Durable Medical Equipment (DME): Billing Codes And Reimbursement Rates (Dura Cd)

Durable Medical Equipment (DME): Billing Codes dura cd

and Reimbursement Rates 1

This section lists the HCPCS codes and maximum allowances for Durable Medical Equipment (DME). Refer to the Durable Medical Equipment (DME): An Overview section in the appropriate Part 2 manual for general policy information.

Note: Per California Code of Regulations (CCR), Title 22, Section 51321(g): Authorization for durable medical equipment shall be limited to the lowest cost item that meets the patient’s medical needs.

Authorization Authorization is required for all oxygen contents, oxygen equipment and respiratory equipment except for all of the following, which require authorization only for quantities exceeding the stated billing limit:

· A7005 (administration set, with small volume non-filtered pneumatic nebulizer, non-disposable) – billing limit of one every 6 months.

· E0484 (oscillatory positive expiratory pressure device,
non-electric, any type, each) – billing limit of two per 12 months.

Authorization is required for all other DME products exceeding the following threshold limits (cumulative cost of related items within a group):

· Rental: $50

· Purchasing: $100

· Repair or maintenance: $250

Rentals and Purchases Reimbursement for rental or purchase of DME includes the following policies.

Rental Rate DME rental rates include reimbursement for equipment-related

Includes Supplies supplies. Supplies are not separately reimbursable, except as noted.

Rental Period Unless otherwise noted, DME rental is based on a rental period of one calendar month, with the beginning date of rental as the date of service.

Rental Reimbursement Cap For information about the DME rental reimbursement cap, refer to the Durable Medical Equipment (DME): An Overview section in the appropriate Part 2 manual.

2 – Durable Medical Equipment (DME): Billing Codes

and Reimbursement Rates August 2016

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Guarantees Purchased equipment is to be guaranteed for at least six months from the date of purchase. Out-of-guarantee repairs are to be guaranteed for at least three months from the date of such repair. Reimbursement will not be allowed for parts or labor during a guarantee period if the need for repair is due to a defect in material or workmanship

Billing Codes Refer to the Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC) Product Classification Lists at
www.palmettogba.com or call the SADMERC/HCPCS help line at
1-877-735-1326 to determine proper billing codes for DME items.

Codes and Rates Reimbursement for purchased DME is subject to the Upper Billing Limit defined in California Code of Regulations, Title 22, Section 51008.1. Claims submitted are not to exceed an amount that is the lesser of:

· The usual charges made to the general public, or

· The net purchase price of the item, which shall be documented in provider’s books and records, plus no more than a 100 percent
mark-up.

For more information regarding the maximum allowable DME purchase billing amounts, refer to “Net Purchase Price” in the
Durable Medical Equipment (DME): An Overview section.

The following listed rates are the maximum amounts allowed for each procedure code:

Note: If the net purchase price of the item, plus a 100 percent
mark-up, adds up to less than the maximum amount indicated for the code on the pages that follow, the billed amount is to be the net purchase price, plus the 100 percent mark-up, i.e., not the maximum amount allowable listed.

2 – Durable Medical Equipment (DME): Billing Codes

and Reimbursement Rates August 2016

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HCPCS Monthly

Code Description Rental Purchase

AMBULATION DEVICES

Canes and Crutches

A4635 / Underarm pad, crutch, replacement, each / -- / $ 4.10
A4636 / Replacement handgrip, cane, crutch or walker, each / -- / 3.22
A4637 / Replacement tip, cane, crutch or walker, each / -- / 1.64
E0100 / Cane, includes canes of all materials, adjustable or fixed, with tip / $ 4.75 / 15.99
E0105 / Cane, quad or three prong, includes canes of all materials, adjustable or fixed, with tips / 7.09 / 37.50
E0110 / Crutches, forearm, adjustable or fixed, with tips and handgrips, pair / 12.79 / 62.07
E0112 / Crutches, underarm, wood, adjustable or fixed, pair, with pads, tips and handgrips / 7.94 / 29.60
E0114 / Crutches, underarm, non-wood, adjustable or fixed, pair, with pads, tips and handgrips / 6.86 / 37.75
E0117 / Crutch, underarm, articulating, spring assisted, each / 15.41 / 154.17

§ Rental rate includes supplies.

+ Authorization is required for this procedure.

^ Effective for dates of service on or after November 1, 2007, this code is reimbursable only for repairs to patient-owned

equipment.

