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DURABLE MEDICAL EQUIPMENT ORTHOTICS & PROSTHETICS WEBINARS MAY 2012 Presented by: Debbie Leblanc and Yesenia Osorio HP Enterprise Services PowerPoint PPT Presentation


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DURABLE MEDICAL EQUIPMENT ORTHOTICS & PROSTHETICS WEBINARS MAY 2012 Presented by: Debbie Leblanc and Yesenia Osorio HP Enterprise Services. INTRODUCTIONS. HP Enterprise Services Division of Medical Assistance (DMA). AGENDA. Program Integrity EPSDT N. C. Health Choice

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DURABLE MEDICAL EQUIPMENT ORTHOTICS & PROSTHETICS WEBINARS MAY 2012 Presented by: Debbie Leblanc and Yesenia Osorio HP Enterprise Services

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Durable medical equipment orthotics prosthetics webinars may 2012 presented by debbie leblanc and yesenia osorio hp

DURABLE MEDICAL EQUIPMENT

ORTHOTICS & PROSTHETICS WEBINARS

MAY 2012

Presented by:

Debbie Leblanc and Yesenia Osorio

HP Enterprise Services


Introductions

INTRODUCTIONS

  • HP Enterprise Services

  • Division of Medical Assistance (DMA)


Agenda

AGENDA

  • Program Integrity

  • EPSDT

  • N. C. Health Choice

  • Community Care of North Carolina/Carolina Access

  • Policy Updates

  • Prior Approval

  • Billing Tips

  • Q & A


Durable medical equipment orthotics prosthetics webinars may 2012 presented by debbie leblanc and yesenia osorio hp

PROGRAM INTEGRITY

Dma


Program pi integrity unit

Federally mandated

Prevent, identify, and combat fraud, waste, and abuse within the

Medicaid Program

Ensure Medicaid recipients receive quality care and do not abuse their benefits

Take administrative actions when aberrancies are identified

Program (PI) Integrity Unit


Program pi integrity unit1

Program (PI) Integrity Unit

It is the mission of Program Integrity to ensure

compliance, efficiency, and accountability within the N.C. Medicaid Program by detecting and preventing fraud, waste, program abuse, and by ensuring that Medicaid dollars are paid appropriately by implementing tort recoveries, pursuing recoupments, and identifying avenues for cost avoidance.


Program pi integrity authority

Federal

Code of Federal

Regulations (Title 42 Public Health)

Social Security Act

Amendments

Affordable Care Act

State

General Statues

State Plan

State Clinical

Policies and Bulletin Articles

Program (PI) Integrity Authority


Program integrity sections

Provider Medical Review

Home Care Review Section

Behavioral Health Review Section

Third-Party Recovery Section

Special Projects Section

Quality Assurance Section

Program Integrity Sections


Ibm fraud and abuse management system fams

IBM Fraud and Abuse Management System (FAMS)

  • Data mining software using behavior models to detect common fraud and abuse schemes

    • Models configured to North Carolina Medicaid using input from DMA staff

  • Algorithms and models used across Healthcare Industry (both public and private payers) as well as cell phone companies, property and casualty insurers, and more


Dme model

DME Model

  • Model: Measurement of provider behavior

    • Used to analyze provider as a whole

  • DMA Program Integrity, DMA Clinical Policy, and IBM worked together to develop criteria

    • Example: Number of diapers per patient per month

  • PI Data analytics team performed analysis to identify suspicious behavior for further review


Examples of initial findings

Examples of Initial Findings

  • Billing for up to 480 nutritional kits per patient, per month

  • Various sizes of diapers for same patient, same date of service

  • Two year old receiving enough thickener for 2 gallons of fluid per day


Durable medical equipment orthotics prosthetics webinars may 2012 presented by debbie leblanc and yesenia osorio hp

EPSDT


Early and periodic screening diagnosis and treatment epsdt

EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT)

MEDICAID FOR CHILDREN

Contacts: Directorc/o Assistant Director for Clinical Policy and ProgramsDivision of Medical Assistance2501 Mail Service CenterRaleigh, NC 27699-2501Fax: 919-715-7659


Epsdt websites

EPSDT Websites

  • Basic Medicaid & N.C. Health Choice Billing Guide

    http://www.ncdhhs.gov/dma/basicmed/index.htm

  • Health Check Billing Guide

    http://www.ncdhhs.gov/dma/healthcheck/index.htm#guide

  • EPSDT Provider Page

    http://www.ncdhhs.gov/dma/provider/epsdthealthcheck.htm


Durable medical equipment orthotics prosthetics webinars may 2012 presented by debbie leblanc and yesenia osorio hp

