Revised: January 15, 2019
To be eligible to enroll as a medical supplier, a provider must purchase medical equipment or supplies (or both) for sale or rental to the general public. The provider must be able to perform or arrange necessary repairs and maintenance to equipment offered for sale or rental.
Some kinds of equipment or supplies have special provider requirements. Those requirements are found on the coverage policy page for the specific item.
The following are eligible to provide most medical equipment and supplies:
• Federally qualified health centers
• Home health agencies
• Indian Health Services
• Medical suppliers (including oxygen contract vendors)
• Rural health clinics
The following are eligible providers for medical equipment and supplies only when the medical equipment and supplies are provided as a necessary adjunct to the direct treatment of a member’s condition (for example, crutches, splints) and not incidental to the service provided.
• Clinical nurse specialists
• Hospital outpatient facilities
• Nurse practitioners
• Physician assistants
Providers must meet any provider criteria, including accreditation and surety bond requirements, for third party insurance or for Medicare to assist members for whom Minnesota Health Care Programs (MHCP) is not the primary payer. Providers who do not meet Medicare requirements must refer and document the referral of dual eligible members to Medicare providers when Medicare is determined to be the appropriate payer for services including supplies and equipment. Providers who do not meet provider criteria for the primary payer will not be reimbursed by MHCP.
If Medicare downcodes an item, MHCP must pay based on the downcoded Medicare explanation of benefits (EOB), regardless of any MHCP prior authorization. Providers may choose to offer only Medicare-covered equipment to dual eligible recipients if a Medicare Local Coverage Determination states that specific items will be downcoded.
All MHCP members are eligible for coverage. Exceptions to coverage indicated in the Programs and Services section of this manual or in the coverage policy page for specific items.
MHCP covers medical supplies and equipment, subject to limitations, authorization and other requirements. Additional restrictions apply to supply and equipment coverage for members residing in long term care (LTC) facilities.
• When the medical equipment or supply is purchased for a member, the item is the member’s property. Rent for most durable medical equipment is covered up to 13 months, or to the purchase price of the equipment. After 13 months of rental or when the purchase price is reached, the item is the member’s property. All rental months, whether paid fee-for-service or by a prepaid MHCP health plan, count toward the purchase price unless there is a break in continuous use. A break in continuous use is defined as a period of two months or more during which the provider has removed the equipment from the member’s home, or the member is not using the equipment because of an inpatient hospital or skilled nursing facility stay.
• Durable medical equipment determined by Medicare to require frequent and substantial servicing is not subject to the 13 month and purchase price rental limit. MHCP assumes a reasonable useful lifetime of five years for all durable medical equipment. MHCP will not cover equipment that serves the same purpose as usable equipment previously purchased for the member
• MHCP covers repairs to medically necessary member-owned equipment and maintenance on equipment that requires frequent cleaning or routine calibration to ensure proper working order. All purchased equipment must be new upon delivery to the member. Equipment that is intended to rent until converted to purchase must be new equipment. Used equipment may be used for short-term rental, but if eventually converted to purchase, must be replaced with new equipment.
To determine the appropriate HCPCS code to use for an item, refer to the Medicare Pricing, Data Analysis and Coding (PDAC) Product Classification List.
Refer to the Medical Supply Coverage Guide (PDF) (also available in an Excel format) for information about coverage and limits for supplies and equipment not included in this manual.
Refer to the above guides for services that may be affected by living arrangement.
41: NFI (Nursing Facility I) Medicare Cert
42: NFII (Nursing Facility II) Non-Medicare Cert
43: Intermediate Care Facility-Developmental Disabilities (ICF-DD)
44: Short Term Stay NFI
45: Short Term Stay NFII
46: Short Term Stay ICF-DD
48: Medical Hospital
55: Rule 203 - Adult Foster Home
Durable medical equipment payments will be subject to a Medicare upper payment limit according to the 21st Century Cures Act beginning with dates of service on and after January 1, 2018. Based on the upper payment limit calculation in the first half of 2019, payment in excess of the aggregate Medicare limit may be subject to payment recovery. See the Limit on Federal Financial Participation for Durable Medical Equipment in Medicaid on the Centers for Medicare & Medicaid Services website for more information.