# Rental and purchase price when billed with modifiers RR and NU

† Rental price when billed with modifier RR

@ Rental and purchase price when billed with modifiers RR, KC, RA and NU

* Effective October 1, 2009, bill as a disposable medical supply. Refer to the Medical Supplies Billing Codes, Units and Quantity Limits spreadsheet.

! Item included in the payment for the initial wheelchair. Not separately reimbursable within the same month of service.

Authorization is required for DME products exceeding the following threshold limits (cumulative cost of related items within a group):

rental - $50; purchase - $100; and repair or maintenance - $250. This policy also applies to daily amounts that exceed the respective dollar limits for rental, purchase, repair or maintenance for an individual item or combination of similar group DME items.

2 – Durable Medical Equipment (DME): Billing Codes

and Reimbursement Rates July 2016

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HCPCS Monthly

Code Description Rental Purchase

Walkers

E0130 / Rigid (pick-up), adjustable or fixed height / $ 12.86 / $ 53.75
E0135 / Folding (pick-up), adjustable or fixed height / 13.20 / 64.17
E0140 / Walker w/trunk support, adjustable or fixed height / 27.62 / 276.06
E0141 / Rigid walker, wheeled, adjustable or fixed height / 17.13 / 88.24
E0143 / Folding walker, wheeled / 16.53 / 85.69
E0144 / Walker, enclosed, four sided framed, rigid or folding, wheeled with posterior seat / 24.38 / 254.76
E0147 / Walker, heavy duty, multiple braking system, variable wheel resistance / 28.41 / 279.69
E0148 / Walker, heavy duty, without wheels, rigid or folding, any type, each / 9.74 / 97.25
E0149 / Walker, heavy duty, wheeled, rigid or folding, any type / 17.09 / 170.82
E0153 / Platform attachment, forearm crutch, each / 6.27 / 55.50
E0154 / Platform attachment, walker, each / 6.55 / 53.97
E0155 / Wheel attachment, rigid pick-up walker, per pair / 2.94 / 24.14
E0156 / Seat attachment, walker / 2.22 / 20.23
E0157 / Crutch attachment, walker, each / 5.86 / 53.30
E0158 / Leg extensions, per set of four / 2.72 / 24.62
E0159 / Brake attachment for wheeled walker, replacement, each / 1.38 / 13.67

§ Rental rate includes supplies.

+ Authorization is required for this procedure.

^ Effective for dates of service on or after November 1, 2007, this code is reimbursable only for repairs to patient-owned

equipment.

# Rental and purchase price when billed with modifiers RR and NU

† Rental price when billed with modifier RR

@ Rental and purchase price when billed with modifiers RR, KC, RA and NU

* Effective October 1, 2009, bill as a disposable medical supply. Refer to the Medical Supplies Billing Codes, Units and Quantity Limits spreadsheet.

! Item included in the payment for the initial wheelchair. Not separately reimbursable within the same month of service.

Authorization is required for DME products exceeding the following threshold limits (cumulative cost of related items within a group):

2 – Durable Medical Equipment (DME): Billing Codes

and Reimbursement Rates July 2016

dura cd

HCPCS Monthly

Code Description Rental Purchase

BATHROOM EQUIPMENT

E0163 / Commode chair with fixed arms / $ 19.54 / $ 88.23
E0165 / Commode chair with detachable arms / 13.53 / 162.36
E0167 / Pail or pan for use with commode chair, replacement only / 1.06 / 9.60
E0168 / Commode chair, extra wide and/or heavy duty, stationary, or mobile, with or without arms, any type, each / 13.39 / 120.74
+ E0170 / Commode chair with integrated seat lift mechanism, electric, any type / 128.58 / 1,542.91
+ E0171 / Commode chair with integrated seat lift mechanism, non-electric, any type / 23.14 / 277.63
E0240 / Bath/shower chair, with or without wheels, any size / -- / By Report
E0241 / Bathtub wall rail, each / -- / 14.62
E0242 / Bathtub rail, floor base / -- / By Report
E0243 / Toilet rail, each / -- / 42.76
E0244 / Raised toilet seat / -- / 46.04
E0245 / Tub stool or bench / -- / 55.07
E0246 / Transfer tub rail attachment / -- / 37.08
E0247 / Transfer bench for tub or toilet with or without commode opening / -- / 81.42
E0248 / Transfer bench, heavy duty, for tub or toilet with or without commode opening / -- / By Report

§ Rental rate includes supplies.

+ Authorization is required for this procedure.

^ Effective for dates of service on or after November 1, 2007, this code is reimbursable only for repairs to patient-owned

equipment.