N. C. HEALTH CHOICE


N c health choice nchc claims

N. C. Health Choice (NCHC) Claims

  • Run-out period with BCBSNC was February 29, 2012 for dates of service through September 30, 2011

  • Dates of service prior to October 1, 2011 contact DMA Claims Analysis unit at 919-855-4045

Basic Medicaid Billing Guide – Section 3


Health choice eligibility criteria

Health Choice Eligibility Criteria

  • Children ages 6-18 (last day of month they turn 19)

  • No EPSDT

  • Does not qualify for Medicaid, Medicare, or other federal government sponsored health insurance

  • NC resident

  • Has paid enrollment fee (if applicable)

  • Within 101% - 200% of the Federal Poverty Level

  • Co pays do not apply for DME or O&P

Basic Medicaid Billing Guide – Section 3


Health choice identification card

Health Choice Identification Card

Basic Medicaid Billing Guide – Section 3


Health choice secondary insurance

Health Choice Secondary Insurance

Pursuant to N.C. GEN. STAT. §108A – 70.18(8): Health Choice does not allow secondary insurance. It is the recipient’s duty to notify the Department of Social Services (DSS) prior to approval, and/or within 10 days of receipt of the other health insurance. The DSS, upon receipt of notice, shall disenroll the child from the Program.

Basic Medicaid Billing Guide – Section 3


Health choice resources

Health Choice Resources

  • Clinical Coverage Policies

    http://www.ncdhhs.gov/dma/hcmp/index.htm

  • What’s New in DMA

    http://www.ncdhhs.gov/dma/provider/index.htm

  • NC Healthy Start Foundation

    www.NCHealthyStart.org

  • Fee Schedules

    http://www.ncdhhs.gov/dma/fee/index.htm

  • Children with Special Health Care Needs Help Line

    1-800-737-3028


Medicaid id card

Medicaid ID Card

ISSUE DATE MARCH 1, 2012

DHHS Customer Service Center at 1-800-662-7030.


Federal regulations

Federal Regulations

  • Medicaid is the “payer of last resort”

  • If the Medicaid-allowed amount is more than third-party payment, Medicaid will pay the difference up to the Medicaid-allowed amount

  • If insurance payment is more than Medicaid-allowed amount Medicaid will not pay any additional amount

  • Does not apply to NCHC


Noncompliance denials

Noncompliance Denials

  • Medicaid does not pay for services denied by private health plans due to noncompliance with the private health plan’s requirements

  • Compliance with the plan’s requirements is the responsibility of the provider and the patient

  • It is the recipient’s responsibility to inform the County DSS of any third-party insurance as well as any changes in insurance coverage.


Durable medical equipment orthotics prosthetics webinars may 2012 presented by debbie leblanc and yesenia osorio hp

CCNC/CA


Ccnc structure

CCNC Structure

  • Statewide program of 14 regional networks

    • Non-profits that operate in partnership with hospitals, health depts., DSS, PCPs and others

    • Include more than 3000 physicians

    • Physician led by clinical director

      http://www.ncdhhs.gov/dma/ca/ccncproviderinfo.htm

Basic Medicaid Billing Guide – Section 6


Process for giving a ccnc ca referral

Process for Giving a CCNC/CA Referral

  • For Carolina ACCESS enrollees, the PCP’s NPI number must be provided to the specialist or other health service provider as the authorization number

  • Please use the NPI that the PCP reported to DMA for the Medicaid Provider Number (MPN) used to link Carolina ACCESS recipients to their practice

Basic Medicaid Billing Guide – Section 6


Ccnc ca override requests

CCNC/CA Override Requests

  • Only for extenuating circumstances

  • Only considered within 6 months

  • Carolina Access Override Request Form http://www.ncdhhs.gov/dma/provider/forms.htm

  • DME Override Requests are forwarded to DMA for evaluation

Basic Medicaid Billing Guide – Section 6


Durable medical equipment orthotics prosthetics webinars may 2012 presented by debbie leblanc and yesenia osorio hp

POLICY


Policy guidelines

Policy Guidelines

  • Refer to Clinical Coverage Policy:

    • 5A, Durable Medical Equipment refer to website http://www.ncdhhs.gov/dma/mp/dmepdf.pdf

    • 5B, Orthotics and Prosthetics refer to website http://www.ncdhhs.gov/dma/mp/5B.pdf


General dme policy updates

General DME Policy Updates

  • Changes retroactive to October 1, 2011

  • HCPCS Code list, item description and lifetime expectancy or quantity limitations – Attachment A of policy

  • Effective May 11, 2012, please note the additions to the following sections of the Medical Coverage Policy #5, Durable Medical Equipment have been posted for 15 day public comment; section 5.3.6 Rental Wheelchairs, section 5.6 Delivery of Service and

    section 7.2 Record Keeping.


