CurrentAnthemPolicy G-06081

Facility Take-Home DME and Medical Supplies, Reimbursement Policy

Governs Anthem Blue Cross Medi-Cal Managed Care reimbursement for durable medical equipment (DME) and medical supplies dispensed by inpatient hospitals for take-home use; affects inpatient facilities, DME/supply vendors, and claims processors in California.

Policy Summary

PayerAnthem

PolicyFacility Take-Home DME and Medical Supplies, Reimbursement Policy

Policy CodePolicy G-06081

Change TypeNo material change

Effective Date05/22/2024

Next Review Date

Key ActionSubmit claims for take-home DME and supplies through a DME/supply vendor; inpatient facility claims with take-home revenue codes will be denied.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

G-06081policy identifier

05/22/2024effective / last approval date

72max hours facility may dispense at discharge

Crutchesitem allowed for facility reimbursement

Facility take-home DME and supplies

Facility take-home DME and supplies criteria

Anthem reimbursement rules for inpatient facility-dispensed DME and supplies:

Anthem does not allow reimbursement for DME and medical supplies dispensed by inpatient hospital facility for take-home use unless provider, state, federal, or CMS contracts or requirements indicate otherwise.

Inpatient facility claims submitted with revenue codes denoting take-home use will be denied.

Claims for take-home DME and medical supplies should be submitted by a DME/supply vendor; reimbursement is based on the contract or negotiated rate for participating vendors, or the out-of-network fee schedule or negotiated rate for nonparticipating vendors.

Exceptions allowed (ONE of the following)

Crutches billed on facility claims using revenue codes other than take-home are allowable for facility reimbursement.

Policy Summary

PayerAnthem

PolicyFacility Take-Home DME and Medical Supplies, Reimbursement Policy

Policy CodePolicy G-06081

Change TypeNo material change

Effective Date05/22/2024

Next Review Date

Key ActionSubmit claims for take-home DME and supplies through a DME/supply vendor; inpatient facility claims with take-home revenue codes will be denied.

SourceLink

On This Page

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No more than 72 hours of medical supplies billed on facility claims using revenue codes other than take-home are allowable when a vendor could not be obtained by discharge.

Standard correct coding applies.

Coding, billing, and supply limits

Coding and billing guidancemixed

Use appropriate CPT, HCPCS and/or revenue codes; take-home revenue codes on inpatient facility claims will be denied

Maximum facility-dispensed supplies at discharge when vendor unavailable

Maximum supply duration at dischargeFacility may dispense no more than 72 hours of medical supplies at discharge when a vendor could not be obtained by discharge.

Allowed item exampleCrutches may be reimbursed when billed with non-take-home revenue codes.

ConditionThis exception applies only if the provider was unable to obtain supplies from a vendor by discharge.

Claims submission and denial risk

Denial Risk

Claims submission and denial risk for take-home DME/supplies

Inpatient facility claims for DME and medical supplies billed with revenue codes that denote take-home use will be denied. Claims for take-home DME and supplies must be submitted by a DME/supply vendor (reimbursement based on participating vendor contract/negotiated rate or out-of-network fee schedule for nonparticipating vendors). Facilities may bill for certain items at discharge using non-take-home revenue codes (for example, crutches or up to 72 hours of supplies if a vendor could not be obtained by discharge).

Do not submit inpatient facility claims using revenue codes that indicate take-home use — such claims will be denied.
Submit claims for take-home DME and supplies through a DME/supply vendor for reimbursement under the vendor’s contract or applicable fee schedule.
When a vendor cannot be obtained by discharge, facility may bill supplies with non-take-home revenue codes for crutches and no more than 72 hours of supplies.

Terminology

Take-home use — definition

DefinitionUse intended for use outside of a facility (take-home use).

ContextTake-home use is referenced in the policy clarifying reimbursement and billing requirements for inpatient-dispensed DME and supplies.

Related materialSee General Reimbursement Policy Definitions for broader definition context.