MHCP has implemented National Correct Coding Initiative (NCCI) edits. Two types of NCCI edits exist and apply to durable medical equipment, medical supplies, prosthetics and orthotics:
• Code-to-code edits that define pairs of HCPCS/CPT codes that should not be reported together
• Medically Unlikely Edits (MUEs) or units-of-service edits that define for each HCPCS/CPT code the number of units of service beyond which the reported number of units is unlikely to be correct
When an authorization is required for an item, an appropriate NCCI modifier may be added to the authorization request and entered on the claim.
An authorization for an item that does not require authorization does not bypass an NCCI edit. If the NCCI should not apply to the claim, select the appropriate modifier and report it on the claim to bypass the NCCI edit.
Review the Minnesota National Correct Coding Initiative (NCCI) page available on the MHCP provider website for additional information.
Use the most specific HCPCS code for the item being dispensed. Do not use miscellaneous codes for the sole purpose of trying to receive higher reimbursement.
MHCP accepts the following miscellaneous HCPCS codes:
Prior Authorization Requirements
Incontinence supply; miscellaneous
Use for supplies (with no specific HCPCS code) relating to urinary or fecal incontinence
Ostomy supply; miscellaneous
Use for any miscellaneous supplies for ostomies in the colon, ileum, abdomen, etc. (use S8189 for tracheostomies)
Surgical supply; miscellaneous
Use for miscellaneous wound care supplies and items related to surgical procedures
Over $400 and specific items listed in chapter
Miscellaneous DME supply or accessory; not otherwise specified
Use for an accessory or an added on part to a piece of DME that has no code, not the entire piece of equipment, just a part of it
Enteral supplies; not otherwise classified
Use for supplies relating to enteral nutrition
Parenteral supplies; not otherwise classified
Use for supplies relating to parenteral nutrition
Durable medical equipment (DME); miscellaneous
Use for durable medical equipment that does not have a specific code and only for the entire piece of equipment, not parts
Over $400 and specific items listed in chapter
Tracheostomy supply; not otherwise classified
Use for miscellaneous tracheostomy supplies only
Supply; not otherwise specified
Use for disposable supplies that do not fit into any of the other more specific miscellaneous supply codes
When billing for multiple products that are different but require the use of the same miscellaneous HCPCS code, use the correct miscellaneous code and modifier for the first line item, and add the 76 modifier to each additional line using the same miscellaneous HCPCS code. If billing multiple units of the same product, bill using the correct miscellaneous code and modifier and indicate the number of units dispensed.
The following miscellaneous HCPCS will be automatically priced if the correct description of the product is entered on the notes field on the Services tab in MN–ITS for each line item.
A7520, A7521 and B4088 require the use of the NU modifier for auto pricing at the fee schedule rate. For auto pricing of specialized items, enter the appropriate HCPCS code with the U3 modifier and the long description.
A4335, A4421, A4649, A9999, B9998 and S8189 require the use of the NU modifier and the long description for auto pricing.
Members who self-administer medications using syringes may receive sharps disposal containers. Bill using A4211 and modifier U3 along with appropriate pricing information as outlined in the Billing Policy section. An attachment is required for Medicare claims.
Code: A4649 NU
WoundSeal Powder, QR Powder for Lacerations, QR Powder for Kid’s Cuts and Scrapes, QR Powder for Nosebleeds, and Gentle Formulation QR Powder for Nosebleeds are covered when prescribed by a physician for members with bleeding disorders, including bleeding disorders caused by use of anticoagulants. The claim must include a diagnosis code specific to the bleeding disorder. Up to four units may be dispensed in anticipation of future need. It is not necessary to open packaging; providers may dispense a box of two or four applications. One unit equals one application.
Code: E1399 NU
EarPopper Home Version is covered when prescribed by a physician for members over three years old with otitis media with effusion or eustachian tube dysfunction who are unable to independently perform the Politzer maneuver.
Code: E1399 NU
Weighted blankets or vests are covered for members who have developmental disabilities, including autism spectrum disorders. The function of the weighted blankets is to provide proprioception (deep pressure), which has a calming effect that allows people with developmental disabilities to interact with their environment. Documentation needs to include relevant diagnoses of the member and evaluation performed by an occupational therapist that justifies medical necessity. Authorization is required for submitted charge over $400.