Roche accu chek diabetic supplies under the dme and pharmacy programs

Roche ACCU-CHEK Diabetic Supplies Under the DME and Pharmacy Programs

  • Effective November 15, 2011, Roche Diagnostics Corporation Diabetes Care is N.C. Medicaid's designated preferred manufacturer for blood glucose monitors, diabetic test strips, control solutions, lancets, and lancing devices. These products are covered under the Durable Medical Equipment and Outpatient Pharmacy Programs and will be reimbursed under the pharmacy point-of-sale system with a prescription.   

  • Prior authorization will be allowed for insulin-pump dependent recipients who cannot use Roche products.  Pharmacy and DME providers need to ensure that invoices are easily retrievable in case documentation is needed to support the billing of these products.  This could be requested to support the quantities being invoiced to Roche for the rebates due back to N.C. Medicaid and N.C. Health Choice.

  • Effective November 15, 2011, there are no designated preferred manufacturers of insulin syringes.

  • For additional information, providers may call ACCU-CHEK Customer Care, 1-877-906-8969 or DMA Clinical Policies and Programs at 919-855-4310 (DME) or 919-855-4300 (Pharmacy).


Diabetic supplies

Diabetic Supplies

  • Roche ACCU-CHEK Diabetic Supplies Program Extension.

  • Prodigy diabetic supplies coverage extended until July 31, 2012.

  • Roche and Prodigy diabetic supplies will be covered until July 31, 2012.

  • Overrides will not be required. This applies to the durable medical equipment (DME) and pharmacy point-of-sale claims processing systems.

  • Effective August 1, 2012 only ACCU- CHEK diabetic supplies will be covered.


Prior authorization instructions for insulin pump users

Prior Authorization Instructions for Insulin Pump Users

With an effective date based on date of service of January 15, 2012 prior authorization will be required for insulin-pump dependent recipients who cannot use Roche products due to a dedicated glucometer communicating with their insulin pump.  In these instances the provider must be a durable medical equipment (DME) provider or a pharmacy/DME provider.  Claims with a prior authorization on file will need to be submitted with a NU and U9 modifier.  Claims for test strips not supplied by Roche that do not have a Prior authorization on file for A4253 NU, U9 will be denied for lack of authorization.  The U9 modifier will indicate that test strips not supplied by Roche have been authorized for payment.  Prior authorization requests should be submitted to HPES at the following addresses: 

N.C. Medicaid

P.O. Box 31188 

Raleigh, NC 27622

N.C. Health Choice

P.O. Box 322490

Raleigh, NC 27622


Prior authorization instructions for insulin pump users1

Prior Authorization Instructions for Insulin Pump Users

Billing Instructions for Submitting Diabetic Supplies under Pharmacy Point-of-Sale System Claims for diabetic test strips, control solution, lancets and lancing devices submitted at point-of-sale must be billed using the NDC.  Test strips must be billed in multiples of 50 and lancets must be billed in multiples of 100 except for the ACCU-CHEK Compact Test Strips, 51 count package size and the ACCU-CHEK Multiclix Lancets, 102 count package size.  In order to accommodate the unbreakable package sizes under the pharmacy point-of-sale system, the ACCU-CHEK Compact Test Strips (NDC 50924-0988-50) can be billed up to 204 test strips per month for recipients 21 years of age and older and up to 306 test strips per month for recipients under 21 years of age will be allowed.  At this time, test strip quantities over 204 per month must be requested through the DME program; however, point-of-sale system changes are underway to accommodate the higher quantity limits for pediatric recipients.  Additional information will be provided when this system change has been completed.  The same rules apply for the ACCU-CHEK Multiclix Lancets (NDC 50924-0450-01).  For Medicaid billing, 1 lancing device = 1 unit.  Rates apply to these diabetic supplies; therefore, no copayments and no dispensing fees apply.


