Durable Medical Equipment professional reimbursement policy reminders

In the April 2016 edition of Network Update, we shared details about the professional reimbursement policy, Durable Medical Equipment. Following are some important reminders about this policy.

 

• Certain DME is not routinely purchased up-front; rent-to-purchase durable medical equipment (DME) is eligible for rental reimbursement up to the purchase price or 10 months rental, whichever comes first. We are receiving claims billed with up-front purchases and we are denying those claims because they must be billed as rent-to-purchase. If you receive such a denial, please do not request a medical necessity review as that was not the reason for the denial. Instead, please bill claims for these services correctly as rent-to-purchase.  

 

• For dates of service on or after July 1, 2016, the following HCPCS codes for sleep apnea equipment are only eligible for reimbursement when reported as rented items, and should not be reported with DME purchase modifiers NR (new when rented (use modifier NR when DME that was new at the time of rental is subsequently purchased)), NU (new equipment), or UE (used durable medical equipment): 

 

• E0470 (respiratory assist device, bi-level pressure capability, without backup rate feature)
• E0471 (respiratory assist device, bi-level pressure capability, with back-up rate feature)
• E0561 (humidifier, non-heated, used with positive airway pressure device)
• E0562 (humidifier, heated, used with positive airway pressure device)
• E0601 (continuous positive airway pressure (CPAP) device)

 

For more information about the Durable Medical Equipment reimbursement policy, visit the professional reimbursement policy webpage at anthem.com.