This policy addresses reimbursement for Durable Medical Equipment (DME) for Professional Providers.
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.
Blue Cross Blue Shield of North Dakota (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.
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.
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.
Take Home DME
BCBSND follows the same billing guidelines as the Centers for Medicare & Medicaid Services (CMS) for billing take home DME. When take home DME is needed after an inpatient stay, a supplier may deliver the item to a patient in a hospital or nursing facility for the purpose of fitting or training the patient on use of the item. This may be done up to 2 days prior to the anticipated discharge date. The supplier should bill the claim on the CMS-1500 Claim Form with the date of service as the date of discharge and use place of service (POS) 12 (patient’s home). The item must be for subsequent use in the patient’s home.
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.
ND BCBS Reimbursement Policies
Correct Coding Guidelines
ND BCBS Medical Policies
BCBSND Medical Policies
Created Durable Medical Equipment reimbursement policy
Added language that this policy applies to professional providers. Removed links to individual medical policies and instead made a link to the medical policy search page on BCBSND.com. There are many medical policies related to durable medical equipment.
Added a section for how to bill for take home DME.