This policy describes how UnitedHealthcare reimburses for the rental and/or purchase of certain items of Durable Medical Equipment (DME), Prosthetics and Orthotics. The provisions of this policy apply to the Same Specialty Physicians and Other Health Care Professionals, which includes DME, Prosthetic and Orthotic vendors, renting or selling DME, Prosthetics or Orthotics.
For purposes of this policy, Same Specialty Physician or Other Health Care Professional is defined as physicians and/or other health care professionals of the same group and same specialty reporting the same Federal Tax Identification number (TIN).
Refer to the UnitedHealthcare "Maximum Frequency per Day" policy for additional information pertaining to reimbursement for physician claims submitted with multiple units for the same CPT or HCPCS code on the same date of service.
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Q: Why is a rental month defined as a Calendar Month when months vary as to their number of days?
A: The rationale for reimbursing rental once per Calendar Month rather than once per 30 day period is due to the fact that some months are less or greater than 30 days. Billing trends indicate that rentals are reported on a cycle billing method; i.e., item dispensed on 1/9, and rented for 3 continuous months. Resulting bills will be submitted with 1/9 and 2/9 and 3/9 dates of service.
Q: How should monthly rental of DME items be reported?
A: According to the National Uniform Billing Committee (NUBC) and the National Uniform Claim Committee (NUCC), monthly rental of an item should be reported on a single claim line with one unit and a single calendar month date span—that is, for one month, enter the rental initiation date in the From field and the end date of that month’s rental in the To field. Rental charges for multiple months should not be reported on the same line. If two claims are submitted that show From dates in the same month for the same item from the Same Specialty Physician or Other Health Care Professional, only one claim will be allowed and the second claim for the same month will not be covered. See the policy section titled Reporting Monthly Rental for an example of how to report more than one month’s rental for the same item. Note that each line in the example has a From date in a different month.
Q: Why does UnitedHealthcare pay a full Calendar Month rental rate when modifier KR is used, which indicates the item is only rented for a partial Calendar Month?
A: Regardless of whether the item is used for a full Calendar Month or only a few days within a Calendar Month, UnitedHealthcare allows reimbursement only once per calendar month to the Same Specialty Physician or Other Health Care Professional. For example, E0202 is reported with modifier KR and 7 units to indicate the number of days it was used in a calendar month. Regardless of the number of days it is used within that calendar month, UnitedHealthcare pays a single monthly rate and does not prorate the services to allow a daily rate. The exceptions to the above are the items listed in the section titled Daily Rental.
Q: How should a vendor report devices that have been provided for extension and flexion on both sides of the body, e.g., code E1800?
A: Because two devices are needed for each side of the body, it is appropriate to report these items as E1800-RR-RT with two units for the right side, and E1800-RR-LT with two units for the left side.
Q: Are repair codes K0739, K0740 or K0462 reimbursed during the rental period for Durable Medical Equipment?
A: Repair of DME items is included in the rental payment and not separately reimbursed. Repair may be allowed for DME items that are purchased (patient-owned).