Refer to the following sections:
Lower Limb Prosthetics
Orthopedic and Therapeutic Footwear
Physiatrist: A physician who specializes in physical medicine or who possesses specialized knowledge of rehabilitation and who is certified by the American Board of Physical Medicine and Rehabilitation.
Prosthetic or Orthotic Device: An artificial device, as defined by Medicare, to replace a missing or nonfunctional body part, to prevent or correct a physical deformity or malfunction, or to support a deformed or weak body part.
• A physician who is knowledgeable in orthopedics or physical medicine and rehabilitation
• A physician in consultation with an orthopedist, physiatrist, physical therapist or occupational therapist
• A podiatrist within the scope of his or her profession. MHCP covers podiatrist services to treat below the knee
A prosthetic or orthotic must be prescribed by:
Authorization is required when:
• Required by a specific policy
• Miscellaneous prosthetic or orthotic codes total billing over $400
Implantable Prosthetics L8609, L8614 and L8619 always require authorization.
Submit authorization requests through MN–ITS (Authorization Request 278). Fax the MN–ITS response with the required documentation, physician’s orders and appropriate additional information to the Authorization Medical Review Agent. Write the MN–ITS Authorization Request number on each page of each document.
• Submit the prosthetic base HCPCS code on the first line of the authorization request if a new prosthetic is being requested. Do not submit the base code if repairs are requested.
• List all add-on items on separate lines on the authorization request, even if the individual item does not require authorization. List each item by HCPCS code, appropriate modifier, quantity and charge.
• MHCP will not authorize more units per line than are allowed by Medicare’s Medically Unlikely Edits (MUEs). When requesting authorization for bilateral prosthetics or orthotics where more units are required than are allowed by the MUEs, the units must be requested on different lines, with modifiers NU RT and NU LT as appropriate.
• When multiple items that are different but require the same miscellaneous code are requested, each item must be listed on a separate line of the authorization request. A unique description of each item must be entered into the model number field for each line. The unique description may be a model number or narrative description up to 20 characters
• Documentation for purchase must address the member’s medical need, and how the requested prosthetic meets that need. Although all add-ons and accessories must be listed on the request, only the major components will be reviewed for medical necessity.
• Each line will be approved or denied, with the allowed dollar amount listed if approved.
Follow these guidelines when billing for items that do not require authorization:
• Submit the usual and customary charge for each line, not the approved amount from the authorization letter. Payment will be the balance of the lesser of the billed amount or the approved amount, after any primary or secondary payers have made payment.
• Bill repairs to prosthetics or orthotics with the appropriate HCPCS code representing the item and the modifier RB. The charges represent the materials necessary to accomplish the repair. Bill replacement of parts using the HCPCS code representing the replacement part, and the NU or RA modifier to indicate the item is a purchase.
• When billing labor, specify the number of units of labor and the hourly rate. Do not bill for setup and delivery, or for service calls that do not involve actual labor time for repairs.
• MHCP will not pay claims for more units per line than are allowed by Medicare’s Medically Unlikely Edits (MUEs). When billing for bilateral prosthetics or orthotics where more units are required than are allowed by the MUEs, the units must be billed on different lines, with modifiers NU RT and NU LT as appropriate.
Follow these guidelines when billing for items approved on a multi-line authorization:
• Submit one claim for the approved base and all approved add-ons and accessories. Make sure the HCPCS codes, modifiers and descriptions on the claim match the same information on the prior authorization.
• Enter the authorization number in the authorization field for each line.
• When the model number field is used, do not use the Notes field on the Services tab. Use the Claim Notes field on the Claim Information tab.
• Prosthetic and orthotic devices for which fabrication has begun, but has not yet been completed as of the date of the member’s termination from MHCP eligibility, will be reimbursed on a prorated basis.
Skin care products classified as drugs and provided for members with catheters, ostomies, or other conditions may be covered only under the following circumstances:
• The item must be produced by a manufacturer that has a rebate agreement with CMS.
• The pharmacy provider must submit the claim electronically using the 11-digit National Drug Codes (NDC). State law does not allow medical equipment and supply providers or home health care agencies to provide items that meet the definition of a drug.
The following items are defined as drugs and may be covered only as described above. This is not an inclusive list. Not all products that fit into one of the categories listed below are covered. Call the Provider Call Center at 651-431-2700 or 800-366-5411 to verify drug coverage using the NDC.
