Supply and Equipment

Description

This policy describes how supplies and equipment will be reimbursed by Blue Cross Blue Shield North Carolina (Blue Cross NC).

Policy

Blue Cross NC will reimburse supplies and equipment according to the criteria outlined in this policy.

Reimbursement Guidelines

Blood Glucose Test Strip(s)

Blood glucose test or reagent strips (A4253) is limited to 20 units (boxes) per quarter for patients with insulin dependent diabetes, and 6 units (boxes) per quarter for patients with non-insulin dependent diabetes.

Breast Pump(s) / Breast Pump Supplies

Standard member benefits provide coverage for only one (1) manual (E0602) or electric (E0603) breast pump purchase per delivery.

Standard member benefits do not provide coverage for hospital-grade breast pumps (E0604).

Replacement breast pump supplies (A4281-A4286) are not separately reimbursable on the same date of service as the breast pump (E0602-E0603), as they are included in the initial purchase of the pump.

Breast pump supplies (A4281-A4286) are limited to 2 units per code, per year.

Devices, Implants, Blood Products, & Therapeutic Imaging Agents

Certain implants, devices, blood products, and therapeutic imaging agents require the applicable procedure to also be billed. Blue Cross NC requires that the relevant associated procedure code for the implant, device, or therapeutic imaging agent to be billed. Additionally, the related procedure must also be reimbursable for the implant, device, or therapeutic imaging agent to be separately reimbursable. For example, a therapeutic imaging agent should not be billed without the requisite imaging procedure. In this example, the imaging agent will not be reimbursable without the related reimbursable procedure. Similarly, device-dependent procedures will not be eligible for reimbursement in the absence of a device.

Blue Cross NC will not provide reimbursement for autologous blood collection, processing and storage on the same date as a transfusion as these codes are intended to be used when blood is collected but not transfused. Likewise, if Blue Cross received and adjudicated a claim for autologous blood collection, processing and storage, then the transfusion of the blood product will not be eligible for reimbursement on the same date of service.

Gradient Compression Garment(s)

Gradient compression garments are limited to four (4) pairs or eight (8) individual units per year.

Nighttime gradient compression garments are limited to two (2) individual units per year.

Appropriate coding for anatomical area and compression needs are expected.

E1399 is an inappropriate code to represent gradient compression garments.

Mastectomy Bra(s)

Mastectomy bras (L8000-L8002) are limited to two per year.

Medical, Surgical Supplies and DME in a Facility Setting

Medical and surgical supplies (including drugs and vaccines) and DME are not reimbursable as professional services when billed in a facility setting as they are typically billed by the facility or DME provider. Additionally, DME is not eligible for separate reimbursement in an Ambulatory Surgical Center (ASC) as ASCs are reimbursed at an all-inclusive rate, thus the DME is considered included in the all-inclusive rate.

Temporomandibular Joint (TMJ) Splints

Occlusal orthotic devices (D7880) are limited to one per year.

Adjustments (D7881) performed within 1 year of device (D7880) insertion are included in the reimbursement of the device.

Adjustments (D7881) performed after 1 year of device (D7880) insertion are reimbursable once every 3 months. 

Supplies and Equipment Billing Requirements

Supplies are reimbursable on a monthly basis. Regardless of utilization, a supplier must not dispense more than one (1) month quantity at a time.

Supplies and accessories related to DME are not eligible for reimbursement when DME hasn’t been previously provided.

PAP mask, nasal interface, or tubing are not eligible for reimbursement more than once every 3 months by any provider.

VAD (Ventricular Assist Device) accessories are not eligible for reimbursement more than one (1) unit per year unless appended with an appropriate modifier (RA, RB).

The purchase of a new TENS device is not eligible for reimbursement if not previously rented in the prior 90 days by any provider.

A TENS device must be billed with modifier RR or NU to be eligible for reimbursement.

Adult Orthotics and Prosthetics have an expected reasonable life span of 5 years. Therefore, reimbursement is limited to one (1) unit every five (5) years by any provider.

Diabetic therapeutic inserts are not eligible for reimbursement when billed with toe fillers. Reimbursement of therapeutic shoe inserts and modifications for diabetics is limited to 6 units per calendar year.

Reimbursement of diabetic shoes are limited to 2 units per calendar year.

Previously purchased DME is not eligible for additional rental or purchase during the reasonable lifetime period of the equipment.

Indwelling catheter reimbursement is limited to three (3) units every three (3) months by any provider.

Intermittent urinary catheter reimbursement is limited to 600 units every three (3) months by any provider.

