CurrentBlue KCPolicy POL-PP-195

Durable Medical Equipment and Supplies Payment Policy

Defines Blue KC's coverage, billing, and payment rules for durable medical equipment, rentals, supplies, coding, and exclusions; applies to facility and DME providers across specified lines of business.

Policy Summary

PayerBlue KC

PolicyDurable Medical Equipment and Supplies Payment Policy

Policy CodePolicy POL-PP-195

Change TypeMultiple additions and clarifications (billing, documentation, MUE enforcement)

Effective DateNov 1, 2020

Next Review DateNov 1, 2026

Key ActionWhen submitting an unlisted code for supplies/DME, submit a detailed description, physician's order, and manufacturer invoice with pricing.

SourceLink

POLICY UPDATE CHANGES

Added information on when NCCI has no MUE for a code with examples (L8000 and A4287).

For items requiring a face-to-face encounter, a practitioner visit is required within 6 months preceding the order; suppliers using a delivery/shipping service may use the shipping date as the date of service on the claim.

When submitting an unlisted code for supplies/DME the provider must submit a detailed description, physician's order and manufacturer invoice with pricing.

Blue KC will enforce NCCI MUEs for DME effective 4/1/2023 and DME monthly billing guidelines were added.

DME providers are required to use a date range when billing for monthly supplies.

Per CMS certificates of medical necessity and DME information forms have been discontinued.

Added information on payment and informational modifiers.

4/1/2023NCCI MUE enforcement

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Coverage, Medical Necessity, and Billing Rules

Coverage criteria and billing rules

Coverage is benefit- and contract-dependent. Durable medical equipment (DME) must meet the DME definition and be medically necessary. Some items require a face-to-face visit and/or follow specific rental-versus-purchase rules.

ALL of the following

DME must: withstand repeated use; be used primarily for medical purposes; not be useful in the absence of illness or injury; be determined to be reasonable and necessary; be prescribed by a practitioner operating within the scope of his/her license; represent the most cost-effective alternative.
Supplies are normally items designed for single use only.

ALL of the following

Some DME items require a face-to-face visit with the ordering provider no more than 6 months preceding the order date.

ALL of the following

The cumulative DME rental allowance will not exceed the then-current Blue KC fee schedule purchase allowance (rental payments cease once the purchase allowance is met).
Rental billed up to 13 months; after 13 months the equipment is considered purchased (some items may be billed for a maximum of 3 months to assess compliance prior to purchase).

Lifetime rental items (examples)

Ventilators (including backup ventilators for ventilator-dependent patients)
Negative-pressure ventilators
CPM (Continuous Passive Motion) machines
Oximeters
Oxygen delivery systems (portable or at home)

Examples of possible non-coverage / ineligible items

Mechanical or electrical convenience features—these are generally non-covered unless medical necessity is documented; considered on individual basis.
Replacement of items that are still functional and/or under warranty—benefit not provided.
Environmental control devices (examples: air conditioners, humidifiers, air filters, whirlpools, jacuzzi pumps, waterbeds)—usually excluded on most contracts.
Equipment used in facilities—facility expected to provide such equipment; separate benefit not provided.
Non-reusable, non-rental supplies (examples: support hose, surgical face masks, disposable sheets, diapers/pads, emesis basins)—benefit not provided.
Other items not primarily medical in nature or inappropriate for home use (examples: bedside/over-bed tables, oscillating beds, treadmills, standard paraffin units).

ALL of the following

Examples include abdominal support belts for pregnant women, adaptive eating equipment, air conditioners, air filters, bedpans and urinals, car seats, computer hardware/software, exercise equipment (bicycles, treadmills), home monitors, incontinence supplies, vehicle modifications, whirlpools/Jacuzzis, and others listed in policy.

ALL of the following

DME/supplies purchased from internet or private parties (e.g., eBay) are not covered unless supplied by a DME/supply company with a provider number; otherwise claims will be denied.

ALL of the following

Supplies are allowed separately only in conjunction with approved home health care; office supplies are part of professional service overhead and will be denied if billed separately.

ALL of the following

Unlisted supply codes should be used only when no other code exists; providers must submit a detailed description of the supply, physician's order, and manufacturer invoice (see unlisted-code billing requirements).

ALL of the following

Claims must use the HCPCS Level II code that most appropriately describes the item and submit units consistent with the billing descriptor.
Date of service should equal date delivered; place of service should be Home.
Maintain documentation (e.g., Certificate of Medical Necessity) available upon request (note: CMS CMN/DME forms discontinued—retain other required documentation).

ALL of the following

Apply required purchase and informational modifiers per policy (examples include NU, RR, RA, BP, NR, RT/LT and applicable GA/GZ/GY/KX where required). Specific codes may require specific modifiers; follow Blue KC guidance for modifier placement and payment calculations (including CMS-based payment rules for power wheelchairs).

ALL of the following

Blue KC enforces National Correct Coding Initiative (NCCI) Medically Unlikely Edits (MUEs) for all DME, accessories, and supplies effective 4/1/2023.
When no NCCI MUE exists for a code, Blue KC will establish appropriate limits (examples and guidance provided in policy).

