471 Neb. Admin. Code, ch. 7, § 005

Current through June 17, 2024

Section 471-7-005 - BILLING AND PAYMENT FOR DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS, AND MEDICAL SUPPLIES (DMEPOS)

005.01BILLING.

005.01(A)GENERAL BILLING REQUIREMENTS. Providers must comply with all applicable billing requirements codified in 471 NAC 3. In the event that individual billing requirements in 471 NAC 3 conflict with billing requirements outlined in this chapter, the individual billing requirements in this chapter will govern.

005.01(B)SPECIFIC BILLING REQUIREMENTS. Providers must bill the Department on the appropriate claim form or electronic format. Any item billed to Medicaid must actually be dispensed or directly supplied by the provider that bills for the item. This does not preclude a provider from contracting with billing agents. Providers may not bill for durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) dispensed in advance.

005.01(B)(i)PROCEDURE CODES AND MODIFIERS. The provider will bill the Department using the Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) procedure codes and modifiers.

005.01(B)(ii)RENTAL BILLING PROCEDURES. Providers must use the following rental billing procedures:

(1) Bill for rental only while the item continues to be medically necessary and appropriately used by the client;

(2) Rental items not used by the client for more than a one month period, during inpatient hospitalization, may not be billed to Medicaid. The provider is responsible for determining whether the item continues to be used by the client;

(3) Bill rental on a monthly basis unless the item is used for less than a one-month period. When billing for monthly rental, the unit of service "1" indicates a one-month rental period. The provider will use the appropriate procedure code modifier when billing for monthly rental. The beginning rental date for each month will be the day of the month on which the item was initially provided. A monthly rental period is not necessarily a calendar month or a standard number

(4) of days. The monthly billing period begins the day of rental and extends to the day prior to the corresponding numerical day the following month. When rental equipment is needed at any time by the client for less than a one-month rental period, the rental is paid on a daily pro-rated basis. The provider will use the appropriate procedure code modifier when billing for daily rental. The unit of service must reflect the number of days the item was actually used; and

(5) When billing for rental items, indicate both from and to dates of service and the initial rental date.

005.01(B)(iii)USED ITEMS. When billing for used durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) items, the provider must use the used equipment (UE) procedure code modifier.

005.01(B)(iv)APNEA MONITOR SUPPLIES. Apnea monitor supplies are covered for use with rented and client-owned apnea monitors. For rented apnea monitors, the apnea monitor supplies must be billed on the same claim as the apnea monitor rental.

005.01(B)(v)HOME PHOTOTHERAPY. The provider must bill for home phototherapy daily rental on a single claim and indicate the total number of rental days as the units of service.

005.01(B)(vi)UTERINE MONITORS, HOME. The provider must indicate on the claim the condition which necessitates use of the monitor and, when billing for the final rental period, the date of discontinuation of the monitor.

005.01(B)(vii)OXYGEN THERAPY. When billing for oxygen therapy, the durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider must use the appropriate unit of service as described in the procedure code. Units of service should be rounded to the nearest unit of the procedure code description.

005.02PAYMENT.

005.02(A)GENERAL PAYMENT REQUIREMENTS. Medicaid will reimburse the provider for services rendered in accordance with the applicable payment regulations codified in 471 NAC 3. In the event that individual payment regulations in 471 NAC 3 conflict with payment regulations outlined in this chapter, the individual payment regulations in this chapter will govern.

005.02(B)SPECIFIC PAYMENT REQUIREMENTS. Medicaid pays for covered durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) at the lower of:

(1) The provider's submitted charge; or

(2) The allowable amount for that procedure code in the Nebraska Medicaid Practitioner Fee Schedule in effect for that date of service.

005.02(B)(i)MEDICARE AND MEDICAID CROSSOVER CLAIMS. Information on payment of Medicare and Medicaid crossover claims is found in 471 NAC 3.

005.02(B)(ii)ORTHOSES AND PROSTHESES. Medicaid payment for orthoses and prostheses includes:

(1) Evaluations only when no device, orthosis, prosthesis, part, repair, or adjustment is provided;

(2) Fitting;

(3) Cost of parts and labor;

(4) Repairs due to normal wear and tear for a minimum of 90 days from the date dispensed; and

(5) Adjustments made when fitting and for a minimum of 90 days from the date dispensed when the adjustments are not necessitated by changes in the client's medical condition or the client's functional abilities.

005.02(B)(iii)RENTAL PAYMENT. Payment for rental includes:

(1) All necessary repair and replacement parts; and

(2) All accessories and supplies necessary for the effective use of the equipment, unless specifically allowed as outlined in the coverage criteria for the item.

005.02(B)(iv)AIR FLUIDIZED AND LOW AIR LOSS BED UNITS. Medicaid rental payment includes:

(1) Air fluidized or low air loss bed unit and all accessories and services necessary for proper functioning and effective use of the bed;

(2) Weekly on-site client evaluation and wound care consultation by a registered nurse employed by the provider, with 24 hour per day availability; and

(3) Complete caregiver training on use of equipment, wound care, and prevention.

005.02(B)(v)APNEA MONITORS. Medicaid rental payment includes complete parent or caregiver training on use of the equipment and record keeping. Medicaid does not make separate payment for remote alarms. When provided, payment for a remote alarm is included in the monitor rental payment.

005.02(B)(vi)HOME PHOTOTHERAPY PAYMENT. Medicaid daily rental payment includes:

(1) Phototherapy unit and all supplies, accessories, and services necessary for proper functioning and effective use of the therapy;

(2) A minimum of one daily visit to the home by a licensed or certified health care professional is required. The daily visits must include:

(a) A brief home assessment; and

(b) Collection and delivery of blood specimens for bilirubin testing when ordered by the authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider to be collected in the home. The authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider must be informed by the provider that this service is available. An outside agency or laboratory with whom the provider contracts for collection and delivery of blood specimens may not bill Medicaid directly since payment is included in the daily rental payment. Daily home visits must occur for home assessment even if the blood collection is done outside the home; and

(3) Complete caregiver training on use of equipment and completion of necessary records.

005.02(B)(vii)RATE NOT ESTABLISHED CODES. For rate not established (RNE) codes on the Nebraska Medicaid Practitioner Fee Schedule, payment will be determined based on manufacturer's invoice cost.

005.02(B)(viii)SEAT LIFTS. Payment for seat lift chairs which incorporates a recliner feature along with the seat lift is limited to the amount payable for a seat lift without this feature.

005.02(B)(ix)UTERINE MONITORS, HOME. Medicaid rental payment includes all equipment, supplies, and services necessary for the effective use of the monitor. This does not include medications or authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider's professional services.

005.02(B)(x)DIALYSIS EQUIPMENT AND SUPPLIES. Medicaid reimburses for dialysis systems, related supplies, and equipment only to approved renal dialysis facilities under the Medicare Method I composite rate payment methodology. Payment cannot be made to suppliers, pharmacies, or home health agencies for dialysis systems, related supplies, and equipment.

471 Neb. Admin. Code, ch. 7, § 005

Amended effective 2/20/2024