# Rental and purchase price when billed with modifiers RR and NU

† Rental price when billed with modifier RR

@ Rental and purchase price when billed with modifiers RR, KC, RA and NU

* Effective October 1, 2009, bill as a disposable medical supply. Refer to the Medical Supplies Billing Codes, Units and Quantity Limits spreadsheet.

! Item included in the payment for the initial wheelchair. Not separately reimbursable within the same month of service.

Authorization is required for DME products exceeding the following threshold limits (cumulative cost of related items within a group):

2 – Durable Medical Equipment (DME): Billing Codes

and Reimbursement Rates July 2016

dura cd

HCPCS Monthly

Code Description Rental Purchase

DECUBITUS CARE EQUIPMENT

A4640 / Replacement pad for use with medically necessary alternating pressure pad owned by patient / -- / $ 45.18
E0181 / Pressure pad, alternating with pump / $ 20.85 / 250.20
E0182 / Replacement pump for alternating pressure pad / 23.24 / 251.33
E0184 / Dry pressure mattress / 19.66 / 132.40
E0185 / Gel or gel-like pressure pad for mattress, standard mattress length and width / 35.95 / 255.89
E0186 / Air pressure mattress / 16.24 / 194.88
E0187 / Water pressure mattress / 18.57 / 222.82
E0188 /

Synthetic sheepskin pad

2.47

21.14

E0189 /

Lambswool sheepskin pad

4.50

41.57

E0193 / Powered air flotation bed (low air loss therapy) (daily rental) / 24.09 / By Report
E0194 / Air fluidized bed (daily rental) / 55.00 / By Report
E0196 / Gel pressure mattress / 25.99 / 311.90
E0197 / Air pressure pad for mattress, standard mattress length and width / 24.46 / 177.26
E0198 / Water pressure pad for mattress, standard mattress length and width / 18.61 / 179.65
E0199 / Dry pressure pad for mattress, standard mattress length and width / 2.55 / 25.64
E0210 / Electric heat pad, standard / 2.46 / 26.11
E0277 / Powered pressure-reducing air mattress (daily rental) / 18.76 / By Report
E0371 / Nonpowered advanced pressure reducing overlay for mattress, standard mattress length and width (daily rental) / 10.62 / By Report
E0372 / Powered air overlay for mattress, standard mattress length and width (daily rental) / 13.70 / By Report
E0373 / Nonpowered advanced pressure reducing mattress (daily rental) / 14.76 / By Report

§ Rental rate includes supplies.

+ Authorization is required for this procedure.

^ Effective for dates of service on or after November 1, 2007, this code is only reimbursable for repairs to patient-owned

equipment.

Authorization is required for DME products exceeding the following threshold limits (cumulative cost of related items within a group):

2 – Durable Medical Equipment (DME): Billing Codes

and Reimbursement Rates March 2008

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HCPCS Monthly

Code Description Rental Purchase

HOSPITAL BEDS AND ACCESSORIES

E0271 / Mattress, innerspring / $ 17.66 / $ 146.15
E0272 / Mattress, foam rubber / 16.18 / 154.88
E0273 / Bed board / By Report / By Report
E0291 / Hospital bed, fixed height, without side rails, without mattress / 35.33 / 443.14
E0293 / Hospital bed, variable height, hi-lo, without side rails, without mattress / 46.53 / 583.49
E0295 / Hospital bed, semi-electric (head and foot adjustment), without side rails, without mattress / 97.46 / 1,222.56
E0297 / Hospital bed, total electric (head, foot, and height adjustments), without side rails, without mattress / 103.82 / 1,302.24
E0300 / Pediatric crib, hospital grade, fully enclosed / 217.24 / 2,270.90
E0303 / Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress / 222.08 / 2,785.63
E0304 / Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, with mattress / 589.82 / 7,398.43
E0305 / Bed side rails, half length / 13.62 / 170.78
E0310 / Bed side rails, full length / 17.42 / 145.76
E0316 / Safety enclosure frame/canopy for use with hospital bed, any type / 155.50 / 1,950.43
E0328 / Hospital bed, pediatric, manual, 360 degree side enclosures, top of headboard, footboard, and side rails up to 24 in. above the spring, includes, mattress / By Report / By Report
E0329 / Hospital bed, pediatric, electric or semi-electric, 360 degree side enclosures, top of headboard, footboard, and side rails up to 24 in. above the spring, includes mattress / By Report / By Report

§ Rental rate includes supplies.