Pediatric specialty beds

Pediatric Specialty Beds

  • New addition to hospital beds

  • Examples are SleepSafe or Pedicraft bed

  • Special safety features

  • Designed for children with physical/cognitive disabilities

  • Prior Approval (PA) required

Clinical Coverage Policy 5A - Section 5.3.1


Wheelchairs

Wheelchairs

  • PA is required for all wheelchairs

  • Basic criteria must be met

  • In addition, more justification for other wheelchairs

  • Standard criteria change

    • Home evaluation required

    • Adequate access between rooms

    • Maneuvering space and services

  • All Wheelchairs are to be used in the home

Clinical Coverage Policy 5A - Section 5.3.6


Ultra light weight wheelchair

Ultra Light Weight Wheelchair

  • Recipient in wheelchair minimum of 6 hours

  • MUST have clinical wheelchair evaluation from a Physical or Occupational Therapist (PT/OT)

  • Description of recipient’s medical condition, mobility limitations, and other physical /functional limitations

  • PT/OT shall have no financial relationship with supplier

  • Manufacturer Suggested Retail Price (MSRP) quote for PA required for wheelchair and accessories

Clinical Coverage Policy 5A - Section 5.3.6


High strength lightweight wheelchair

High-Strength Lightweight Wheelchair

  • Basic manual wheelchair coverage criteria

  • Recipient in wheelchair minimum of 6 hours a day

Clinical Coverage Policy 5A - Section 5.3.6


Adult manual wheelchair

Adult Manual Wheelchair

  • Basic Manual Wheelchair coverage criteria

  • Coverage criteria for tilt in space option

  • Letter of medical necessity from PT/OT

  • MSRP quote

  • Clinical wheelchair evaluation

Clinical Coverage Policy 5A - Section 5.3.6


Transport chairs rollabout chairs

Transport Chairs/Rollabout Chairs

  • Adult/Pediatric covered if recipient needs to be mobilized by caregiver

  • Covered when medically necessary

  • PA IS required for transport chairs

  • PA is NOT required for rollabout chair

  • For specific codes covered refer to: Attachment A, C: Procedure Code(s) Lifetime Expectancies and Quantity Limitations for DME and Supplies, Transport Chairs

Clinical Coverage Policy 5A - Section 5.3.6


Power wheelchairs

Power Wheelchairs

  • Standard power wheelchair criteria plus additional information has to be met

  • Height, weight, and body measurements must be included in evaluation for Heavy Duty Power chairs

  • Manufacturer’s specified weight capacity is needed

  • Power Seat Elevation ONLY covered for 0-20 years of age

Clinical Coverage Policy 5A - Section 5.3.6


Power wheelchairs1

Power Wheelchairs

  • Face-to-face examination consisting of in-person visit to treating physician required to request chair and comprehensive medical exam

    • Examination must be documented in detail in physician chart

    • Must indicate major reason for visit was mobility exam

    • Must document recipient strength, mobility and functional deficits to support need

Clinical Coverage Policy 5A - Section 5.3.6


Power wheelchairs2

Power Wheelchairs

  • Face-to-face evaluation prior to physician’s order

    • Information of condition and progression of disease

    • Ambulatory status

    • Medical justification for accessories billed

    • Additional clinical health care records can be submitted to supplement

Clinical Coverage Policy 5A - Section 5.3.6


Power wheelchairs3

Power Wheelchairs

  • Onsite written assessment of recipient’s home required

    • Verifies, documents and supports use

    • Performed by supplier

    • Must include measurements of home layout, doorway widths and thresholds and surfaces traveled

Clinical Coverage Policy 5A - Section 5.3.6


Power wheelchairs4

Power Wheelchairs

  • MSRP quote from the manufacturer required

    • Wheelchair supplier generated form MUST NOT be used for documentation of physician’s exam

    • Backup chairs are not covered

    • Power wheelchair is not medically necessary when condition is reversible and length of need less than 3 months