• Aluminum acetate solution and lime sulfur dressing and soaks
• Aluminum chloride, fluorouracil and hydroquinone solutions
• Anti-acne medications
• Antibiotic-steroid combinations
• Antifungal compounds
• Anti-psoriasis and anti-eczema medications
• Burn anti-infective agents
• Lactic acid lotion
• Scabicides and pediculicides
• Sterile saline or water (includes irrigation solutions labeled as Rx legend)
• Topical anesthetic and antipruritic solutions
• Topical anti-infective agents and cleaners
• Topical corticosteroid
• Urea solutions
• Vitamin A & D ointments
• Wart medications
• Zinc oxide compounds
Non-topical products: Lubricants for ostomy members, non-legend sterile saline irrigation solutions, skin barriers and other topical products that do not contain active ingredients and are not classified as drugs may be billed using MN–ITS 837P Professional claim with the appropriate HCPCS code. These items require a written order from the physician that includes the exact description of the product to be dispensed, the amount needed and the length of time needed.
The following list of noncovered services is not all-inclusive:
• Air conditioners
• Bathroom scales
• Bathtub wall rails
• Beds - oscillating and lounge beds, bed baths and lifters, bedboards, tables and other bed accessories
• Blood glucose analyzer - reflectance colorimeter
• Car seats, standard use
• Cervical roll or pillow
• Control units and battery device adapters
• Dehumidifiers - room or central
• Diathermy machines
• Disposable wipes - including Attends wash cloths
• Disposable ice packs and disposable heat wraps
• Elevators and stair lifts that are affixed to the home
• Enuresis or bed-wetting alarms
• Environmental products (for example, air filters, purifiers, conditioners, hypoallergenic bedding and linens)
• Exercise equipment
• Food blenders
• Grab bars that are affixed to the home
• Heat and massage foam cushion pads
• Home security systems
• Household equipment and supplies such as ramps, switches, tableware and feeding instruments
• Humidifiers - room type or central
• Hygiene supplies and equipment, including hand-held shower units and shower trays, and dental care supplies and equipment
• Instructional materials (for example, pamphlets and books)
• Isolation gowns, surgical gowns and masks
• Magnifying glasses
• Massage devices
• Medical alert bracelets and response systems
• Medical supplies defined as drugs
• Medication boxes or medication dispensing equipment
• Menses products (e.g., sanitary pads)
• Motorized lifts for a vehicle
• Orthopedic mattresses
• Personal computers and printers, tape recorders or video recorders
• Pulse tachometers
• Ramps that are affixed to the home
• Reading glasses
• Saline or other solutions for the care of contact lenses
• Table foods
• Telephones, telephone alert systems, telephone arms or answering machines
• Tennis or gym shoes
• Thermometer covers
• Toothbrushes and toothettes
• Washable or reusable incontinence undergarments
• White canes for the blind
Follow the general billing information in the Billing Policy section of the manual. Additional information about billing of specific items can be found in the policy section for those items. The Medical Supply Coverage Guide (PDF) may have additional information.
An add-on is a noncovered item that can be added to a piece of covered equipment. For example, a basket for a walker is a noncovered add-on to a covered piece of equipment.
An upgrade is a piece of equipment with extra, more desirable features that substitutes for a less costly piece of equipment. Often, MHCP will cover the upgraded item for members who meet criteria if authorization is obtained. For example, MHCP covers manual hospital beds without authorization for members with positioning needs. A semi-electric hospital bed would be an upgrade unless the member meets MHCP coverage criteria.
If MCHP pays for the equipment, a provider can bill a member for a noncovered add-on. Refer to the MHCP Advance Recipient Notice (DHS-3640) (PDF). If MHCP makes any payment toward the equipment, the provider cannot bill the member or accept payment on behalf of the member for the difference between the covered equipment and the upgraded equipment. Refer to Noncovered Services in the Billing the Recipient section.
MHCP will not pay for repairs or maintenance to noncovered add-ons or upgraded equipment.
Medical equipment that has features that go beyond what is medically necessary are considered upgrades. Providers may choose to supply upgraded equipment but charge MHCP for the non-upgraded item. The reason for this may be that the provider chooses to carry only upgraded equipment in order to reduce the costs of maintaining a broader inventory of models or replacement parts. Upgrades must be medically appropriate for the member’s medical condition and the purpose of the physician’s orders. Examples of upgrades include a power wheelchair for a member for whom a manual wheelchair is medically necessary and sufficient or a standard hospital bed with a mahogany headboard and footboard rather than a plastic headboard and footboard.
