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MAPAP 243

DME Capped Rental


Provider Administrative Policy

Section
Ancillary Provider
Policy Date
June 2012
Status/Date
New/June 2012

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.

Policy

DME Capped Rental

The CMS DMEPOS fee schedule identifies capped rental items as category CR. After 13 months of rental, a beneficiary owns the capped rental DME item and Blue Cross of Idaho pays for reasonable and necessary repairs and servicing of the item (i.e., parts and labor not covered by a supplier's or manufacturer's warranty).

CAPPED DME RENTAL SUPPLIES MAY INCLUDE:

Commode chair Wheelchair including power, and accessories
Pressure ulcer equipment Patient lift
Bilirubin light Defibrillator
Paraffin bath Negative pressure wound pump
Bed, bedrails, safety frame for bed Traction equipment
Mattress Nebulizer
Apnea monitor Respiratory device

 CAPPED DME MODIFIERS MAY INCLUDE:

KH - DMEPOS item, initial claim, purchase or first month rental
KI -  DMEPOS item, second or third month rental
KJ -  DMEPOS item, rental months four to 13

Please not that there are two separate payment methodologies for power-driven wheelchairs and for all other Capped DME supplies.

Power-driven wheelchairs - The total rental payments equal 105 percent of the purchase price.

Month 1 2 3 4 5 6 7 8 9 10 11 12 13
KH 15%                        
KI   15% 15%                    
KJ       6% 6% 6% 6% 6% 6% 6% 6% 6% 6%

All other capped DME supplies - The total rental payments equal 105 percent of the purchase price.

Month 1 2

3

4 5 6 7 8 9 10 11 12 13
KH 10%                        
KI   10% 10%                    
KJ       7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5%

Pricing: If the RR modifier is present, but without the KH, KI or KJ capped rental modifiers, we will return the claim for corrected bill.

REPAIR AND REPLACEMENT:
Replacement items and repairs require prior authorization after satisfying the eligibility timeline requirements.

  1. With the exception of supply code K0739, repairs are not allowed during the rental period. Blue Cross of Idaho Medical Management requires prior authorization of code K0739. No replacement is allowed before five years from the date of purchase.
  2. Use Modifier RA to report loss, irreparable damage, or a stolen item. Use Modifier RB for replacement parts furnished in order to repair member owned DME.

    RA - Replacement of a DME item
    RB - Replacement of a part of DME furnished as part of a repair

Note:  Blue Cross of Idaho's Special Investigation Unit may perform post audit review to monitor provider billing for appropriate use of Capped Rental modifiers.


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