Notification



Notification Issue Date:



Claim Payment Policy


Title:Repair and Replacement of Durable Medical Equipment (DME)

Policy #:05.00.44k

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

Repair or replacement of durable medical equipment (DME), or of a medically necessary accessory that is needed for the essential functioning of the DME in relation to the individual's condition, are covered and eligible for reimbursement consideration by the Company as follows:

REPAIR

The repair of a DME item or accessory is covered and eligible for reimbursement consideration when all of the following are met:
  • The repair of DME is covered under the member's benefit contract.
    • Benefits for the repair of DME are provided in accordance with the member benefit contract and vary by product and group. For specific coverage criteria regarding limits and existing contractual exclusions, individual member benefits must be verified.
  • The DME item itself is covered.
  • The DME or accessory is provided by a DME supplier.
  • The cost to repair, rather than replace, the item is justified based on the useful lifetime of the item.
  • The continued use of the DME remains medically necessary.

Labor associated with the repair of DME is eligible for separate reimbursement consideration and is reported using the applicable Health Common Procedure Coding System (HCPCS) Level II code.

REPLACEMENT

The replacement of a previously approved DME item or accessory is covered and eligible for reimbursement consideration when all of the following criteria are met:
  • The replacement of DME is covered under the member's benefit contract.
    • Benefits for the replacement of DME are provided in accordance with the member benefit contract and vary by product and group. For specific coverage criteria regarding limits and existing contractual exclusions, individual member benefits must be verified.
  • The DME item itself is covered.
  • The replacement DME item or accessory is provided by a DME supplier.
  • The continued use of the DME remains medically necessary for the individual.
  • The DME replacement is not an additional item (e.g., for use when traveling or for an additional residence).
  • The replacement is equivalent to a previously approved DME item.
  • The replacement accessory is for a DME item previously owned/purchased by or for the individual and either one of the following applies:
    • There is a change in the individual's condition that requires a replacement (e.g., weight loss or gain, growth)
    • The DME does not function properly because it has reached or exceeded its life expectancy as determined by the manufacturer.
      • The Company may determine the reasonable useful lifetime of a specific item based on the manufacturer's recommendation or the Food and Drug Administration (FDA)--approved labeling. In the absence of the manufacturer's recommendations or FDA labeling, the Company may determine the reasonable useful lifetime of a specific item, but in no case can it be less than 5 years. Replacement due to wear is not covered during the reasonable useful lifetime of the equipment; however, the Company will cover repair up to the cost of replacement for medically necessary equipment owned by the individual.

Requests for technological advancements or newly released upgrades to equipment, when the original equipment still functions properly and/or there are no significant changes in the individual's condition, are considered not medically necessary and are not covered.

REPAIR AND REPLACEMENT

If a rental item breaks, it is the individual's responsibility to work with the supplier to replace or repair the item.

If a purchased item breaks and is under warranty, it is the individual's responsibility to work with the manufacturer to replace or repair the item.

If a purchased item breaks and is not under warranty, the Company will provide benefits for the repair or replacement of the item as long as the above criteria are met.

The Company does not cover repair or replacement of DME due to abuse or loss of the item. In such instances, therefore, repair and replacement of DME are not eligible for reimbursement with the following exception: DME may be replaced in cases of loss for individuals enrolled in Medicare Advantage products.

REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation:

PRESCRIPTION (ORDER) REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES
The durable medical equipment (DME) supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately seven days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately five days before the individual would exhaust their on-hand supply.

If required documentation is not available on file to support a claim at the time of an audit or record request, the durable medical equipment (DME) supplier may be required to reimburse the Company for overpayments.
Guidelines

The repair and/or replacement of DME and associated accessories should be reported using the specific code describing the repair or replacement item. Items without a specific replacement code should be reported using the standard code for the item being replaced.

This policy addresses repair and replacement of DME in general. When there is a policy addressing the repair or replacement of a specialized or specific item, the information in the specific policy supersedes this general policy.

Description

Durable medical equipment (DME) is equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, is generally not useful to a person in the absence of illness or injury, and is appropriate for use in the home. Examples of DME include, but are not limited to, wheelchairs, commodes, crutches, and hospital beds.

Repair is the restoration of a DME item or one of its components to correct problems due to wear, damage, or defect.

Replacement is the removal and substitution of a DME item or one of its components that is necessary for proper functioning.
References


Centers for Medicare & Medicaid Services (CMS). Carriers Manual. Part 3 - Claims Process. Chapter II - Coverage and Limitations. 2100.1: Definition of Durable Medical Equipment. [CMS Web site]. 09/08/05. Available at:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1725B3.pdf. Accessed August 29, 2017.