The member may not be billed for the provider initiated upgrades. If the provider chooses to supply upgraded equipment, the provider chooses to accept the MHCP for the non-upgraded item as payment in full.
When billing for a provider initiated upgraded item, the claim must include only the charge and the HCPCS code for the non-upgraded item. The HCPCS code for the non-upgraded item must be accompanied by the GL modifier (medically unnecessary upgrade provided instead of the standard item, no charge). In the narrative field of the claim, specify the make and model of the item actually furnished, and describe why the item is an upgrade.
If prior authorization is needed for the non-upgraded item, submit the request for the HCPCS code of the non-upgraded item, using the GL modifier. Include all required documentation for the medically necessary (non-upgraded) item, and specify the make and model of the item that will actually be furnished. Describe why this item is an upgrade.
If repairs are needed to a provider initiated upgraded item, MHCP will only pay for the repairs that might reasonably be required if the non-upgraded item had been provided unless the upgraded item is now medically necessary. For example, if a standard hospital bed was ordered and a semi-electric bed was provided as a provider initiated upgrade, MHCP will pay for repairs to a broken caster, but would not reasonably require repair to a motor. If there has been a change in the member’s condition, so that the semi-electric bed is now medically necessary, MHCP will pay for the repairs. If the repair would not be reasonably required by the medically necessary item, the provider must repair the upgraded item but cannot bill MHCP or the member for the repairs.
Prior authorization is required for all repairs when parts and labor total over $400 for DME other than wheelchairs. Prior authorization is required for all repairs to wheelchairs when parts and labor total over $1000, or when parts to be replaced are less than one year old. Submit the request using the HCPCS code for the non-upgraded item, using the GL modifier, and the NU/RP/RA/RB modifiers as appropriate. Include documentation of the make and model of the upgraded item. If the repair would be reasonable required by the medically necessary item, submit documentation sufficient to show this. If the upgraded item is now medically necessary, submit all documentation about the required repair.
The provider must obtain authorization when required. Refer to the Coverage Criteria for specific HCPCS codes within this section of the MHCP Provider Manual or the Medical Supply Coverage Guide (PDF) (also available in an Excel format).
The provider may not request or accept payment from the member for any service for which the required authorization was not obtained.
• The dispensing order
• The detailed written order
• Member’s diagnosis from the testing physician
• Any information required for use of specific modifiers or attestation statements
• Adequate information to assure that coverage criteria for an item have been met
• Information in the medical record must adequately support the medical necessity for the item, or the supplier is liable for the dollar amount involved
• Proof of delivery documentation
The medical supplier must have the following information on file:
Provide proof of delivery in any of the following methods:
Method 1: Supplier delivers items directly to the member or authorized representative
• The delivery slip must be signed and dated by the member or authorized representative to verify the DME or supply item was received
• The date of the signature on the delivery slip must be the date DME or supply was received by the member or authorized representative
• The delivery slip must include the member’s name, quantity, a detailed description of the item(s) delivered, brand name and serial number (if applicable)
• The date of service on the claim must be the date the DME or supply item was received by the member or authorized representative
Date of service exception: If the DME item is delivered to a member in a hospital up to two days prior to discharge (home) and for the benefit of the member for the purpose of fitting or training of the member in its use, the supplier must bill the date of service on the claim as the date of discharge (home) and must use place of service "12" (home).
Method 2: Supplier delivers certain items without the member’s signature of receipt
• For medical supplies that are not vulnerable to damage by weather, and that do not require fitting or training, the member or authorized representative may consent in advance to waive in-person signature
• The consent must be in writing, and must specify a preferred location at the member’s residence for supplies to be left
• The delivery slip must be signed by the person delivering the goods, and must specify the date, time and place of delivery
• The delivery slip must include the member’s name, a detailed description of the item(s) delivered, quantity, brand name and serial number (if applicable)
• MHCP will not pay for items reported damaged or missing. Providers are encouraged to talk to their insurers to discuss liability for replacing items if a member reports the product damaged or missing
• The date of service on the claim must be the date on the delivery slip
• Date of service exception: If the DME item is delivered to a member in a hospital up to two days prior to discharge (home) and for the benefit of the member for the purpose of fitting or training of the member in its use, the supplier must bill the date of service on the claim as the date of discharge (home) and must use place of service "12" (home).
