Policy Enhancements for DME

Date Issued: 4/9/2019

EmblemHealth has been working to implement enhancements to our DME payment policies. The goal of this enhancement is to implement DME claim payment policies that are consistent with current industry and national standards and promote correct coding.

EmblemHealth’s enhanced DME medical and payment policies come from these primary sources:

  • National CMS (National Coverage Decisions)
  • Regional CMS (Durable Medical Equipment Regional Carriers “DME MAC” Manual), and
  • HCPCS Level II code definition

According to the DME Supplier Manual, DMEPOS items are only covered when reported in a covered place of service:

  • 01 - Pharmacy
  • 04 - Homeless Shelter
  • 09 - Prison/Correctional Facility
  • 12 - Home
  • 13 - Assisted Living Facility
  • 14 - Group Home
  • 16 - Temporary Lodging
  • 33 - Custodial Care Facility
  • 54 - Intermediate Care Facility/Mentally Retarded
  • 55 - Residential Substance Abuse Treatment Facility
  • 56 - Psychiatric Residential Treatment Center
  • 65 - End Stage Renal Disease (ESRD) Treatment Facility (valid POS for Parenteral Nutritional Therapy)

Coverage consideration for DMEPOS items in a Skilled Nursing Facility (31) or Nursing Facility (32) is limited to the following:

  • Prosthetics, orthotics, and related supplies
  • Urinary incontinence supplies
  • Ostomy supplies
  • Surgical dressings
  • Oral anticancer drugs
  • Oral antiemetic drugs
  • Therapeutic shoes for diabetics
  • Parenteral/enteral nutrition (including E0776BA, the IV pole used to administer parenteral/enteral nutrition)
  • ESRD - dialysis supplies only
  • Immunosuppressive drugs

According to the DMEPOS Fee Schedule, a DMEPOS item listed in the Capped Rental Category (CR) must be reported with the designated capped rental modifier (RR).

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html

Exceptions:
The following items can be purchased:

Power Wheelchairs: (K0835-K0864)

Wheelchair Accessories: (E0955, E1002-E1008, E1010, E1012, E1020, E1028, E1030, E2310-E2313, E2321, E2322, E2325-E2330, E2351, E2368, E2369, E2370, E2373, E2374, E2375, E2376, E2377, E2378) and K0015.