Notification



Notification Issue Date:



Policy Attachment


Attachment to Policy # 05.00.21t


Attachment:B

Policy #:05.00.21t

Description:Items that Do Not Meet the Definition of Durable Medical Equipment (DME)

Title:Durable Medical Equipment (DME) and Consumable Medical Supplies


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.



ITEMS THAT DO NOT MEET THE COMPANY'S DEFINITION OF DURABLE MEDICAL EQUIPMENT (DME)

Examples of items that do not meet the Company's definition of durable medical equipment (DME) and are, therefore, not covered are listed in the following tables.

TABLE I
COMFORT AND CONVENIENCE ITEMS
HCPCS CODES
NARRATIVE DESCRIPTION
A9280
Alert or alarm device, not otherwise classified
E0265
Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, with mattress
E0266
Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, without mattress
E0296
Hospital bed, total electric (head, foot, and height adjustments), without side rails, with mattress
E0297
Hospital bed, total electric (head, foot, and height adjustments), without side rails, without mattress
E0625
Patient lift, bathroom or toilet, not otherwise classified
E1300
Whirlpool, portable (overtub type)
N/A
American sonoid and massage foam cushion pad
N/A
Bed wetting alarms
N/A
Carafe
N/A
Emesis basin
N/A
Lounge bed, (power or manual, not classified as a hospital bed)
N/A
Massage devices
N/A
Ramps
N/A
Sauna baths
N/A
Telephone arm


TABLE ll
EQUIPMENT USED FOR ENVIRONMENTAL CONTROL
HCPCS CODES
NARRATIVE DESCRIPTION
N/A
Air cleaners
N/A
Air conditioners
N/A
Dehumidifiers
N/A
Heating and cooling plants
N/A
Portable room heaters


TABLE III
EQUIPMENT INAPPROPRIATE FOR HOME USE
HCPCS CODES
NARRATIVE DESCRIPTION
E0270
Hospital bed, institutional type includes: oscillating, circulating and stryker frame, with mattress
E0481
Intrapulmonary percussive ventilation system and related accessories
E0746
Electromyography (EMG), biofeedback device
E0761
Non-thermal pulsed high frequency radiowaves, high peak power electromagnetic energy treatment device
E0769
Electrical stimulation or electromagnetic wound treatment device, not otherwise classified
S8130
Interferential current stimulator, 2 channel
S8131
Interferential current stimulator, 4 channel
N/A
Data transmission used for devices for telemedicine purposes
N/A
Diathermy machines
N/A
Medcolator
N/A
Pulse tachometer
N/A
Traction units (Designed for facility use)


TABLE IV
CONSUMABLE MEDICAL SUPPLIES
HCPCS CODES
NARRATIVE DESCRIPTION
A4244
Alcohol or peroxide, per pint
A4246
Betadine or pHisoHex solution, per pint
A4247
Betadine or iodine swabs/wipes, per box
A4248
Chlorhexidine containing antiseptic, 1 ml
A4360
Disposable external urethral clamp or compression device, with pad and/or pouch, each
A4520
Incontinence garment, any type, (e.g., brief, diaper), each
A4553
Non-disposable underpads, all sizes
A4554
Disposable underpads, all sizes
A4674
Chemicals/antiseptics solution used to clean/sterilize dialysis equipment, per 8 oz
A4927
Gloves, nonsterile, per 100
A4928
Surgical Mask, per 20
A4930
Gloves, sterile, per pair
A4931
Oral thermometer, reusable, any type, each
A6000
Noncontact wound-warming wound cover for use with the noncontact wound-warming device and warming card
A6250
Skin sealants, protectants, moisturizers, ointments, any type, any size
E0188
Synthetic sheepskin pad
E0189
Lambswool sheepskin pad, any size
T4521
Adult sized disposable incontinence product, brief/diaper, small, each
T4522
Adult sized disposable incontinence product, brief/diaper, medium, each
T4523
Adult sized disposable incontinence product, brief/diaper, large, each
T4524
Adult sized disposable incontinence product, brief/diaper, extra large, each
T4525
Adult sized disposable incontinence product, protective underwear/pull-on, small size, each
T4526
Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each
T4527
Adult sized disposable incontinence product, protective underwear/pull-on, large size, each
T4528
Adult sized disposable incontinence product, protective underwear/pull-on, extra large size, each
T4529
Pediatric sized disposable incontinence product, brief/diaper, small/medium size, each
T4530
Pediatric sized disposable incontinence product, brief/diaper, large size, each
T4531
Pediatric sized disposable incontinence product, protective underwear/pull-on, small/medium size, each
T4532
Pediatric sized disposable incontinence product, protective underwear/pull-on, large size, each
T4533
Youth sized disposable incontinence product, brief/diaper, each
T4534
Youth sized disposable incontinence product, protective underwear/pull-on, each
T4535
Disposable liner/shield/guard/pad/undergarment, for incontinence, each
T4536
Disposable liner/shield/guard/pad/undergarment, for incontinence, each
T4537
Incontinence product, protective underpad, reusable, bed size, each
T4538
Diaper service, reusable diaper, each diaper
T4539
Incontinence product, diaper/brief, reusable, any size, each
T4540
Incontinence product, protective underpad, reusable, chair size, each
T4541
Incontinence product, disposable underpad, large, each
T4542
Incontinence product, disposable underpad, small size, each
T4543
Adult sized disposable incontinence product, protective brief/diaper, above extra large, each
T4544
Adult sized disposable incontinence product, protective underwear/pull-on, above extra large, each
T4545
Incontinence product, disposable, penile wrap, each
N/A
Disposable sheets and bags
N/A
Catheters (non-urinary)
(see code A4554)
Incontinence Pads
N/A
Irrigating kits


