Repairs - JA DME

For the purposes of Medicare reimbursement, repairs are not synonymous with replacements. Repairs (parts and labor) of DMEPOS items are performed on the base item.

• The replacement of parts or components that make up the base item is considered to be a repair.
• The furnishing of new separately payable accessories that were not part of the initial base item but are part of the repair are considered to be replacements.

The definition of a repair is found in the CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.2.A. This section generally defines a repair as to fix or mend, and to put the item back in good condition after damage or wear.

Repairs to Beneficiary-Owned Equipment

Per the Standard Documentation Requirements Policy Article A55426 - Repairs to items that a beneficiary owns are covered when necessary to make the items serviceable. However, "routine periodic maintenance" such as testing, cleaning, regulating, and checking is not covered. If the expense for repairs exceeds the estimated expense of purchasing or renting another item of equipment for the remaining period of medical need, no payment can be made for the amount of the excess. It is expected that the beneficiary's medical records will reflect the medical necessity for the item provided. This documentation must be available upon request.

Medicare does not separately reimburse for repairs of:

• Items Requiring Frequent and Substantial Servicing
• Oxygen and Oxygen Equipment
• Capped Rental Items during capped rental period
• Inexpensive and Routinely Purchased (IRP) which are being rented
• Parts and labor covered under a manufacturer's or supplier's warranty
• Previously denied items

Order Requirements for Repairs

Per the Standard Documentation Requirements Policy Article A55426 - A new treating physician/practitioner's order is not needed for repairs but continued medical need per the Standard Documentation Requirements Policy Article A55426, must be met.

In the case of repairs to a beneficiary owned DMEPOS item, if Medicare paid for the base item initially, medical necessity for the base item has been established. With respect to Medicare reimbursement for the repair, there are two documentation requirements:

• Treating physician/practitioner must document that the DMEPOS item being repaired continues to be reasonable and necessary (continued medical need per the Standard Documentation Requirements Policy Article A55426)
• Treating physician or supplier must document that the repair itself is reasonable and necessary

The supplier must maintain detailed records describing the need for and nature of all repairs including:

• A detailed explanation justifying replacement of any component or part
• The labor time to restore the item to its functionality

For this purpose, documentation is considered timely when it is on record in the preceding 12 months, unless otherwise specified in the relevant Medicare policy.

Order requirements for repair of prosthetics - Adjustments and repairs of prostheses and prosthetic components are covered under the original order for the prosthetic device.

Loaner Equipment and Service Charge for Beneficiary-Owned Equipment

Medicare will pay for a temporary replacement of a beneficiary owned DMEPOS item while it is being repaired. In these situations, the DME supplier provides the beneficiary a "loaner" piece of equipment and bills Medicare with Healthcare Common Procedure Coding System (HCPCS) K0462 (temporary replacement for beneficiary-owned equipment being repaired, any type).

• One month's rental for a DME loaner item (K0462) is covered if a beneficiary-owned item is being repaired. Payment is based on the type of replacement device that is provided but will not exceed the rental allowance for the item that is being repaired.
• HCPCS K0462 requires the following in the narrative section of the claim:
  • Narrative description, manufacturer, and brand name/number of equipment being repaired
  • Narrative description, manufacturer, and brand name/number of replacement equipment
  • Description of what was repaired
  • Description of why repair took more than one day to complete

Narrative example for a temporary PAP device out for repair: "Blower broken on PAP, Pur-06/21, loaner-ResMed S8 Elite II."

Note: There is no fee schedule for HCPCS K0462. Payment is determined as the equivalent of one month's rental for the type of equipment owned by the beneficiary that is being repaired.

You cannot charge the beneficiary any type of service charge, curb side fee, or delivery charge while repairing the equipment.

Claims Requiring Narrative

A narrative is required on all claims in Item 19 of the 1500 hard copy claim form or the 2400/NTE segment of an electronic claim when:

• Billing for repair labor
• Billing for minor parts without specific HCPCS codes
• Billing for loaner equipment (HCPCS K0462)
• Billing a Not otherwise classified (NOC) codes
• When appending RA modifier due to loss, stolen or irreparably damaged item
• When appending the RB modifier

Narrative Requirements for Not Otherwise Classified (NOC) Codes

Not Otherwise Classified (NOC) Codes items billed with any HCPCS code with a description that includes miscellaneous, NOC, unlisted, or non-specified, must include the following information in loop 2400 (line note), segment NTE02 (NTE01=ADD) of the electronic claim format or on Item 19 of the paper claim form in the narrative field. Enter as much information as possible to ensure prompt processing of the claim.

The NTE 2400 Field of an electronic claim is limited to 80 characters; therefore, suppliers are encouraged to use our list of Common Abbreviations to Use as Narratives to condense all of the required information into this field.
Required Elements in Narrative:

• Description of the item or service
• Manufacturer name
• Product name, model name and number
• Supplier Price List (PL) amount
• HCPCS code of related item (if applicable)
• If repair part, HCPCS code of item being repaired
• Example
  • Titanium Hooks 3010865 Manufacture, for XXXXX (HCPCS Code), Supplier Price List (PL) amount $XXX.XX
  • Indicate what it is, what is it for, what is Supplier Price List (PL) amount

Denials

• If the narrative information is not added to the claim, the claim will deny as missing/incomplete/invalid description of service for a Not Otherwise Classified (NOC) code and must be corrected and rebilled as the denial will indicate there are no appeal rights because the claim is unprocessable.
• If claim is processed and denied, for reason other than above, request redetermination with all documentation to support medical necessity
  • Medical necessity for item (medical records)
  • If item is custom-fabricated, provide complete and clear description of item including:
    • What makes item unique
    • Breakdown of charges (materials and labor)

Refer to the specific Local Coverage Determination (i.e., oral anti-cancer drugs, immunosuppressive drugs, etc.) for instructions regarding the submission of a drug under a NOC HCPCS code. In addition, some NOC HCPCS codes have additional policy-specific narrative requirements.

