifier NU is to be appended when the DME item is purchased new. Modifier UE is to be appended when the DME item is purchased used. II. Purchase and Rent to Purchase (P/RTP): Items assigned to this classification are not routinely purchased up-front. They are reusable, not service intensive, not customized, and/or may only be needed for short term use. The applicable modifier must be appended to the DME HCPCS code. a. Purchase/rent to purchase items may be rented up to the Health Plan s allowed amount for the purchase price or 10 months, whichever comes first NY 0022 Page 2 of [6]
b. Once the item has reached the allowed amount for the purchase price or the 10 month rental limit, no further reimbursement is allowed.** **An exception to this rule is when there is a consecutive 3-month break in rental or when the rental of a DME item is discontinued from one provider and then obtained from a different provider, the 10-month RTP reimbursement limit begins again with the resumption month or the new rental from the new provider. c. If an item is rented for a trial period and then purchased, the rental fee paid during the trial period is deducted from the allowed amount for the purchase price. d. During the rental period, maintenance, loaner equipment, and/or repairs are not eligible for separate reimbursement as they are included in the rental allowance. Some examples of items in this category include: Pneumatic compressors (lymphedema pumps) Portable nebulizers Transcutaneous electric stimulators Nebulizer with compressor or heater, suction pumps Continuous airway pressure (CPAP) devices Wheelchairs, bedside patient lifts, and trapeze bars III. Continuous Rental: This category includes equipment which is never purchased and the rental reimbursement is not capped at a purchase price. These items are also referred to as frequently serviced (FS) items and the Health Plan reimburses these FS items as rentals for as long as is medically necessary. Reimbursement for continuous rental items is based on the Health Plan s allowed amount for the monthly rental period. Continuous rental items include items such as oxygen related equipment, ventilators, and intermittent positive pressure breathing (IPPB) machines. Required supplies, repairs, and replacement are included in the reimbursement for the monthly rental. Modifier RR is to be appended when the DME item is a continuous rental IV. Daily Rental: Daily rental items are considered short term rentals, which are generally rented for less than a month, and includes such items as phototherapy bilirubin lights, continuous passive motion (CPM) exercise machines, or negative pressure wound therapy pumps. When reporting daily rental items, a from and through date may be listed on one claim line with the appropriate number of days listed in the units field on the claim form. Modifier RR is to be appended when the DME item is a daily rental V. Reporting DME Rental and Purchase: NY 0022 Page 3 of [6]
To designate that a DME item is being rented, modifier RR must be appended to the applicable HCPCS code. For a purchased DME item, modifier NR, NU, or UE must be appended to the applicable HCPCS code(s). a. The Health Plan recognizes there may be times when a supplier delivers a home use DME item to a patient while the patient is in a facility setting (usually within two days of discharge). Therefore, consistent with CMS guidelines, the item must be submitted to the Health Plan with the date of service equal to the date of discharge and the patient s residence as the place of service. b. The Health Plan does not reimburse for DME rental or purchase when reported with place of service ambulatory surgical center or surgical suite, emergency room, hospital inpatient, or hospital outpatient c. The Health Plan does not reimburse for standard DME rental or purchase when reported with place of service skilled nursing facility d. The Health Plan does not reimburse for DME rental when reported with place of service office e. The Health Plan does not pay more than one monthly rental payment in any 30 day period except for daily rental items (see Daily Rental section above) f. When the rental period is per month one unit is reported in the unit field, and the from and through dates are indicated in the date of service fields g. When multiple months of consecutive rental are reported on one claim, each monthly time frame must be reported on separate lines with one unit reported in the units field of the claim form. VI. Repair/Replacement/Maintenance/Servicing: The repair or replacement of a DME item may be necessary through normal wear and tear, or body growth and change. The Health Plan provides reimbursement for maintenance, repairs, and replacement of approved medically necessary DME that has been purchased. Reimbursement for repair or replacement may include DME that had been purchased prior to the contract effective date for the covered member. Repairs, replacement, or maintenance fees are not separately payable while equipment is rented. a. Repair and Replacement: To report the repair or replacement of a DME item, modifier KC (replacement of special power wheelchair interface), modifier RA (replacement of a DME) or RB (replacement of a part of a DME item furnished as part of a repair) must be appended to the HCPCS code for the repair item, and HCPCS code K0739 (repair or nonroutine service for DME other than oxygen, per 15 minutes) or K0740 (repair or nonroutine service for oxygen equipment, per 15 minutes) is reported for the labor component. NY 0022 Page 4 of [6]
Routine repair and replacement of DME and/or parts that are classified as frequently serviced DME items by the Health Plan are not eligible for reimbursement (e.g., oxygen systems, ventilators, nublizers). The Health Plan will reimburse for reasonable and necessary repairs or replacement of approved medically necessary member-owned equipment except when the cost of repairs exceeds the allowed amount for the purchase of a replacement item; or when the required repairs are due to damage, neglect, misuse or mistreatment of the equipment by the member. b. Maintenance and Servicing: Modifier MS (six month s maintenance and servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warranty) must be appended to the applicable HCPCS code to report the maintenance and servicing of the identified DME item. Maintenance and servicing that is eligible for reimbursement will be reimbursed equivalent to one month s rental allowance of the indentified DME item for a maximum of two times per year. The Health Plan will provide separate reimbursement for the maintenance and servicing of DME equipment items classified by the Health Plan as Continuous Rental (never purchased items) only when the DME item had been purchased prior to the effective date of the covered member s contract. The guidelines for reporting maintenance and servicing as outlined above will apply. When maintenance and servicing is eligible for reimbursement for oxygen concentrators and ventilators, the following services are included in that reimbursement: Routine checks to ensure equipment is operating according to manufacturers guidelines On-call services for members in need of help this includes after hours and weekends When equipment needs to be taken from the member s possession while maintenance is performed, the DME provider/supplier must provide a loaner to the member during the period of maintenance. Such loaner is not eligible for separate reimbursement. Required cannulas, extension tubing and other routine supplies (applicable to O 2 concentrators) The Health Plan does not reimburse for the cost of loaner equipment, such as HCPCS code K0462 (temporary replacement for patient-owned equipment being repaired, any type) even when reported with any modifier. Such cost is included in the reimbursement for the repair, maintenance, or servicing of the serviced DME item. CPT is a registered trade mark of the American Medical Association NY 0022 Page 5 of [6]
Use of Reimbursement Policy: This policy is subject to federal and state laws, to the extent applicable, as well as the terms, conditions, and limitations of a member s benefits. Reimbursement Policy is constantly evolving and we reserve the right to review and update these policies periodically. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan. 2014 Empire BlueCross BlueShield NY 0022 Page 6 of [6]