TABLE V
EQUIPMENT THAT IS NOT PRIMARILY MEDICAL IN NATURE
HCPCS
CODES
NARRATIVE DESCRIPTION
A9300
Exercise equipment
A9273
Cold or hot fluid bottle, ice cap or collar, heat and/or cold wrap, any type
E0240
Bath/shower chair, with or without wheels, any size
E0241
Bathtub wall rail, each
E0242
Bathtub rail, floor base
E0243
Toilet rail, each
E0244
Raised toilet seats
E0245
Tub stool or bench
E0246
Transfer tub rail attachment
E0247
Transfer bench for tub or toilet with or without commode opening
E0248
Transfer bench, heavy duty, for tub or toilet with or without commode opening
E0273
Bedboard
E0274
Over-bed table
E0315
Bed accessory: board, table, or support device, any type
E0316
Safety enclosure frame/canopy for use with hospital bed, any type
N/A
American bidet toilet seat
N/A
Bathtub lifts
N/A
Car seats
N/A
Car beds
N/A
Carrying cases or mounting hardware for the AED
N/A
Ear plugs
N/A
Electronically controlled heating and cooling units for pain relief
N/A
Elevators
N/A
Feeding chairs
N/A
Silverware/utensils
N/A
Speech teaching machines
N/A
Stairglides
N/A
Standing table
N/A
Strollers
N/A
Toilet seats
N/A
Toileting systems
E1902
Communication board, non-electronic augmentative or alternative communication device
E2230
Manual wheelchair accessory, manual standing system
E2300
Wheelchair accessory, power seat elevation system, any type
E2301
Wheelchair accessory, power standing system, any type
K0108*

Wheelchair transit brackets

*K0108 Wheelchair component or accessory, not otherwise specifiedis an unspecified code
that could be used to report other miscellaneous wheelchair accessories
K0830
Power wheelchair, group 2 standard, seat elevator, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0831
Power wheelchair, group 2 standard, seat elevator, captains chair, patient weight capacity up to and including 300 pounds


TABLE VI
EQUIPMENT WITH FEATURES OF A MEDICAL NATURE
THAT ARE NOT REQUIRED FOR AN INDIVIDUAL'S CONDITION
HCPCS CODES
NARRATIVE DESCRIPTION
E0217
Water circulating heat pad with pump
E0218
Fluid circulating cold pad with pump, any type
E0236
Pump for water circulating pad
E0249
Pad for water circulating heat unit, for replacement
only
E0575
Nebulizer, ultrasonic, large volume
E0635
Patient lift, electric, with seat or sling
E0636
Multi-positional patient support system, with integrated lift, patient accessible controls
    E0637
Combination sit to stand frame/table system, any size including pediatric, with seatlift feature, with or without wheels.
E0639
Patient lift, moveable from room to room with
disassembly and reassembly, includes all
components/accessories
E0640
Patient lift, fixed system, includes all components/accessories
E1035
Multi-positional patient transfer system, with integrated seat, operated by care giver, patient weight capacity up to and including 300 lbs
E1036
Multi-positional patient transfer system, extra-wide, with integrated seat, operated by caregiver, patient weight capacity greater than 300 lbs
N/A
Vitrectomy frame/ table/chair
E8000
Gait trainer pediatric size, posterior support, includes all accessories and components
E8001
Gait trainer, pediatric size, upright support, includes all accessories and components
E8002
Gait trainer, pediatric size, anterior support, includes all accessories and components


TABLE Vll
DUPLICATE EQUIPMENT FOR USE WHEN TRAVELING OR FOR AN ADDITIONAL RESIDENCE, WHETHER OR NOT PRESCRIBED BY A PROFESSIONAL PROVIDER
HCPCS CODES
NARRATIVE DESCRIPTION
N/A
N/A


TABLE VIII
SERVICES NOT PRIMARILY BILLED FOR BY A PROVIDER
HCPCS
CODES
NARRATIVE DESCRIPTION
A9901
DME delivery, set up, and/or dispensing service component of another HCPCS code
N/A
Set up and installation of rented or purchased equipment
E1600
Delivery and/or installation charges for hemodialysis equipment


TABLE IX
MODIFICATIONS TO VEHICLES, DWELLINGS, AND OTHER STRUCTURES
HCPCS CODES
NARRATIVE DESCRIPTION
N/A
N/A


Version Effective Date: 01/01/2019
Version Issued Date: 01/10/2019
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.