For additional information on payment of DMEPOS, refer to CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 20.

Pricing information for NOC codes.

Billing for Repairs

Narrative information should be entered in loop 2400 (line note), segment NTE02 (NTE01=ADD) of the electronic claim format or on Item 19 of the paper claim form.

DME Labor HCPCS Codes

• K0739 - Repair or nonroutine service for DME other than oxygen requiring the skill of a technician, labor component, per 15 minutes (see chart below)
  • Claim line narrative must include:
    • What is being repaired
    • Amount of time for repair
• K0740 - Repair or nonroutine service for oxygen equipment requiring the skill of a technician, labor component, per 15 minutes
  • Claim line narrative must include:
    • What is being repaired
    • Amount of time for repair

Orthotics Labor and Minor Parts HCPCS Codes

• L4205 - Repair of orthotic device, labor component, per 15 minutes
  • Claim line narrative must include:
    • Explanation of what is being repaired
• L4210 - Repair of orthotic device, repair or replace minor parts (e.g., those without specific HCPCS codes).
  • Claim line narrative must include:
    • HCPCS code of item being repaired
    • Description of each item that is billed
    • Supplier Price List (PL) amount
• Example
  • Titanium Hooks 3010865 Manufacture, for XXXXX (HCPCS Code), Supplier Price List (PL) amount $XXX.XX
  • Indicate what it is, what is it for, what is Supplier Price List (PL) amount

Prosthetics Labor and Minor Parts HCPCS Codes

• L7510 - Repair of prosthetic device, repair or replace minor parts (e.g., those without specific HCPCS codes)
  • Claim line narrative must include:
    • HCPCS code of item being repaired
    • Description of each item that is billed
    • Supplier Price List (PL) amount
• Example
  • Titanium Hooks 3010865 Manufacture, for XXXXX (HCPCS Code), Supplier Price List (PL) amount $XXX.XX
  • Indicate what it is, what is it for, what is Supplier Price List (PL) amount
• L7520 - Repair prosthetic device, labor component, per 15 minutes
  • Code L7520 is used to bill for labor associated with adjustments and repairs that either do not involve replacement parts or that involve replacement parts billed with code L7510.
    • Claim line narrative must include:
      • Explanation of what is being repaired
  • Code L7520 must not be billed for labor time involved in the replacement of parts that are billed with a specific HCPCS code. Labor is included in the allowance for those codes.
  • Documentation must exist in the supplier's records indicating the specific adjustment and/or repair performed, and the time involved. The time reported for L7520 must only be for actual repair time. Time performing the following services (not all-inclusive) must not be billed using code L7520:
    • Evaluation to determine the need for a repair or adjustment or follow-up assessment
    • Evaluation of problems regarding the fit or function of the prosthesis
    • General beneficiary education or gait instruction
    • Programming of electronic componentry

Repairs to a prosthesis are covered when necessary to make the prosthesis functional. If the expense for repairs exceeds the estimated expense of purchasing another entire prosthesis, no payments can be made for the amount of the excess.

Labor Payment Rates

Repair or maintenance of equipment is billed with applicable HCPCS codes for replacement parts. Claims for labor for patient-owned equipment require one of these HCPCS codes.

• K0739 - Repair or nonroutine service for DME other than oxygen requiring the skill of a technician, labor component, per 15 minutes
• L4205 - Repair of orthotic device, labor component, per 15 minutes
• L7520 - Repair of prosthetic device, labor component, per 15 minutes

Labor payment rates listed per year.

Repair Modifiers

• RT/LT - Depending on the item being repaired, the RT and/or LT modifier must be appended to the claim for the parts being billed as part of that repair, when appropriate.
• RB - When a repair requires the replacement of a component that has its own HCPCS code, as part of a repair to the base item, that component or part requires the RB modifier on the claim line. The RB modifier identifies that the component is part of a repair.
  • RB not required - When the HCPCS code description of the replacement component indicates the item is a replacement.

Gap Filling

The fee schedule for items for which pricing is not available is calculated based on:

• Fee schedule amounts for comparable equipment
• Fee schedule amounts of other DME MACs
• Supplier price lists
• Manufacturers wholesale price

Repair Labor Billing and Payment Policy (K0739)

K0739 - The following table contains repair units of service allowances for commonly repaired items billed under HCPCS code K0739 (Repair or Nonroutine Service for Durable Medical Equipment Other than Oxygen Equipment Requiring the Skill of a Technician, Labor Component, Per 15 Minutes). This applies to items not being rented and out-of-warranty items. Units of service include basic troubleshooting and problem diagnosis. One unit of service = 15 minutes. There is no Medicare payment for travel time or equipment pick-up and/or delivery.

Suppliers may only bill the allowable units of service listed in the table below for each repair, regardless of the actual repair time.

• Claims for repairs must include narrative information itemizing each repair and the time taken for each repair.
• Suppliers are also reminded that Medicare does not pay for repairs to capped rental items during the rental period or items under warranty.