ALL of the following

No additional claims for rental or purchase of the same device should be submitted after the Blue KC allowed purchase amount has been met.

Coverage determinations depend on the member's benefit and contract terms; check member benefit for coverage and prior-authorization requirements.

Refer to policy for full lists and contract-specific benefit determination

Billing and documentation criteria

Billing and documentation requirements and special rules:

ALL of the following

When submitting an unlisted code for supplies/DME, the provider must submit a detailed description of the supply, a copy of the physician's order, and the manufacturer invoice with pricing.

ALL of the following

DME providers are required to use a date range when billing for monthly supplies.
Suppliers who use a delivery/shipping service may use the shipping date as the date of service on the claim when applicable.

ALL of the following

Blue KC enforces NCCI MUEs for DME effective 4/1/2023; providers must follow NCCI MUE limits where applicable.

HCPCS Codes, MUEs, and Coding Examples

Example HCPCS supply codes and narrativesHCPCSCovered

A4927	Glove, non-sterile, per 100
A4930	Gloves, sterile, per pair
A4287	Disposable collection and storage bag for breast milk, any size, each (example with MUE guidance)

HCPCS code ranges for DME and suppliesHCPCS

A9150-A9999	Administrative, Miscellaneous, and Investigational medical and surgical supplies
B4034-B9999	Enteral and Parenteral Therapy supplies
C1600-C1606	Surgical, imaging devices, and grafts
E0100-E8002	Durable medical equipment
K1004-K1037	Components, accessories, and supplies
L0112-L4361	Orthotic procedures and services
L5000-L9900	Prosthetic Procedures
Q0035-Q9999	Temporary codes
S0012-S9999	Temporary national codes (non-Medicare)
V2020-V2799	Vision Services

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Custom MUE / Allowance Example (Blue KC)

Custom MUE / allowance (Blue KC example)A4287 — Disposable collection and storage bag for breast milk: Blue KC allows 100 storage bags every 30 days when NCCI has no MUE.

Basis for custom limitsWhen NCCI has no MUE for a code, Blue KC sets limits using HCPCS/CPT descriptors, CPT coding instructions, anatomic considerations, CMS policies, nature of service/analyte/equipment, prescribing information, and clinical judgment.

Unit billing example guidanceFollow HCPCS unit descriptors (e.g., submit one unit for a 100-count box of gloves for A4927 as shown in examples).

NCCI MUE Enforcement

NCCI MUE enforcement effective dateBlue KC enforces NCCI MUEs for DME effective 4/1/2023.

Provider Responsibilities, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Certain durable medical equipment may require prior authorization. For a complete list of equipment and services requiring prior authorization, refer to the Blue KC list of items/services requiring prior authorization at www.bluekc.com.

Effective 4/1/2023, Blue KC enforces the National Correct Coding Initiative (NCCI) Medically Unlikely Edits (MUEs) for all durable medical equipment, accessories, and supplies.
When a DME item is covered, benefits may include supplies and accessories required for effective functioning, and repairs, adjustments, or replacement of components as allowed by the member's contract.
Note: Accessories, replacements, or repairs may not be reimbursed separately when the primary item is being rented.

Documentation Required

Unlisted Code Submission Requirements

When submitting an unlisted HCPCS/CPT code for supplies or durable medical equipment, the provider must include a detailed description of the item, a copy of the physician's order, and an invoice from the manufacturer showing pricing.

Definitions and References

Durable Medical Equipment (DME)

DefinitionDurable Medical Equipment (DME): medical equipment that can withstand repeated use, has a medical purpose, is generally not useful without illness or injury, and is appropriate for home use.

Common examplesWheelchairs, hospital beds, oxygen equipment, CPAP machines.

Key attributesReusable, medically necessary, prescribed by a licensed practitioner, and appropriate for use in the home setting.

Medical Supplies

DefinitionMedical supplies: items used to prevent, diagnose, treat, and rehabilitate illnesses and injuries; often single-use items such as bandages, gloves, needles, syringes, and catheters.

Examples from coding guidanceA4927 — Glove, non-sterile, per 100; A4930 — Gloves, sterile, per pair.

Policy Summary

PayerBlue KC

PolicyDurable Medical Equipment and Supplies Payment Policy

Policy CodePolicy POL-PP-195

Change TypeMultiple additions and clarifications (billing, documentation, MUE enforcement)

Effective DateNov 1, 2020

Next Review DateNov 1, 2026

Key ActionWhen submitting an unlisted code for supplies/DME, submit a detailed description, physician's order, and manufacturer invoice with pricing.

SourceLink

On This Page

Billing Rule

Monthly Supplies Billing and Date-of-Service Guidance

DME providers are required to use a date range when billing for monthly supplies. If the supplier uses a delivery/shipping service, the supplier may use the shipping/delivery date as the date of service on the claim.

Use date ranges for monthly supplies billing (e.g., 01/01/2024-01/31/2024).
When billing monthly rental fees or supplies, follow Blue KC billing guidance for date spans and applicable modifiers.