Home medical equipment & prosthetic devices
Home medical equipment (HME) can enhance the quality of life for those in need of services by providing durable medical equipment and supplies. Rehabilitation products are a necessity for anyone who has been involved in any minor or serious injury or condition such as a stroke. For those whose injuries are less severe, HME needs may include items such as crutches, canes and walkers.
Note: View specific information on HME equipment and orthoses for Healthy Options members (PDF).
Home medical equipment (HME) refers to equipment that is:
- Able to withstand repeated use
- Appropriate for use in the home
- Primarily and customarily used to serve a medical purpose
- Not generally useful to a person in the absence of illness or injury
Billing guidelines
All initial claims must include the referring physician’s prescription on file for the HME and documentation of medical necessity.
The prescription and the documentation of medical necessity should include:
- The reason the equipment is required
- The patient’s diagnosis and prognosis
- The physician’s estimate, in months, of the duration of medical need
Note: Every claim must have the prescribing physician’s name in box 17 on the CMS 1500 claim form. If you’re billing electronically, enter the prescribing physician’s name in the comment field.
Sales tax
In compliance with Washington state Senate Bill (SB) 6273, our payment to providers for eligible prescribed durable medical equipment or mobility enhancing equipment claims includes the sales tax or use a tax calculation.
Please note the following billing information:
- A separate line item should appear on claims for the sales tax or tax calculation.
- Use HCPCS S9999 Sales tax when submitting claims to Regence. The tax should be based on the equipment's allowable amount listed in our fee schedules available on the Provider Center.
Our payment to the provider will include the tax in the payment. Providers must then remit the tax to the Department of Revenue.
Services not included
- Items used for convenience only, such as grab bars
- Expendable medical supplies, such as incontinent pads
- Equipment that is inappropriate for home use, such as oscillating beds
- Items that are useful in the absence of illness or injury, such as a stationary bicycle
- Equipment that is primarily used for non-medical purposes, such as air conditioners, dehumidifiers or car seats
Equipment ordered before a patient is eligible for benefits is not covered, even if the equipment is delivered after the effective date of coverage.
Rental/Purchase Guidelines
Rental
- Rental is paid up to the purchase price
- Use Modifier -RR with HCPCS codes to indicate rental
- Repairs required on rented equipment are not separately reimbursable
- One unit of service equals one month’s rental, with the exception of HCPCS E0935 Continuous passive motion exercise device for use on knee only where one unit of service equals one day’s rental
Purchase
If the member contract allows for the purchase and the purchase of an item is more economical than continuing to rent, we will send a letter to request purchase instead of rental.
- Use Modifier –NU if purchasing new HME equipment
- Use Modifier –UE if purchasing used HME equipment
- The outstanding dollars are paid toward the purchase price
- We will only reimburse up to the purchase price regardless of when the decision to purchase is made
Additional Modifiers
When appropriate, use the following modifiers when billing for HME services. If more than one modifier is used, place the modifier in the first position or directly after the procedure and/or HCPCS code.
- Modifier -AW Items furnished in conjunction with surgical dressings
- Modifier -KM Replacement of facial prosthesis including new impression/modulage
- Modifier -KN Replacement of facial prosthesis using previous master model
Shipping and Handling
Shipping and handling charges are not eligible for separate reimbursement.
Repairs and Modifications
If the purchased equipment is not covered by the manufacturer’s warranty, we allow one month’s rental fee for loaner equipment while the equipment is being repaired or serviced.
All claims for repairs and servicing are subject to review and approval to ensure charges do not exceed the purchase price.
Replacement
If an item needs to be replaced, the referring physician must submit a new prescription and the supplier must indicate the condition of the present equipment on the prescription. Claims for replacement are subject to our review and approval.
Customization
When it is necessary for a manufacturer, factory or supplier to create an item to fit a specific patient, it is considered a custom item. Custom items must be purchased rather than rented and medical necessity criteria must be met.
HME Accessories
There are some accessories (e.g., batteries, leads, tubing, and pads) that are eligible for reimbursement in addition to the HME item when medically necessary. Contact provider customer service if you have any questions.
Back Up HME
Back up HME items are not eligible for separate reimbursement.
Deluxe Products/Upgrades
The patient may choose to upgrade from a standard product. We will only reimburse up to the allowable amount for the standard product.
It is the responsibility of the provider to inform the patient that there are standard products available that meet medical necessity. The patient must sign a waiver indicating that he or she has been informed of his or her responsibility for any outstanding balance prior to ordering the product or before the product is delivered. If the patient does not sign a waiver, the outstanding balance will be a provider write-off
Providers should use HCPCS S1001 Deluxe item, patient aware (list in addition to code for basic item) when billing for the cost in excess of the standard product. The signed waiver must accompany the bill and be on file if a health care service requests the waiver at a future date.
Pre-authorization
Pre-authorization may be required. View our pre-authorizations lists, forms and submission information.
Orthoses
Custom-made, functional orthotics are covered when they are medically necessary to treat a condition of the foot, ankle or leg. Prefabricated, supportive, accommodative and digital orthotics are not covered on most of our products.
Billing Guidelines
- Indicate the units of service
- Use HCPCS codes to bill for the orthoses
Note: Reimbursement for HCPCS orthotic codes include the cost of orthoses, cast impression and materials.
Fitting or Adjustment
Adjustment and/or fitting of orthoses and prosthetics is not covered. This service is included in the cost of the device.
Repair and/or Replacement
The repair and/or replacement of an orthotic or prosthetic device may be allowed, based on the patient’s benefit. Please use the appropriate HCPCS or CPT code when submitting a claim for repair or replacement.
Prosthetic Devices
For purposes of this document, the definition of prosthetic devices (other than dental) is: A device which replaces all or part of an internal body organ (including contiguous tissue) or replaces all or part of the function of a permanently inoperative or malfunctioning internal body organ.
A prescription must be on file and the prescribing physician’s name must appear in box 17 on the CMS-1500 claim form. Pre-authorization may be required.
Revised October 2011
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