Enteral formulas and additives are not eligible for reimbursement.

Reimbursement for DME rental is limited to the first provider billing in any given month. DME rental is limited to CMS capped rental period guidelines.

Reimbursement for the rental of a stationary or portable oxygen delivery system is limited to once per month by any provider.

Reimbursement for oxygen accessories and supplies are not eligible for separate reimbursement when billed on the same day or during the same month as a monthly oxygen rental billing.

Maintenance, repairs, replacements, adjustments, supplies, and accessories are not eligible for separate reimbursement from DME rental.

Inexpensive or Routinely purchased DME is not eligible for reimbursement if submitted without a modifier to indicate it is new, used or a rental.

Non-Reimbursable Supplies and Equipment

The following Supplies and Equipment are not eligible for separate reimbursement:

• Pulsed irrigation and evacuation systems 
• Enema systems 
• Belt, strap, sleeve, garment, or covering 
• Non-covered item or service 
• Thermal therapy 
• Dressings, bandages, surgical stockings and non-elastic binder for extremity 
• Orthopedic footwear (L3000-L3595, L3649) billed with diabetic diagnoses 
• Diabetic shoes, inserts, and modifications billed without diabetic diagnoses 
• Socks 
• DME with category IN, CMS considers “purchase only” that are billed with modifier KR, RR or UE.

Rationale

Please refer to the “Guidelines for purchasing DME” section in Provider Manual for more information related to claim filing.

Billing and Coding

Applicable codes are for reference only and may not be all inclusive. For further information on reimbursement guidelines, please see the Blue Cross NC web site at Blue Cross NC.

Related policy

Ambulatory Surgical Center (ASC)

Bundling Guidelines

Durable Medical Equipment (DME) (medical policy)

References

Centers for Medicare & Medicaid Services, CMS Manual System, and Medicare Claims Processing Manual 100-04 

Blue Cross NC Provider Manual 

History

7/1/2021 New policy developed. Gradient compression garment limit reduced from 6 pair to four (4) pair or eight (8) individual units per year. Breast pump supplies limited to 2 units per code, per year. TMJ splint limits added. Notification on 4/30/2021 for effective date 7/1/2021. (eel)

12/30/2021 Supply Billing Requirements clarification added to Reimbursement Guidelines. Routine policy review. Medical Director approved. (eel)

6/1/2022 Policy language updated throughout. Added “Medical, Surgical Supplies and DME in a Facility Setting” and “Devices, Implants, Blood Products, & Imaging Agents“ to Reimbursement Guidelines. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022. (eel)

8/23/2022 Alphabetized Guidelines. Removed medical necessity reference from Compression Garment section for clarity. Removed examples of items not considered gradient compression garments. No change to policy intent. (ckb)

12/31/2022 Routine Policy Review. Minor Revisions only. (cjw)

7/18/2023 Added sections: Supplies and Accessories billing requirements, non-reimbursable equipment and DME rental. Coding section updated. Medical Director approved. Notification on 5/16/2023 for effective date 7/18/2023. (tlc)

7/18/2023 Examples added as clarification to Gradient Compression Garment section. No change to policy intent. (tlc)

11/12/2023 Policy language added to Supplies and Equipment Billing Requirements. Added TENS device modifier requirements, therapeutic mold inserts for diabetics, intermittent catheter, reimbursement of portable oxygen and accessories, routinely purchased DME. Added diabetic shoes and inserts and category “IN” DME to Non-Reimbursable Supplies and Equipment. Medical Director approved. Notification on 9/12/2023 for effective date 11/12/2023. (tlc)

1/1/2024 Language clarification regarding Gradient Compression Garments. Nighttime Gradient Compression Garments added. “Adult” added to clarify lifetime of Orthotics and Prosthetics. Coding section updated with new compression codes. No change to policy intent. (tlc)

3/1/2024 Removed codes L3000-L3595, L3649 from Non-reimbursable Supplies and Equipment grid. No change to policy intent. (tlc)

5/26/2024 Removed codes A4458, A4459, E0350, E0352 from Non-reimbursable Supplies and Equipment grid. No change to policy intent. (tlc)

10/01/2024 Clarified “imaging agents” mean therapeutic imaging agents. RPOC Approved. Notification on 08/01/2024 for effective date 10/01/2024 (ss)

Application

These reimbursement requirements apply to all commercial, Administrative Services Only (ASO), and Blue Card Inter-Plan Program Host members (other Plans members who seek care from the NC service area). This policy does not apply to Blue Cross NC members who seek care in other states.

This policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this policy.