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Billing Tips: Medical Supplies

General Medical Supply Billing Tips
The following list of billing tips was created to help providers submit claims for disposable and incontinence medical supplies based on the new billing requirements effective for dates of service on or after July 1, 2009:

  • Providers should refer to CMS-1500 Completion section in the applicable Part 2 manual for billing instructions. The Durable Medical Equipment (DME) and Pharmacy provider manuals also include instructions in the Incontinence Medical Supplies Examples: CMS-1500 and Medical Supplies: Billing Examples sections.
  • The CMS-1500 Claim Form Tutorial is available in the Medi-Cal Learning Portal. The tutorial includes instructions for submitting claims with a Universal Product Number (UPN) and the product qualifier code.
  • Refer to the updated medical supply sections of the applicable Part 2 provider manuals for the following information:
    • Health Care Common Procedural Coding System (HCPCS) Level II codes
    • Associated UPNs for contracted items and UPN qualifier code
    • Maximum Acquisition Cost (MAC) for providers
    • Maximum Allowable Product Cost (MAPC)
    • Stock (item) numbers
    • “Crosswalks” to local “99” codes
  • For contracted product categories, products offered by manufacturers that have not contracted with Medi-Cal are not reimbursable.
  • Providers must dispense and bill for products contracted by Medi-Cal using the UPN and associated HCPCS Level II code listed in the applicable provider manual. Two-digit manufacturer codes must not be listed with the HCPCS Level II code.
  • On the CMS-1500 claim form, the UPN product qualifier code and UPN must be listed in the shaded area of Date of Service field (Box 24A).
  • On the CMS-1500 claim form, the UPN unit of measure and quantity is requested, but not required, in the shaded area of Procedure Code field (Box 24D).
  • The ASC X12N 837P 5010A1 Companion Guide includes instructions for submitting the UPN in Service Line Loop 2410.
  • When submitting claims transactions in the ASC X12N 837P 5010A1 electronic format, the UPN unit of measure and quantity is requested, but not required in CTP Segments 03 (unit price), 04 (unit of measure) and 05 (quantity).
  • For some contracted products, the UPN may be listed on the product package or label. However, it may be difficult to identify the correct UPN on the packaging barcode. Therefore, providers must submit the UPN and UPN qualifier code as listed in the provider manuals.
  • The UPN product qualifier code is required when submitting claims for contracted products and must be listed on the CMS-1500 form, or electronic transaction, exactly as listed in the provider manuals.
  • Different contracted products that have the same HCPCS Level II code and different UPNs are reimbursable by Medi-Cal. The HCPCS Level II code should be entered on different lines of the claim with the unique UPN and qualifier code on each line of the claim.
  • Billable non-contracted products are not limited to any particular manufacturer.
  • For non-contracted products, the HCPCS Level II codes listed in the applicable Part 2 provider manual sections will be recognized by Medi-Cal and should be listed on claims without the two-digit manufacturer code.
  • If the HCPCS Level II code has an MAPC on file as indicated in the applicable Part 2 provider manuals, then the supplemental pricing information is not required on the claim.
  • When submitting claims for different medical supply products with the same HCPCS Level II code that has an MAPC listed in the Medi-Cal appropriate Part 2 manual, providers can enter one HCPCS Level II code with the total number of units that represent the various products being billed. A pricing attachment is not required when all products billed have an established MAPC.
  • HCPCS Level II codes for non-contracted items without MAPCs listed in the applicable Part 2 provider manual will require supplemental pricing attachments as outlined in the specific manual sections.
  • When submitting claims for different medical supply products with the same HCPCS Level II code that does not have an MAPC, an attachment must be included with the claim identifying each product and the price for each item if the products have different rates.
    • Providers may enter the billable amount for each product on separate service lines of the claim. The claim will suspend so that the invoice attachments can be reviewed and priced accordingly.
    • Providers may also enter the HCPCS Level II code on one service line with the total quantity. Providers should clearly identify each product billed under that specific HCPCS Level II code and the quantity on the attachment.
  • Specific frequency limitations were established for the HCPCS Level II codes and are listed in applicable Part 2 provider manual sections. Providers are encouraged to review these sections of the manuals for any possible changes in frequency limitations due to the HCPCS Level II code conversion.
  • A 90-day grace period for dates of service through June 30, 2009, is in effect for local “99” codes on previously approved Treatment Authorization Request (TARs) and Service Authorization Requests (SARs). If the TARs and SARs with local “99” supply codes were not updated to HCPCS Level II codes, then providers must continue to bill the local “99” codes on claims with approved TARs and SARs for dates of service through June 30, 2009.
  • With the conversion to HCPCS Level II codes, TAR requirements changed for some medical supply items. Providers should refer to the applicable Part 2 provider manual to determine the TAR requirements for HCPCS Level II codes.
  • HCPCS Level II codes are required on crossover claims for medical supplies and will be reimbursed according to existing billing requirements. UPN information is not required on crossover claims.
  • Most medical supplies are not covered by Medicare and can be billed directly to Medi-Cal without billing Medicare. However, there are a few exceptions covered by Medicare such as insulin syringes. The policy regarding the Medicare documentation for covered services has not changed. Medi-Cal requires a copy of either the electronic denial or Explanation of Benefits (EOB) for recipients who are provided with medical supply products that are covered by Medicare.

Invoices

  • Invoices may not be older than one year from the date of service.
  • Invoices must be dated prior to date of service billed.
  • Any explanatory information added to the invoice by the provider to assist in the reimbursement process may only be handwritten. Typed information will result in the claim being denied.

Catalogs

  • Catalogs or price lists must not be dated more than five years prior to the date of service.
  • Include the catalog/price list front cover page indicating the type of catalog and price list used (manufacturer's wholesale, dealer or distributor), as well as the catalog date.

Computer Media Claims (CMC)

  • When billing medical supplies electronically, indicate the catalog name, item number and page number in the Comments section.

If you have any questions, please call the Telephone Service Center (TSC) at 1-800-541-5555.