Durable Medical Equipment And Implantables

(1) Reimbursement for durable medical equipment (DME) and medical supplies, including home DMEs, infusion and oxygen services, other than implantables, shall be reimbursed at the lesser of the provider’s billed charges or the amount listed in the rate tables (based on 100% of Medicare). (a) If no amount is listed in the rate tables and the billed charge is $100 or less, reimbursement shall be 80% of billed charges. (b) If no amount is listed in the rate tables, and the billed charge is greater than $100, reimbursement shall be the original supplier’s or manufacturer’s invoice amount, plus the lesser of 15% of invoice or $1,000, and coded using the HCPCS codes. These calculations are per item and are not cumulative. (c) Durable medical equipment and implantables shall be billed separately from facility and professional service fees only if these charges are not included in facility OPPS or the inpatient hospital DRG methodology. See Rule 0800-02-18-.07 and 0800-02-19-.03. (2) Quality. The reimbursement for supplies/equipment in this fee guideline is based on a presumption that the injured worker is being provided the highest quality of supplies/equipment. All billing shall contain the brand name, model number, and catalog number. (3) Rental/Purchase. Rental fees are applicable in instances of short-term utilization (30-60 days). The maximum allowable rental fee for DME is 100% of the Tennessee Medicare allowable amount. If it is more cost effective to purchase an item rather than rent it, this shall be stressed and brought to the attention of the insurance carrier. The first month’s rent should apply to the purchase price. However, if the decision to purchase an item is delayed by the insurance carrier, subsequent rental fees cannot be applied to the purchase price. When billing for rental, identify with modifier “RR”. (4) Transcutaneous electrical neurostimulators (TENs) Units. All bills submitted to the carrier for TENs, H-wave, Cranial Electrical Stimulator (CES) units and other external stimulator devices should be accompanied by a copy of the invoice, if available. (a) Rentals 1. Include the following supplies: (i) Lead wires; (ii) Two (2) rechargeable batteries, as indicated; (iii) Battery charger; (iv) Electrodes; and (v) Instruction manual and/or audio tape. MEDICAL FEE SCHEDULE CHAPTER 0800-02-18 2. Supplies submitted for reimbursement shall be itemized. In unusual circumstances where additional supplies are necessary and the supplies are not listed in the HCPCS rate tables, use modifier 22 and “BR.” 3. Limited to 30-day trial period. (b) Purchase: 1. Prior to the completion of the 30-day trial period, the prescribing doctor shall submit a report documenting the medical justification for the continued use of the unit. The report should identify the following: (i) Describe the condition and diagnosis that necessitates the use of a TENs unit or other external stimulator units. (ii) Does the patient have any other implants which would affect the performance of the TENs unit or the implanted unit? (iii) Was the TENs unit effective for pain control during the trial period? (iv) Was the patient instructed on the proper use of the TENs unit during the trial period? (v) How often does the patient use the TENs unit? 2. The purchase price should include the items below if not already included with the rental: (i) Lead wires; (ii) Two (2) rechargeable batteries; (iii) Battery charger; (iv) Electrodes; and (v) Instruction manual and/or audio tape (c) Only the first month’s rental price shall be credited to purchase price. (d) The provider shall indicate TENs manufacturer, model name, and serial number. (5) Continuous Passive Motion and Other External Exercise/Treatment Devices (see Medicare Code) (a) Use of this unit in excess of the days recommended by the Bureau’s adopted treatment guidelines requires documentation of medical necessity by the doctor. Only one (1) set of soft goods will be allowed for purchase. (b) The use of cold compression therapy units and other external exercise/treatment devices in excess of seven (7) days (or the length of use recommended by the Bureau’s adopted treatment guidelines) requires documentation of the device’s use and medical necessity and may be subject to utilization review. MEDICAL FEE SCHEDULE CHAPTER 0800-02-18