MEDICAL EQUIPMENT AND SUPPLIESGROUND RULES AND FEES
CPT only copyright 2004 American Medical Association. All Rights Reserved.
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1. GENERAL:
Reimbursement for certain medically necessary equipment, devices, or supplies (except forProsthetic and/or Orthotic devices) that are appropriate and medically necessary as a result of acompensable injury shall be limited to the supplier's cost plus 50%. If the charge for a single item(equipment, device, or supply) or the charge for a line item total is more than $100.00, verification of thesupplier's costs must be attached to the provider's bill.Reimbursement for any prosthetic and/or orthotic devices (excluding prosthetic surgical implants),regardless of the charge, shall be limited to the 2005 Medicare Fee Schedule,
plus an additional 25%
,as reflected by the L Code System of the 2005 Healthcare Common Procedure Coding System (HCPCS).Additionally, any charges for any prosthetic and/or orthotic devices shall be billed using the L CodeSystem of the Healthcare Common Procedure Coding System (HCPCS), and submitted using the CMS(formerly HCFA) 1500 form or an equivalent form containing the same information.Included herein are the Prosthetic and Orthotic Fee Schedule Allowances. The 2005 HCPCS allowanceswere obtained from Cigna HealthCare who is under contract with CMS as the Durable Medical EquipmentRegional Carrier (DMERC). DMERC provides claims administration for Durable Medical Equipment,Prosthetics, Orthotics, and Supplies (DMEPOS). The maximum payments, as listed,
include
anadditional 25% which has been added to the 2005 HCPCS L Codes.Note carefully the -KM and -KN modifiers applicable to facial prostheses (codes L8040 through L8047):-KM Replacement of facial prosthesis including new impression/moulage.-KN Replacement of facial prosthesis using previous master model.
Be advised further that the rates contained within this section for the various L Codes will remainin effect until the next revision of the Kansas Workers Compensation Schedule of Medical Fees.
Any equipment or supplies, including prosthetic and/or orthotic devices, not specifically recommended orprescribed by a health care provider shall not be reimbursed. In the event, however, a health careprovider recommends and/or prescribes the use of any medical equipment or supplies (e.g., special sizeof gauze) that can be purchased over-the-counter, and the injured employee pays for said medical supplydirectly, the injured employee is entitled to be reimbursed for the purchase of such equipment or supplies.The injured employee must submit copies of any receipts and/or proofs of purchase to the employer (orinsurance carrier) for proper reimbursement. However, a pharmacy may bill the insurer directly forpayment, at the usual and customary price for the pharmacy, for items recommended by a health careprovider.
2. PRIOR AUTHORIZATION:
Prior authorization, by the employer (or insurance carrier), is required onwhether to rent or purchase an item. The decision to rent or purchase shall be made by the employer, anauthorized representative, or the insurance carrier, based on a cost comparison of the monthly rental fee,the prescribing health care provider's estimate of how long the item will be needed, and the purchaseprice.
3. FORMS:
Items which are prescribed for work-related injuries should be billed using the CMS 1500 form.
4. COST CONTAINMENT:
Nothing in this section shall preclude an employer (or insurance carrier) fromentering into a contract with a qualified supplier for the renting or purchasing of items that are medicallynecessary. Such contract, if less, will supersede the limitation amounts specified herein. Please refer toK.S.A. 44-510i(e) for further clarification, if necessary.
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