This policy addresses reimbursement for Durable Medical Equipment.
Durable Medical Equipment (DME) is defined as items that can withstand repeated use and are primarily used to serve a medical purpose outside of a health care facility. Such items would not be of use to a person in the absence of illness, injury or disease.
BCBSND reimburses DME on a rental or purchase basis. The total payments for a rental item may not exceed its allowable purchase price, except for those items identified as life sustaining DME.
In most cases, standard equipment should be provided to members. However, rental or purchase of upgraded equipment or supplies may be allowed. The claim submitted must indicate the member’s choice of upgraded equipment. Benefits are based on the fee schedule allowance for the standard model. The member may be billed for the balance of the upgraded item and financial responsibilities should be discussed prior to receiving the equipment. The member cannot be billed for the additional amount until after the claim is filed and the provider has received the payment summary indicating the amount to be collected from the member.
Sales tax on equipment should not be billed as a separate charge. The sales tax amount should be included in the amount billed for the item. Set up fees, shipping and handling, delivery, and education of proper upkeep and use of the equipment are included in the fee schedule allowed amount for the item billed.
Several key components are necessary when coding and billing DME.
Assign the correct code according to the code description in the most current Healthcare Common Procedure Coding System (HCPCS) book. Many codes have quantities included in the description such as “per tablet,” “per strip,” or “per yard.”
Non-specific codes may include in their description terms such as Not Otherwise Classified, Unlisted, Miscellaneous, Not Otherwise Specified, Unspecified or Unclassified. A detailed invoice is required when billing non-specific codes for DME supplies.
Commonly used modifiers for billing DME (not an all-inclusive modifier list):
Repairs to member-owned equipment are reimbursable when necessary to make the equipment serviceable. Reimbursement is limited to the replacement allowance on the current fee schedule. Any amount over the replacement allowance is provider liable.
While reimbursement is considered, payment determination is subject to, but not limited to:
In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.
|1/24/2020||Created Durable Medical Equipment reimbursement policy|