Centers for Medicare & Medicaid Services (CMS). Carriers Manual. Part 3 - Claims Process. Chapter II - Coverage and Limitations. 2100.4: Repairs, Maintenance, Replacement, and Delivery. [CMS Web site]. 09/08/05. Available at:https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1725B3.pdf. Accessed August 29, 2017.

Centers for Medicare and Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 15 - Covered Medical and Other Health Services. 110.2: Repairs, Maintenance, Replacement, and Delivery. [CMS Web site.] 12/23/05. Available at:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf. Accessed August 29, 2017.

Centers for Medicare and Medicaid Services (CMS). Transmittal #30. Change Request (CR) #3693: Policy for Repair and Replacement of Durable Medical Equipment (DME). [CMS Web site]. 02/18/05. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R30BP.pdf. Accessed August 29, 2017.

Centers for Medicare and Medicaid Services (CMS). Transmittal #3713. Change Request (CR) #9966: Extension of Payment Change for Group 3 Complex Rehabilitative Power Wheelchairs Accessories and Seat and Back Cushions under Section 16005 of the 21st Century Cures Act. [CMS Web site]. 02/03/17. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3713CP.pdf. Accessed August 29, 2017.

Company Benefit Contracts.

Provider Manual for Participating Professional Providers (Provider Manual).




Coding

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.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

See Attachment A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: Repair and Replacement of Durable Medical Equipment (DME)
Description: HCPCS Codes For Repair and Replacment DME


 Policy: 05.00.01l:Pneumatic Compression Therapy Devices

 Policy: 05.00.05k:Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes

 Policy: 05.00.08e:Continuous Passive Motion (CPM) Devices in the Home Setting

 Policy: 05.00.09h:Electrical Bone Growth Stimulation and Low-Intensity Ultrasound Accelerated Fracture Healing System

 Policy: 05.00.12g:Manual Wheelchairs

 Policy: 05.00.14j:High-Frequency Chest Wall Oscillation Devices

 Policy: 05.00.15p:Nebulizers and Inhalation Solutions

 Policy: 05.00.21t:Durable Medical Equipment (DME) and Consumable Medical Supplies

 Policy: 05.00.24q:Short-term Interstitial Continuous Glucose Monitoring Systems (CGMSs)

 Policy: 05.00.29k:Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)

 Policy: 05.00.31e:Pulse Oximetry Devices in the Home Setting

 Policy: 05.00.32i:Speech and Non-Speech Generating Devices

 Policy: 05.00.38j:Negative-Pressure Wound Therapy (NPWT) Systems

 Policy: 05.00.39o:Ankle-Foot/Knee-Ankle-Foot Orthoses

 Policy: 05.00.42g:Patient Lifts

 Policy: 05.00.43f:Seat Lift Mechanisms

 Policy: 05.00.47n:Knee Orthoses

 Policy: 05.00.48j:Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum

 Policy: 05.00.54g:Power Wheelchairs (PWCs), Power-Operated Vehicles (POVs), and Push-Rim Activated Power-Assist Devices

 Policy: 05.00.55i:Wheelchair Cushions and Seating

 Policy: 05.00.56i:Hospital Beds and Accessories

 Policy: 05.00.58l:Home Oxygen Therapy

 Policy: 05.00.60g:Pressure-Reducing Support Surfaces

 Policy: 07.07.02j:Ultraviolet Light Therapy for the Treatment of Dermatological Conditions

 Policy: 08.00.17g:Total Parenteral Nutrition (TPN) / Intradialytic Parenteral Nutrition (IDPN) / Intraperitoneal Parenteral Nutrition (IPN)

 Policy: 11.00.06j:Treatment of Obstructive Sleep Apnea (OSA) and Primary Snoring

 Policy: 11.08.19m:Prophylactic Mastectomy, Oophorectomy/Salpingo-Oophorectomy, and Hysterectomy

 Policy: 05.00.30l:Noninvasive Respiratory Assist Devices (RADs): Continuous Positive Airway Pressure (CPAP) Devices and Bi-Level Devices (Independence Administrators)


Policy History

05.00.44k:
10/01/2018This policy has been updated for the HCPCS code update, effective 10/01/2018.

The following HCPCS code has been termed from the policy:

K0037: High mount flip-up footrest, replacement only, each

Version Effective Date: 10/01/2018
Version Issued Date: 10/02/2018
Version Reissued Date: N/A

Connect with Us        


2017 Independence Blue Cross.
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.