Supply and Equipment Reimbursement

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

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.

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.

Supplies and Equipment Billing Requirements

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

The following DME is not eligible for reimbursement when filed without appropriate modifier(s) of AU, AV, AW, CG, GA, GY GZ or KX:

• Wheelchairs or accessories 
• Power mobility devices 
• RAD (Respiratory assist device) and RAD accessories
• Commode chairs
• Chest wall oscillation system vests or hose
• TENS device
• Wound care set/wound therapy
• AFO (Ankle-foot orthosis), KAFO (Knee-ankle-foot orthosis) and Knee orthosis
• Urological supplies
• Lens tint, anti-reflective coating
• Hospital beds and accessories
• Oxygen and Oxygen equipment
• Custom oral devices or appliances for sleep apnea
• Spinal orthosis
• Cervical traction equipment
• Heavy-duty walker
• Tape
• Gradient compression stocking or non-elastic gradient compression stockings
• Orthopedic shoes, additions or modifications
• Skin barriers, wipes or swabs
• Pressure reducing support surfaces

PAP mask, nasal interface, or tubing are not eligible for reimbursement more than once every 3 months by any provider. Bi-level Pap devices or CPAP devices are not eligible for reimbursement if a home ventilator has been billed on the same day or within a month by any provider.

A hospital bed with mattress is not eligible for reimbursement if a support mattress has previously been purchased in the last 5 years or rented in the previous month billed 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.

CMS Method II ESRD (End Stage Renal Disease) miscellaneous supplies, dialysis supplies, artificial kidney machines, and accessories are not eligible for reimbursement when billed by a DME provider.

Saline for oropharyngeal suction is not eligible for reimbursement.

Tape requires modifiers A1-A9 to be eligible for reimbursement.

Disposable drug delivery system, external ambulatory insulin delivery system, oximeters and oximeter replacements do not meet the definition of DME and therefore are not eligible for reimbursement.

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).

Home glucose monitoring supplies are not eligible for reimbursement when filed without an appropriate modifier of KS or KX.

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

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.

Gradient compression stockings or non-elastic gradient compression wraps are only eligible for reimbursement when billed with a CMS requisite diagnosis.

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.

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

Capped rentals when filed with more than 1 capped rental modifier on the same line are not eligible for reimbursement.

Enteral formulas and additives are not eligible for reimbursement.

Therapeutic shoes/inserts are not eligible for reimbursement when the diagnosis is diabetes and modifier KX or GY is not present.

Surgical dressings are not eligible for reimbursement when billed by a DME provider without a modifier of A1-A9 or GY.

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.

Lenses and frames billed without a diagnosis of pseudophakia, aphakia, or congenital aphakia 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.

Inexpensive or routinely purchased DME is not eligible for reimbursement if submitted without a modifier to indicate whether 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
• Wheelchair accessories
• Crutch substitute, lower leg platform, with or without wheels, each
• DME with category IN, CMS considers “purchase only” that are billed with modifier KR, RR or UE.

Rationale

Please refer to the Medicare Blue Cross NC 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 Administrative Policies on the Blue Cross NC web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

Related policy

Bundling Guidelines

References

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

Medicare Blue Cross NC Provider Manual (Blue Book)
https://www.bluecrossnc.com/sites/default/files/document/attachment/providers/public/pdfs/Provider_Manual.pdf

History

6/1/2022 New policy developed. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022. (eel)

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)

9/12/2023 Added CG modifier and Spinal Orthosis Procedures, PAP mask and tubing reimbursement limit, diabetic therapeutic inserts and shoes, ESRD supplies, catheter, portable oxygen and oxygen supplies and routine DME in Supplies and Billing Requirements. Body socks, diabetic shoe molds/inserts, repair or nonroutine service and ostomy irrigation added to Non-Reimbursable Supplies and Equipment. Medical Director approved. Notification on 9/12/2023 for effective date 11/12/2023. (tlc)

1/1/2024 Lymphedema Gradient Compression Garments added. 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)

10/01/2024 Moved Devices, Implants, Blood Products & Imaging Agents section from Facility Billing Guidelines to this policy. Clarified “imaging agents” to 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 Blue Medicare HMO, Blue Medicare PPO, Blue Medicare Rx members, and members of any third-party Medicare plans supported by Blue Cross NC through administrative or operational services.

This policy relates only to the services or supplies described herein. Please refer to the Member's Evidence of Coverage (EOC) 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.