Repairs

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 is considered to be replacement.

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 - 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.

Medicare does not separately reimburse for repairs of:

  • Items in frequent and substantial servicing payment category
  • Oxygen equipment
  • Items in capped rental payment category during capped rental period
  • Items in inexpensive and routinely purchased (IRP) payment category which are being rented
  • Parts and labor covered under a manufacturer's or supplier's warranty
  • Previously denied items

Order - A new certificate of medical necessity (CMN) and/or treating physician/practitioner's order is not needed for repairs but continued medical need 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
  • Treating physician or supplier must document that the repair itself is reasonable and necessary

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.

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.

Prosthetics - Adjustments and repairs of prostheses and prosthetic components are covered under the original order for the prosthetic device.

Loaner Equipment and Service Charge

Medicare will pay for a temporary replacement of a 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 patient 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.

Narrative Requirements

Add a narrative to all claims in item 19 of the 1500 hard copy claim form or the 2400/NTE segment of an electronic claim.

Common Abbreviations

  • Billing for repair labor
  • Billing for minor parts without specific HCPCS codes
  • Billing for loaner (claims billed with loaner equipment HCPCS K0462)
  • Not otherwise classified (NOC) codes
  • When appending RA modifier due to loss, stolen or irreparable damage
  • When appending the RB modifier

Billing for Repairs

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)
    • Include information itemizing each repair and the time taken for each repair in the narrative field on the claim.
  • K0740 - Repair or nonroutine service for oxygen equipment requiring the skill of a technician, labor component, per 15 minutes
    • Include information itemizing each repair and the time taken for each repair in the narrative field on the claim.

Orthotics Labor and Minor Parts HCPCS Codes

  • L4205 - Repair of orthotic device, labor component, per 15 minutes
    • A claim for code L4205 must include an explanation of what is being repaired in the narrative field on the claim.
  • L4210 - Repair of orthotic device, repair or replace minor parts (e.g., those without specific HCPCS codes)
    • A claim for code L4210 must include a description of each item that is billed in the narrative field on the claim.

Prosthetics Labor and Minor Parts HCPCS Codes

  • L7510 - Repair of prosthetic device, repair or replace minor parts
    • Code L7510 is used to bill for any "minor" materials (e.g., those without specific HCPCS codes) used to achieve the adjustment and/or repair.
    • A claim for code L7510 must include a description of each item that is billed. This information should be entered in the narrative field on the claim.
  • 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.
    • A claim for code L7520 must include an explanation of what is being repaired. This information should be entered in the narrative field on the claim.
      • 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.

Maintenance per the manufacturer's recommendations or the construction of the prosthesis that must be performed by the prosthetist is covered as a repair.

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, do not use the RB modifier.

Not Otherwise Classified (NOC) Codes

Items billed with any HCPCS code with a narrative description that indicates miscellaneous, NOC, unlisted, or non-specified, must include the following information in the narrative for each claim line in item 19 on the 1500 claim form or the 2400/NTE segment for an electronic claim.

  • Description of the item or service
  • Manufacturer name
  • Product name and number
  • Supplier Price List (PL) amount
  • HCPCS code of related item (if applicable)
  • If Repair part, HCPCS code of item being repaired

Miscellaneous HCPCS codes billed without this information will be rejected and will need to be resubmitted with the missing information included.

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.

Type of Equipment Part Being Repaired/Replaced Allowed Units of Service (UOS)
CPAP Blower Assembly 2
Hospital Bed Pendant 2
Hospital Bed Headboard/footboard 2
Manual Wheelchair Anti-tipping device 1
Patient Lift Hydraulic Pump 2
Power or Manual Wheelchair Wheel/Tire (all types, per wheel) 1
Power or Manual Wheelchair Armrest or armpad 1
Power Wheelchair Drive wheel motors (single/pair) 2/3
Power Wheelchair Shroud/cowling 2
Power Wheelchair Joystick (includes programming) 2
Power Wheelchair Charger 2
Power Wheelchair Batteries (includes cleaning and testing) 2
Seat Lift Scissor mechanism 3
Seat Lift Hand Control 2

 

Suppliers may only bill the allowable units of service listed in the above table 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.

 

Last Updated Thu, 14 Jul 2022 14:21:49 +0000