Subject: Durable Medical Equipment NY Policy: 0022 Effective: 10/01/2017 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and policy criteria listed below. This reimbursement policy also applies to Employer Group Retiree Medicare Advantage programs. 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. BP: The beneficiary has been informed of the purchase and rental options and has elected to rent the item BR: The beneficiary has been informed of the purchase and rental options and has elected to rent the item EX: Expatriate beneficiary (for Medicare beneficiaries--used when certain durable medical equipment, orthotics, prosthetics, and supplies (DMEPOS) are eligible for reimbursement for those Medicare beneficiaries with permanent addresses outside of the United States for whom items were furnished while the beneficiary was in the United States) KC: Replacement of special power wheelchair interface KI: DMEPOS item, 2nd or 3rd month rental KR: Rental item, billing for partial month LL: Lease/Rental (Used when DME equipment rental is to be applied against the purchase price) NY0022 Durable Medical Equipment Page 1 of 6
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 RA: Replacement of a DME, orthotic or prosthetic item RB: Replacement of a part of a DME, orthotic or prosthetic item furnished as part of a repair 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: 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 guideline 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. NY0022 Durable Medical Equipment Page 2 of 6
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 rental limit, whichever comes first ** **An exception to this policy is when a member was previously covered under another health insurance policy (either with another carrier or with another Anthem, Inc. affiliated health plan) and the previous policy allowed a portion of the MAA for the purchase price or a portion of the 10 rental months, whichever comes first. In this instance, when the DME item is procured from the same provider the Health Plan will apply the previous policy s allowed amount or rental months and consider the remainder of rental up to the Health Plan s current MAA for the purchase price or the remainder of the 10 month rental limit, whichever comes first. For example, when the previous policy allowed 4 months rental on a P/RTP DME item, the Health Plan will consider up to the current MAA for the DME purchase price or the remaining 6 months DME rental, whichever comes first, when the DME item is procured from the same provider. b. Once the item has reached the allowed amount for the purchase price or the 10 month rental limit, no further reimbursement is allowed. This 10 month rental limit applies even when there is a consecutive 3 month break in rental; when rental resumes with the same DME provider, the 10 month rental limit count will continue with the resumption month. ** ** Exceptions to this rule: When the rental of a DME item is discontinued from one DME provider and rental is obtained from a different DME provider, the 10 month RTP reimbursement limit count will start again for the new provider When there is a consecutive 3 month break in rental and rental is resumed with adifferent DME provider, the 10 month RTP reimbursement limit count will start again for the new provider with the resumption month c. When 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. If the Health Plan s allowance for a DME item changes during the rental period, the rental allowance will be calculated based on the new allowance and will be applicable to the dates of service subsequent to the new allowance, and not the allowance in effect before the change. e. During the rental period, maintenance, loaner equipment, and/or repairs are not eligible for separate reimbursement as they are included in the rental allowance. Certain RTP DME items are not routinely purchased up-front and must be reported as rental items with an appropriate DME rental modifier. Reimbursement will be calculated up to the Health Plan s [maximum allowance] for the purchase price or the 10 month rental limit, whichever comes first. When these rent to purchase items are reported with a DME purchase modifier, these items will not be eligible for reimbursement. Some examples of items in this category include: 1. Pneumatic compressors (lymphedema pumps) 2. Portable nebulizers 3. Transcutaneous electric stimulators 4. Nebulizer with compressor or heater, suction pumps NY0022 Durable Medical Equipment Page 3 of 6
5. Wheelchairs, bedside patient lifts, and trapeze bars 6. Positive airway pressure devices and corresponding humidifiers 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. A rental modifier such as BR, KI, KR, LL, or RR is to be appended to the DME code when the DME item is a continuous rental. The Health Plan allows rental of two units per month for DME that requires a back-up unit. These include items such as E0465 (home ventilator, any type, used with invasive interface) and E0466 (home ventilator, any type, used with noninvasive interface). 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. A rental modifier such as BR, KI, KR, LL, or RR is to be appended to the DME code when the DME item is a continuous rental. The Health Plan allows rental of two units per month for DME that requires a back-up unit. These include items such as E0465 (home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube)) and E0466 (home ventilator, any type, used with noninvasive interface, (e.g., mask, chest shell)). V. Reporting DME Rental and Purchase: To designate that a DME item is being rented, modifier BR, KI, KR, LL, or RR must be appended to the applicable HCPCS code. For a purchased DME item, modifier BP, 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 (24), emergency room (23), hospital inpatient (21), or off campus-outpatient hospital (19) or on campus-outpatient hospital (22). c. The Health Plan does not reimburse for standard DME rental or purchase when reported with place of service skilled nursing facility (31) **Exceptions for skilled nursing facility: Hospital beds E0194, E0301, E0302, E0303, and E0304 Wound care items A6550, A7000, and daily rental of E2402 NY0022 Durable Medical Equipment Page 4 of 6
d. The Health Plan does not reimburse for DME rental when reported with place of service office (11) or urgent care facility (20) e. The Health Plan will reimburse one monthly DME rental except for Daily Rentals and for Continuous Rental DME that requires a back-up unit. 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, modifier RA, or RB must be appended to the HCPCS code for the repair item, and HCPCS code K0739 or K0740 is reported for the labor component of a technician. 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. 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 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 NY0022 Durable Medical Equipment Page 5 of 6
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. Use of Reimbursement Policy: State and federal law, as well as contract language, including definitions and specific inclusions/exclusions, take precedence over Reimbursement Policy and must be considered first in determining eligibility for coverage. The member s contract benefits in effect on the date that services are rendered must be used. Reimbursement Policy is constantly evolving and we reserve the right to review and update these policies periodically. 2017 Empire BlueCross BlueShield 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 Empire BlueCross BlueShield. NY0022 Durable Medical Equipment Page 6 of 6