If a nationally recognized CPT or HCPCS code exists for which the narrative adequately describes a DME item, that code should be used. “Unlisted” codes have been established for services or procedures for which a code is not found in the CPT or HCPCS code manuals. When using an unlisted code, the provider must submit a detailed description of the service or equipment provided.
There is no objective basis for approval of one name-brand, specific commercial device of a particular type over another “generic" device that has an established code. DME devices billed with an unspecified code will be reimbursed at the reimbursement rate for a similar/like device with an established HCPCS or CPT code.
Benefits should be provided for rental charge (but not to exceed the total cost of purchase) or, at the option of the Plan, the purchase of the DME.
Repair or Replacement of DME
Repair, adjustment, or replacement of components and accessories of DME, as well as supplies and accessories necessary for effective functioning of covered DME, are eligible for coverage when the:
- DME meets the above general coverage criteria; AND
- DME is being purchased or is already owned by patient; AND
- Repair or replacement is necessary to make the DME serviceable.
Shipping, Delivery, Set-up, Education Regarding Use, Equipment Pick-Up
Shipping, delivery, set-up, education regarding use, and equipment pick-up generally are not separately or additionally reimbursed, as these costs are an integral part of the suppliers’ costs of doing business, and are accounted for in the calculations of fee schedules. However, in rare and unusual circumstances extraordinary delivery expenses may be considered and paid separately on an individual basis when incurred in order to meet the needs of members living in remote areas that are not served by a local dealer or when a local dealer is temporarily out of stock of required equipment.
Disclaimer for coding information on Medical Policies
Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.
The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.
Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.