Prior authorization and MCMN requirements

Providers should consult the DME fee schedule on the SCDHHS website for information on which HCPCS codes require prior authorization and which codes require a signed Medicaid Certificate of Medical Necessity (MCMN) to be attached to the CMS-1500 claim form.

• Obtain and maintain a valid signed MCMN in the beneficiary's file for every HCPCS code billed for reimbursement.
• Visit the SCDHHS website frequently for changes to the fee schedule and to identify codes requiring prior authorization or MCMN attachment.

DME procedure and ICD-10-CM diagnosis code listing

Section contains updated Durable Medical Equipment procedure codes and ICD-10-CM diagnosis codes (diabetes-related) to be used for DME billing; providers must reference these listed diagnosis codes when submitting claims.

• ICD-10-CM diagnosis codes for Type 2 diabetes with ophthalmic complications are listed (examples: E11.3519, E11.3521, E11.3522).
• ICD-10-CM codes for Other specified diabetes mellitus (E13.*) and multiple complications are included (examples: E13.00, E13.311, E13.319).

Use of ICD-10-CM codes by date of service

For dates of service on or after October 1, 2016, providers must use the ICD-10-CM diagnosis codes listed in this section; for dates of service prior to October 1, 2016, refer to the October 2015 Update included in this section.

• The October 2016 update governs codes for services on/after 2016-10-01.
• The October 2015 update applies for earlier dates of service and is included in this section for reference.

Section 4 header and partial ICD-10-CM listing

Section 4: Durable Medical Equipment Procedure Codes — header and partial ICD-10-CM code listing for Section 4 are provided in this extract; the displayed fragments do not include prior authorization, denial risk, or step therapy instructions — consult the full Section 4 and the DME fee schedule for complete procedure code lists and administrative rules.

• SECTION 4 heading: Section 4 Durable Medical Equipment Procedure Codes (procedure codes and modifiers).
• This extract contains partial ICD-10-CM diagnosis code fragments for use with Section 4; full Section 4 contains additional procedure codes and code-specific instructions.

ICD-10-CM diagnosis listings (E11.* and E13.* fragments)

This extract lists ICD-10-CM diagnosis codes for diabetes with ophthalmic complications and related conditions (examples shown); providers must select the appropriate specific ICD-10-CM code from the listed E11.* and E13.* series when billing DME associated with these diagnoses.

• Examples from E11 series: E11.3519 (proliferative diabetic retinopathy), E11.3521 (macular edema, unspecified eye), E11.3522 (traction retinal detachment involving the macula, right eye).
• Examples from E13 series: E13.00, E13.01, E13.311, E13.319 and broader E13.* codes for other specified diabetes mellitus with complications.