Method 3: Supplier uses a delivery or shipping service to deliver items
• Acceptable proof of delivery includes the delivery service's tracking slip and the supplier's shipping invoice
• The supplier's shipping invoice must include the member’s name, quantity, detailed description of the item(s) delivered, brand name, serial number (if applicable), and delivery service's package identification number associated with the member’s package(s)
• The delivery service's tracking slip must reference the member’s package(s), delivery address, and the corresponding package identification number given by the delivery service
• Without the delivery service's tracking log that identifies each individual package with a unique identification number and delivery address, the item will be denied and any overpayment will be recouped
• When the member denies receipt of an item, the item will be denied and an overpayment will be recouped, unless the supplier maintains a detailed shipping invoice and the delivery service’s tracking log
• Mail order DME or supply items: The date of service on the claim must be the shipping date
• Date of service exception: if the DME item is delivered to a member in a hospital up to two days prior to discharge (home) and for the benefit of the member for the purpose of fitting or training of the member in its use, the supplier must bill the date of service on the claim as the date of discharge (home) and must use place of service "12" (home
Method 4: Items delivered to an LTC facility on behalf of the member
• Suppliers must work with the LTC facility staff to implement inventory control to ensure that the:
• LTC facility received delivery and was provided with receipt of what was delivered
• Supplies were identified and retained for use only by intended members
• Intended members use the supplies
• Suppliers receive proof of delivery from the LTC facility
• Medical records in the LTC facility must document use of all supplies and items billed to MHCP. Documentation may be in the nurse’s notes or a special treatment record or form
• The date of service on the claim must be the date the DME item was received by the LTC facility if delivered by the supplier, or the shipping date if the supplier used the delivery or shipping service
Date of service exception: if the DME item is delivered to a member in an LTC facility up to two days prior to discharge (home) and for the benefit of the member for the purpose of fitting or training of the member in its use, the supplier must bill the date of service on the claim as the date of discharge (home) and must use place of service "12" (home).
Proof of delivery must be maintained in the supplier’s records as described in Methods 1 and 2
All services that do not have appropriate proof of delivery from the supplier will be denied, and all overpayments must be returned to DHS. Suppliers who consistently do not provide documentation to support their services will be referred to the DHS Surveillance and Integrity Review Systems (SIRS) Unit and the Office of the Attorney General.
• Clinical nurse specialist
• Nurse midwife
• Nurse practitioner
• Physician assistant
• Dispensing orders are limited orders that are written, faxed or verbal.
• For any DME or supply item to be covered by MHCP, the supplier must have an order from the prescribing provider before dispensing the item. Acting within the scope of practice, the prescribing provider may be a:
MHCP requires that providers dispense one month of supplies at a time. Providers may not ship items on a regular, monthly basis without an indication from the member, family member or authorized representative that the supply is needed.
The order must contain:
• Description of item
• Name of member
• Name of physician
• Date of order
The supplier must maintain documentation of the dispensing order. Dispensing orders may be a photocopy, facsimile image, electronically maintained, or original “pen-and-ink” document. Documentation must be available to DHS upon request. Follow the requirements for electronically maintained records as stated in Minnesota Rules 9505.2190 Subpart 1 and 9505.2197.
Unless required by a primary payer, no prescribing provider’s order is required for the repair of patient owned, medically necessary equipment if the supplier’s documentation includes an order for the equipment.
Detailed written orders contain the dispensing order. Only items that require a detailed written order for Medicare require a detailed written order for MHCP. Detailed written orders may be a photocopy, facsimile image, electronically maintained, or original “pen-and-ink” document. Follow the requirements for electronically maintained records as stated in Minnesota Rules 9505.2190 Subpart 1 and 9505.2197. The treating provider must sign and date the detailed written orders before the claim is submitted to MHCP. Detailed written orders are in addition to the dispensing order, if the supplies are dispensed prior to receipt of the detailed written order. MHCP will not cover a DME or supply item if the supplier only has a verbal order when the claim is submitted.
