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Durable Medical Equipment

Policy ID: NDRP_GC_023
Section: Durable Medical Equipment
Effective Date: February 01, 2020
Last Reviewed: February 06, 2020

Description:

This policy addresses reimbursement for Durable Medical Equipment.

 

Definitions:

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.

Policy:

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.

Billing Instructions:

Several key components are necessary when coding and billing DME.

HCPCS Code Descriptions:

 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.

Modifiers:

Commonly used modifiers for billing DME (not an all-inclusive modifier list):

  • NR – New when rented
  • NU – New equipment
  • RR – Rental
  • GA – Waiver of Liability on file
  • RA – Replacement of DME, orthotic, or prosthetic item
  • RB – Replacement part, DME, orthotic, or prosthetic item

 

Repairs, Maintenance and Replacement:

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.

 

Limitations and Exclusions:

While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

Cross Reference:

ND BCBS Reimbursement Policies

                Correct Coding Guidelines

                Services Not Separately Reimbursed

History:

Date Updates
1/24/2020 Created Durable Medical Equipment reimbursement policy