CurrentBlue Cross Blue Shield - TexasPolicy CPCP022

Pneumatic Compression Devices - Outpatient Use

Defines coding, modifiers, billing, and documentation requirements for outpatient pneumatic compression durable medical equipment (DME) and guidance for reimbursement determinations for Blue Cross Blue Shield - Texas members and providers.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyPneumatic Compression Devices - Outpatient Use

Policy CodePolicy CPCP022

Change TypeNo material changes

Effective DateFeb 26, 2024

Next Review DateN/A

Key ActionSubmit required physician evaluation and supporting documentation when requested to establish medical necessity for reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

E0652-E0676HCPCS codes listed for pneumatic compression devices

3Modifiers defined

3 itemsRequired supporting documentation items

4+Policy update history entries

Coverage and Documentation Requirements

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Documentation and medical necessity requirements

Reimbursement is contingent on meeting the Plan's medical policy documentation criteria and submission of required records; claims remain subject to benefit terms and review.

Claims must meet documentation criteria in the Plan's Medical Policies and coverage decisions are subject to applicable benefit plan terms and law.

ALL of the following

Physician evaluation documentation must include: diagnosis and prognosis.
Physician evaluation documentation must include: symptoms and objective findings, including measurements which establish the severity of the condition.
Physician evaluation documentation must include: reason the device is required, including treatments which have been tried and failed.

Submit documentation of instruction in the operation of the pneumatic compression device (training/supervision).

Provide a treatment plan that defines the pressure to be used, frequency and duration of use, and ongoing monitoring of use and response to treatment.

Record review for DME will include appropriate orders from the treating provider; if equipment is to be used post-operatively, include surgical facility discharge instructions/summary that reflect orders and instructions for use.

Upon request: Providers should submit additional supporting documentation when requested by the Plan (claims subject to review).

HCPCS Codes, Modifiers, and Bundling

Pneumatic compression device HCPCSHCPCS

E0652	Pneumatic compressor, segmental home model with calibrated gradient pressure
E0655	Non-segmental pneumatic compression pump
E0660	Non-segmental pneumatic compression pump
E0665	Non-segmental pneumatic compression pump
E0666	Non-segmental pneumatic compression pump
E0656	Segmental pneumatic compression pump
E0667	Segmental pneumatic compression pump
E0668	Segmental pneumatic compression pump
E0669	Segmental pneumatic compression pump
E0670	Segmental pneumatic compression pump

1–10 of 16

1/2

Accessory bundling rule — E0655–E0673 with E0676

Accessory bundling ruleWhen codes E0655–E0673 are billed with E0676 (the all‑inclusive intermittent limb compression device), accessories will be denied as inclusive and ineligible for separate payment.

Affected code rangeE0655–E0673 when billed alongside E0676.

ReasonE0676 is an all‑inclusive code that includes accessories; ClaimsXten edits will deny separate accessory charges.

Billing implicationDo not bill accessories separately with E0676; separate accessory claims will be denied and not reimbursed.

Claims Submission and Provider Responsibilities

Documentation Required

Claims review and documentation submission

Claims are subject to clinical and coding review and may be audited. Providers must submit accurate, complete claims using HIPAA-approved code sets (CPT®, HCPCS, ICD-10, NDC, DRG, etc.) and follow industry coding guidelines (AMA, CMS NCCI/CCI, UB, DRG rules). Claim submissions are subject to code-edit protocols and claims review for benefit coverage, provider contract terms, medical policies, clinical payment and coding policies, and coding software logic. Upon request, providers must furnish additional documentation to support the claim (e.g., medical records, invoices, proof of purchase or rental). Failure to provide requested documentation may result in delayed processing or denial of payment.

Use valid code combinations and modifiers to identify purchase vs rental where applicable.
Claims may be adjusted or denied if coding edits or policy criteria are not met.
Submit additional documentation promptly when requested to avoid delays.

Documentation Required

Coverage conditioned on medical policy criteria

Reimbursement is conditioned on meeting the Plan's Medical Policy criteria and the member's applicable benefit plan terms. Providers are responsible for ensuring claims meet the documentation and medical necessity criteria set forth in the Plan Medical Policies. Payment will be made only when all clinical and documentation requirements are satisfied; if criteria are not met, services may be denied or refunded. Refer to the Plan's Medical Policies and the Additional Resources section for specific documentation requirements and coverage criteria.

Coverage decisions are subject to plan exclusions, limitations, and applicable law.
Correct coding (including modifiers) and documentation required to determine purchase vs rental and benefit applicability.
Providers must ensure documentation supports medical necessity per the Plan Medical Policies.

Key Terms and Device Definitions

Chronic venous stasis ulcer

DefinitionUlcers thought to occur due to improper functioning of venous valves, usually of the legs; synonyms include venous insufficiency ulcer, stasis ulcer, stasis dermatitis, varicose ulcer.

Typical locationUsually of the legs.

SynonymsVenous insufficiency ulcer; stasis ulcer; stasis dermatitis; varicose ulcer.

Lymphedema

DefinitionSwelling of subcutaneous tissues due to the accumulation of excessive lymph fluid resulting from impaired lymphatic clearance (therapy or disease).

PathophysiologyAbnormal lymph accumulation in interstitial tissues from impaired lymphatic system function.

Common causesMay be caused by prior therapy or disease affecting lymphatic clearance.

Non-segmented pneumatic compressor

DefinitionDevice with a single outflow port on the compressor; air from that single tube may be transmitted to a sleeve/appliance with multiple compartments or segments.

ConfigurationSingle compressor port feeding one tube that can serve multi‑compartment sleeves.

Use noteMay be used with segmental gradient pressure appliances to achieve pressure gradients by sleeve design.

Segmented compressor

DefinitionCompressor with multiple outflow ports that lead to distinct sleeve segments which inflate sequentially.

FunctionEach outflow port supplies a specific segment of the appliance for sequential inflation.

Distinguishing featureMultiple ports corresponding to discrete sleeve segments (vs single‑port non‑segmented devices).

Segmented device with calibrated gradient pressure

DefinitionSegmented device characterized by a manual control on at least three outflow ports enabling individually determined pressure delivery to each segment unit.

Control capabilityManual adjustment of individual segment pressures on three or more ports.

PurposeAllows tailored pressure settings per segment to create calibrated gradient pressure profiles.

Venous thromboembolism (VTE)

DefinitionVenous thromboembolism (VTE) includes deep vein thrombosis (DVT) and pulmonary embolism (PE).

DVT descriptionFormation of a blood clot in a deep vein.

PE descriptionBlockage of an artery in the lungs by a substance that has traveled from elsewhere in the body via the bloodstream.

Clinical significanceA complication associated with major surgeries and significant morbidity and mortality.