A detailed written order must contain:
• The member’s name and address
• A detailed description of the item
• The handwritten or electronic signature of the treating physician (See Minnesota Rules 9505.2197 for details about electronic signatures)
• The date the order is signed (the physician must enter the signature and date and it cannot be a stamp or other substitute)
• If the item has been dispensed prior to the date the detailed written order is signed, the order must specify the start date
• All options or additional features which will be separately billed or which will require an upgraded code
• The description can be either a narrative description (for example, lightweight wheelchair base) or a brand name and model number
• Rented item orders must include the length of need
• Accessories or supplies provided on a periodic basis must include the quantity used, frequency of change or use and length of need
Someone other than the treating provider may complete the detailed description of the item. The treating provider must review, sign and date the order.
Medical records must contain the following information:
• The medical condition to substantiate the necessity of the type and quantity of items ordered and for the frequency of use or replacement (if applicable)
• The diagnosis and other pertinent information including duration of the condition, clinical course (worsening or improvement), prognosis, nature and extent of functional limitation, other therapeutic interventions and results, past experience with related item, etc.
• The clinical information that supports the medical necessity for the item and substantiates the information on a supplier prepared statement or physician attestation (if applicable)
• Not limited to the physician’s office records
• May include hospital, nursing home or home health agency records
• Records from other professionals including nurses, physical or occupational therapists, prosthetists and orthotists
DHS may request this information in selected cases. The supplier is liable for dollar amount involved if the information is not received, or does not substantiate medical necessity
Neither a physician's order, a supplier’s prepared statement, nor a physician attestation by itself provides sufficient documentation of medical necessity, even though it is signed by the treating physician.
A new order is needed when one of the following happens:
• An order changes for accessory, supply, drug, etc.
• Yearly except for items specified in coverage policy
• The item is replaced
• The supplier changes
Except as noted in the Supplier Documentation section, do not bill for medical equipment and supplies ordered for subsequent use in the member’s home prior to the date of the member’s discharge (home). This includes:
• Drugs, supplies used with the DME or prosthetic devices
• Surgical dressing, urological supplies or ostomy supplies applied in the hospital, including items worn home by the member
Suppliers are responsible for delivering the DME to the member’s home following discharge.
Follow these guidelines when dispensing equipment and supplies:
• Dispense no more than one month of supplies at a time unless specifically permitted by coverage policy
• Requests must come from the member or an authorized representative each time additional supplies are needed
• It is acceptable for medical supply providers to call the member to verify a re-order
• Automatically shipping supplies without an indication from the member or the member’s authorized representative confirmation is not permitted
Starting July 1, 2017, Minnesota Health Care Program (MHCP) members are required to have a face-to-face encounter with a physician and certain authorized non-physician practitioners before ordering certain medical equipment, appliances and supplies within six months before the start of service (initial dispensing date).
• Non-physician practitioners including a nurse practitioner, clinical nurse specialist or physician assistant are authorized to conduct face-to-face encounters.
• Physician assistants are required to work under the supervision of the physician.
• Only DME items subject to the face-to-face rule by Medicare are subject to the rule by MHCP. A list of items subject to the face-to-face rule may be found in Chapter 3 of the DME MAC Jurisdiction B Supplier Manual. Refer to the Medicare contractor supplier documentation (PDF), ACA 6407 Specified Items, pages 11-17.
• Face-to-face encounters may occur through telehealth. See Telemedicine for more information.
• The rule applies to managed care effective January 1, 2018, to align managed care and fee-for-service.
Exclusions: nurse midwives, audiologists and podiatrists
• Providers must maintain written or electronic documentation of face-to face encounters on file and available to DHS upon request. Documentation must include:
• The identity of the physician or non-physician practitioner who conducted the face-to-face encounter. Non-physician practitioners are authorized to complete the documentation requirements.
• The date of the face-to-face encounter.
• The specific diagnosis or medical condition that was the reason for the face-to-face encounter and ordered service.
• Documentation of face-to-face encounters by the physician or non-physician practitioner may be included in clinical and progress notes and discharge summaries.
• Documentation for the medical supplier’s records may be copies of physician or non-physician practitioner notes, documentation of a phone call with the physician or non-physician practitioner to confirm the face-to-face, or a written summary from the physician or non-physician practitioner. All forms of documentation must include the identity of the physician or non-physician practitioner who completed the face-to-face encounter, the date of the face-to-face encounter, and the specific diagnosis or medical condition that was the reason for the face-to-face encounter and ordered service.
