CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPO22

Pneumatic Compression Devices - outpatient DME coding and billing

Describes coding, billing, documentation, and reimbursement guidance for durable medical equipment (DME) pneumatic compression devices for outpatient use under Blue Cross Blue Shield of Oklahoma plans. Applies to providers and DME suppliers submitting claims to BCBSOK.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPneumatic Compression Devices - outpatient DME coding and billing

Policy CodePolicy CPCPO22

Change TypeAnnual reviewadministrative/wording updates

Effective DateFeb 16, 2024

Next Review DateN/A

Key ActionSubmit claims with required documentation demonstrating medical necessity (physician evaluation, treatment plan, device operation instruction) and append the appropriate modifier (NU, RR, UE) or risk denial of payment.

SourceLink

POLICY UPDATE CHANGES

02/09/2024 Annual Review.

07/05/2019 New policy; subsequent annual reviews and disclaimer/verbiage updates recorded.

1.0policy version

2024-02-16effective date

8HCPCS codes referenced

3applicable modifiers

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Policy Snapshot

This policy, Pneumatic Compression Devices - outpatient DME coding and billing, describes coding, billing, documentation, and reimbursement guidance for durable medical equipment (DME) pneumatic compression devices intended for outpatient use under Blue Cross Blue Shield of Oklahoma plans. It applies to providers and DME suppliers submitting claims to BCBSOK and explains requirements necessary for accurate benefit determination and claims processing, including appropriate HCPCS coding and the use of applicable modifiers to distinguish rental versus purchase.

Providers are expected to submit claims using HIPAA-approved code sets and follow industry-standard coding guidelines. Documentation that supports medical necessity — including physician evaluation, treatment plan (pressure, frequency, duration, monitoring), and instruction in device operation — must be submitted with the claim or upon request. For member-specific coverage questions or plan details, contact the Plan or your Network Representative. See related medical policies MED202.060 and DME101.000 for clinical coverage criteria.

Clinical and Coverage Criteria

HCPCS Codes and Modifiers

Pneumatic compression device HCPCSHCPCS

E0650	Non-segmental pneumatic compression pump (listed)
E0652	Pneumatic compressor, segmental home model with calibrated gradient pressure
E0671	Segmental pneumatic compression pump
E0672	Segmental pneumatic compression pump (listed)
E0673	Segmental gradient pressure pneumatic appliance / segmental pneumatic compression pumps
E0675	High pressure, rapid inflation/deflation pneumatic compression device (Arterial insufficiency only)
E0676	Intermittent limb compression device, includes all accessories; all-inclusive code often used for DVT prophylaxis
E0655	Accessory codes referenced (used in edits section)

Modifiers for DMEModifier

NU	Purchase of new DME equipment (may be appropriate for lymphedema patients)
RR	Rental of the DME equipment; one unit billed per monthly period
UE	Used DME equipment

Billing Rule

Accessories billing edit

When codes E0655-E0673 are billed for compression device accessories together with E0676 (the all‑inclusive device code), the accessories will be denied as inclusive and are not separately payable.

E0655
E0650
E0652
E0671
E0672
E0673
E0676

Billing Rule

Place of Service reporting

DME suppliers must report the Place of Service (POS) code where the device is intended to be used. Devices not intended for home use are not eligible for separate home POS reimbursement; equipment intended for office use is considered office equipment.

Documentation, Claim Submission & Denial Risks

Documentation Required

Billing/documentation required to support medical necessity

Providers must submit documentation with the claim or upon request to establish medical necessity and support billing for pneumatic compression devices.

Physician oversight/evaluation documenting medical necessity (including diagnosis, prognosis, symptoms, objective findings and measurements, reason device is required, and prior treatments tried and failed)
Instruction in device operation
Treatment plan specifying pressure, frequency, duration, and ongoing monitoring of use and response
Post‑operative orders or surgical discharge summary orders/instructions when applicable
Relevant codes/modifiers: Relevant HCPCS device code and appropriate modifier (NU, RR, UE)

Denial Risk

Coverage subject to benefit terms and medical policies

Clinical and Administrative Background

Pneumatic compression devices consist of an inflatable garment and an electrical pneumatic pump that intermittently inflates and deflates chambers to apply therapeutic pressures for conditions such as lymphedema and chronic venous insufficiency. The policy defines device types used in outpatient settings, including non-segmented compressors, segmented compressors, and devices with or without calibrated gradient pressure.

This is an administrative and coding policy focused on outpatient DME use: DME suppliers must report the intended Place of Service for the device and devices not intended for home use are not eligible for separate home POS reimbursement. Suppliers and providers are responsible for appropriate coding (including modifiers NU, RR, UE where applicable), submission of required documentation to establish medical necessity, and adherence to plan benefit terms and related medical policies.

Key Definitions

Definitions

Non-segmented pneumatic compressorDevice with a single outflow port on the compressor; air may be transmitted to a sleeve with multiple compartments.

Segmented compressorCompressor with multiple outflow ports leading to distinct segments on the appliance which inflate sequentially.

Segmented device with calibrated gradient pressureDevice with manual controls on at least three outflow ports to deliver individually determined pressure to each segment.

Segmented device without calibrated gradient pressureDevice where same pressure is present in each segment or a predetermined gradient exists but pressures cannot be individually set.

Segmental gradient pressure pneumatic applianceAppliance/sleeve used with a nonsegmental compressor that achieves a pressure gradient through tubing or chamber design.

Pneumatic compression device

Policy Updates

2024-02-09Annual ReviewLatest

Annual Review — no clinical or coverage changes documented in the update history.

2023-01-30Annual Review

Annual Review recorded as part of ongoing policy updates.

2021-12-10Annual Review