Clinical Coverage Policy 5A - Section 5.3.6


Activity positioning chairs

Activity/Positioning Chairs

  • PA required and now reviewed at HPES

  • Recipients ages 0 - 20 years of age

  • Physical disabilities and positioning support to sit and perform activities

  • Meet medically necessary criteria

Clinical Coverage Policy 5A - Section 5.3.7


Osteogenesis stimulator

Osteogenesis Stimulator

  • Surgery removed as requirement

  • Requires 2 sets of radiographs prior to treatment

  • Radiographs require multiple views of facture site

  • Written interpretation by MD, PA or NP of no evidence healing

Clinical Coverage Policy 5A - Section 5.3.13


Continuous glucose monitoring system and supplies

Continuous Glucose Monitoring System and Supplies

  • Ages 0 - 20 years

  • PA required

  • Medicaid covered criteria:

    • Insulin-dependent diabetes

    • Documentation of recurrent severe hypoglycemic episodes or fasting hyperglycemia, nocturnal hypoglycemic episodes, hypoglycemic unawareness

    • Recipient has external insulin pump which communicates with a CGMS

Clinical Coverage Policy 5A - Section 5.3.15


High frequency chest wall oscillation device

High-Frequency Chest WallOscillation Device

  • Diagnoses added to criteria

    • Neuromuscular diagnosis

    • Neuromuscular conditions

    • High level spinal cord injuries

  • Covered diagnoses – Attachment A & B in Policy

Clinical Coverage Policy 5A - Section 5.3.18


Cough stimulating device

Cough-Stimulating Device

  • Diagnoses added to criteria

    • Neuromuscular diagnosis

    • Neuromuscular conditions

    • High level spinal cord injuries

  • Covered diagnoses – Attachment A & B in Policy

Clinical Coverage Policy 5A - Section 5.3.19


Oral nutrition metabolic formula

Oral Nutrition Metabolic Formula

  • Metabolic formulas are covered for recipients ages 0 - 115

    • In-born errors of metabolism diagnosed at birth and before the age of 10 years

Clinical Coverage Policy 5A - Section 5.3.23


Oral nutrition metabolic formula1

Oral Nutrition Metabolic Formula

  • Medical necessity must be re-established at specific intervals by providing Oral Nutrition Product Request Form and CMN/PA

    • Every 12 months for diagnosed inborn error of metabolism

    • Every 6 months with documentation for other conditions

    • For recipients receiving modular components and feeding devices, submit at either 6 or 12-month interval

    • http://www.ncdhhs.gov/dma/forms/OralNutritionProdReq.pdf

Clinical Coverage Policy 5A - Section 5.3.23


Bath and toilet aids

Bath and Toilet Aids

  • Pediatric 0 – 20 years

  • PA now reviewed at HPES

  • Accessory Codes NO LONGER W4047

  • Accessory Codes NOW E0700

Clinical Coverage Policy 5A - Section 5.3.27


Durable medical equipment orthotics prosthetics webinars may 2012 presented by debbie leblanc and yesenia osorio hp

PRIOR APPROVAL


Due process

Due Process

  • Effective March 21, 2012

  • Notice of Request for Additional Information to recipients and providers from HPES

  • Medicaid is requesting medically necessary documentation to meet clinical policy criteria

  • Return all information initially submitted to HPES plus the additional documentation requested

  • Not a denial but must be submitted timely

  • Submission deadline date on Notice of Request


Prior approval

Prior Approval

  • See Basic Medicaid & N.C. Health Choice Billing Guide Section 7

  • CMN 3-part required for all services

  • PA obtained before rendering a service, product or procedure

  • Does not guarantee payment

  • PA not transferable

  • Usually takes 5 business days from receipt


Prior approval1

Prior Approval

  • Height and weight required on the CMN regardless of diagnosis

  • CMN/PA forms in use prior to 2005 that did not contain the height and weight requirement will no longer be accepted after June 1, 2012

  • Contact HPES at: 1-800-688-6696 or 919-851-8888, option #2


Dme prior approval tips

DME Prior Approval Tips

Common reasons for PA returns:

  • Original signed/dated CMN missing

  • Both state and national codes not included on CMN, or incorrect code listed

  • Use of signature stamp not acceptable

  • Correction tape/fluid used on CMN

  • Sections 14 through 23 not completed correctly

  • All items including supplies & accessories need to be listed separately


Dme prior approval tips1

DME Prior Approval Tips

Wheelchairs and Beds:

  • Include height and weight

  • Mark “Confined” in field 22 when appropriate

  • When “Not confined” is marked, provider must complete “Walks” section and specify max distance walked

  • Procedure codes in Groups 2 and 3 must include specific wound documentation


Dme prior approval tips2

DME Prior Approval Tips

Wound Documentation:

  • Be specific when documenting. Example: for tunneling, do not write yes or no. Provide location, size, drainage, etc.