Ongoing services are not subject to the face-to-face rule. A face-to-face encounter is only required for new medical equipment, supplies or appliances.
MHCP will assume providers are in compliance with the face-to-face rule (42 CFR Part 440) for claims submitted on or after July 1, 2017. Payment for services can be subject to payment recovery for which a timely face-to-face encounter was not documented. For more information, see the Federal Register for the federal rule 42 CFR Part 440.
Follow these billing guidelines:
• Use MN–ITS 837P Professional. Refer to the MN–ITS User Guide for DME/Med Supply/Prosthetics/Orthotics for billing instructions.
• Report the name and NPI number of the actively enrolled ordering MHCP provider in the Other Provider Types section of the MN–ITS Interactive 837P claim.
• Use current HCPCS procedure codes and modifiers.
• To determine the appropriate HCPCS code to use with a covered service, access the Medicare Pricing, Data Analysis and Coding (PDAC) Product Classification List website.
• Use a modifier to indicate rental, repair or replacement of part, or purchase. Additional modifiers may be appropriate depending on the item or service.
• For capped rental items that are billed as rental, use modifiers KH for the first month, KI for the second and third months, and KJ for months 4-13 of rental. MHCP reimburses for modifiers KH and KI at 100 percent and modifier KJ at 75 percent of the MHCP Fee Schedule monthly rental rate. Modifiers KH, KI and KJ also apply to any authorization request for a capped rental item. Each K modifier must be on a separate line on the authorization request.
• The cost of shipping, handling or freight charges are all-inclusive in the MHCP payment rate and are not reimbursable. If these charges are included on the invoice or as part of the Manufacturer’s Suggested Retail Price, they will be excluded from the payment.
• Follow Medicare guidelines for when to use modifiers AU, AV, AW, KC, KE, KF, KL, KM and KN. When billing for these modifiers, providers must also include modifier NU to be reimbursed at the appropriate Medicare rate.
• Do not bill for service calls that do not involve actual labor time for repairs.
• Reimbursement for all rental items will cap at the Medicare purchase rate or the MHCP maximum allowed payment rate when renting any equipment. Do not continue to bill monthly rental after the maximum rate has been reached. Apply full rental payments (including all payments received from primary third party payers) to all purchases. After MHCP purchases the medical equipment or supply for a member, the item is the member’s property.
• If a claim does not cross over from Medicare, and you received payment from Medicare, submit a claim to MHCP for the coinsurance or deductible. Complete the claim exactly as Medicare requires and include the member’s MHCP ID number and your NPI number. Complete the COB tab in MN–ITS.
• For an equipment or medical supply item that requires manual pricing or is not listed on the MHCP Fee Schedule, attach the manufacturer’s invoice or price list to the claim.
• Clearly indicate which item on the documentation corresponds to each item on the claim.
• Do not modify, alter or change the price list or invoice.
• Do not block out any information on the invoice or price list.
• If the manufacturer’s invoice or price list is not available, submit a quote from the manufacturer, dated no earlier than three months before the date of service and no later than the date of service.
• If authorization is required, the claim must match HCPCS code, modifiers and description or model number as noted on the authorization letter. Refer to the MN–ITS User Guide or for batch billers, the HIPAA Implementation Guide and the Minnesota Uniform Companion Guide for field requirements.
• Although a claim may include lines with different authorization numbers, it may not include lines with and lines without authorization numbers.
• Do not bill for sales tax. Refer to the Minnesota Department of Revenue’s Durable Medical Equipment Sales Tax Fact Sheet 117B (PDF) for additional information.
Minnesota Statutes 148.235, subd.2
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Minnesota Statutes 256B.04, sub.14
Minnesota Statutes 256B.071
Minnesota Statutes 256B.0625, subd.31
Minnesota Statutes 256D.03, subd.4 (5); (8)
Minnesota Statutes 297A.67, subd. 7
Minnesota Rules 9505.0310; 9549.0020; 9549.0040
Minnesota Rules 9505.0365; 9505.0445
Minnesota Rules 9505.2190, subp. 1; 9505.2197
42 CFR 410.38
42 CFR 410.10 (g)(h)
42 CFR 410.36