Suggested Language for a DMEPOS SBR for Improper Invoice Request

Some claims administrators incorrectly require that DMEPOS bills be accompanied by an invoice, when only dangerous devices need invoices.

For a DMEPOS underpayment, do you have any SBR language suggestions?

ANSWER: To appeal workers' comp incorrectly paid DMEPOS bills due to the claims administrator failure to pay the allowed 120% of the Medicare CMS rate, we suggest language similar to this:

Language Suggestion for DMEPOS SBR for MUE Denial

Generally, when submitting a workers' comp SBR for incorrectly denied payment, the SBR must include a specific reason that additional reimbursement is due.

NCCI Edits (such as MUEs) and the DMEPOS Fee Schedule

NCCI edits, such as medically unlikely edits (MUEs), do not apply to the DMEPOS fee schedule. In fact, none of the physician fee schedule billing rules apply to the DMEPOS fee schedule, because the latter is not part of the physician fee schedule.

Dangerous Devices and DMEPOS Billing

For California workers' comp billing, the only DMEPOS that require invoices are dangerous devices.

Invoices for Work Comp DMEPOS Bills

Generally, invoices are not required for workers' comp DMEPOS bills.

Are splinting and casting codes included in the DMEPOS fee schedule for work comp?

ANSWER: As of 4/1/2014, the workers' comp DMEPOS fee schedule includes splinting and casting codes. These splinting and casting codes are commonly referred to as Q codes.

Calculating DMEPOS Reimbursements

The DMEPOS fee schedule is a separate fee schedule from the physician and non-physician fee schedule. For workers' comp, DMEPOS is reimbursed at 120% of the currently adopted Medicare DMEPOS rate for California.

California Non-Rural (NR) / California Rural (R)

In the 2016 changes to the physician fee schedule, the DWC introduces two new columns to the DME file: CA (NR) and CA (R).

§ 9789.60 Durable Medical Equipment, Prosthetics, Orthotics, Supplies

Regulation 9789.60 states that DMEPOS reimbursements shall not exceed one hundred twenty (120) percent of the rate set forth in the CMS' (which is also known as Medicare) Durable Medical Equipment, Prosthetics/Orthotics, and Supplies (DMEPOS) Fee Schedule for California.

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