  • Reviewed each month

  • Procedure codes in Groups 2 and 3 must include specific wound documentation


Dme prior approval tips3

DME Prior Approval Tips

Oxygen:

  • When recertifying, include original qualifying oxygen percent saturation level and the date (mm/dd/yy) taken

  • At the end of 36 months, ALL recipients must be recertified


Dme prior approval tips4

DME Prior Approval Tips

CPAP and ByPAP:

  • Diagnosis of Obstructive Sleep Apnea (OSA)

  • Sleep study done within 1 year must be provided

    • Cannot be an in home sleep study


Prior approval form cmn

Prior Approval Form (CMN)

  • Providers may obtain CMN/PA Forms by contacting: HPES at 1-800-688-6696 or 919-851-8888, option #3

  • CMN/PA forms that were in use prior to 2005 that did not contain the height and weight requirement will no longer be accepted after June 1, 2012


Orthotics prosthetics prior approval tips

Orthotics & Prosthetics Prior Approval Tips

All CMN requests should include:

  • Two provider numbers in Field 7

  • Two signatures in Field 27

  • Manufacturer’s price quote sheet for manually priced items


Orthotics prosthetics prior approval tips1

Orthotics & Prosthetics Prior Approval Tips

  • Diabetic Shoes CMN criteria:

    • Recipient has diabetes mellitus

    • Recipient has one or more required conditions

    • Physician certification


Orthotics prosthetics prior approval tips2

Orthotics & Prosthetics Prior Approval Tips

  • PA Forms are found in Attachment G of Policy 5B for:

    • Component L5781 or L5782

    • Component L5930

    • Component L5968

    • Component L5980

    • Component L5987

    • Component L5988


Prior approval contacts

Prior Approval Contacts

Send CMN to:

HPES/PA

P. O. Box 31188

Raleigh, NC 27627

Health Choice Prior Approvals processed by HPES:

N.C. Health Choice

P. O. Box 322490

Raleigh, NC 27622


Durable medical equipment orthotics prosthetics webinars may 2012 presented by debbie leblanc and yesenia osorio hp

BILLING TIPS


Dme labor repair replacement

DME Labor/Repair/Replacement

Effective July 1, 2011 Medicaid & effective October 1, 2011 N.C. Health Choice will pay for:

  • K0739 (labor)

  • Repair of medical equipment owned, not under warranty

  • Installation of replacement parts

  • Repair estimate required

  • Breakdown of charges

  • Number of hours of labor

  • Prior Approval Required


Labor repair replacement

Labor/Repair/Replacement

  • Medicaid & N.C. Health Choice will NOT pay for:

    • Pick up or delivery

    • Assembly of new equipment

    • Freight

    • Provider travel time or expense

    • Maintenance or service contracts

  • Rental Equipment:

    • Service and repairs provided as part of rental rate

    • No additional payment by Medicaid or N.C. Health Choice


Dme labor repair replacement example

DME Labor/Repair/Replacement Example

  • Power Wheelchair K0823

  • Complaint – batteries will not charge

  • Solution – replace batteries

  • Labor – 2 units (installation of replacement parts)

    If seat and housing to be removed, more complex repair

  • Labor – up to 4 units (installation of replacement parts)

    Examples/scenarios are not all inclusive and labor units are rough estimates of what might be considered reasonable


Dme labor repair replacement example1

DME Labor/Repair/Replacement Example

  • Manual Wheelchair K0003

  • Complaint – Brake assembly fell off

  • Solution – Replace brake assembly

  • Provider – Provides and installs replacement parts

  • Labor – up to 3 units (installation)

    Examples/scenarios are not all inclusive and labor units are rough estimates of what might be considered reasonable


Nebulizer billing by pharmacies

Nebulizer Billing by Pharmacies

  • Nebulizers and related supplies must be billed with DME NPI & not as Point-of-Sale

  • Recipients must meet medical necessity requirements as listed in DME Clinical Coverage Policy No. 5A

  • Self-contained, ultrasonic nebulizer and related supplies require Prior Approval

  • Attachment A - Specific HCPCS codes covered by Medicaid or N.C. Health Choice

  • Attachment A - Procedure Code(s) Lifetime Expectancies and Quantity Limitations


Durable medical equipment orthotics prosthetics webinars may 2012 presented by debbie leblanc and yesenia osorio hp

Q & A


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