Billing Tips: Medical Supplies
General Medical Supply Billing Tips
Medical supply Healthcare Common Procedure Coding System (HCPCS) Level II codes billable by Durable Medical Equipment (DME) and Pharmacy providers are listed in the spreadsheet Medical Supplies Billing Codes, Units and Quantity Limits in the Medical Supplies section of the provider manual.
- Providers are required to submit electronic medical supply claim transactions in the 837 5010A1 professional format using the CMS-1500 claim form except for the “Pharmacy-only” medical supply items.
- The “Pharmacy-only” medical supply items are billed using the NCPDP 1.2 batch transaction standard format with the 11-digit UPN or Universal Product Codes (UPCs).
- Medical supplies including “Pharmacy-only” medical supply items may not be billed on a Compound Pharmacy Claim Form (NCPDP or 30-4).
- 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 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
- For contracted medical supply HCPCS Level II Codes, 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.
- 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).
- Claims for contracted medical supplies require the UPN, as provided on the appropriate list of contracted supplies. The UPN on the claim billed must be the exact UPN for the product dispensed.
- 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 medical supply HCPCS Level II codes are not limited to any particular manufacturer.
- If the non-contracted HCPCS Level II code has an MAPC on file as indicated in the applicable Part 2 provider manuals, then the documentation of product cost as an attachment to the claim is not required.
- 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.
- For non-contracted HCPCS Level II codes without MAPCs listed in the applicable Part 2 provider manual will require documentation of product cost (an invoice, manufacturer's catalog page or price list), as an attachment to the claim for reimbursement 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, documentation of product cost as an attachment must be included with the claim clearly 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.
- 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.
- Medicare covers some medical supplies. When Medicare covers an item and the recipient is eligible for Medicare, providers bill Medicare before billing Medi-Cal.
- 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.
- Refer to the appropriate provider manual section regarding the required invoice certification.
- 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.
If you have any questions, please call the Telephone Service Center (TSC) at 1-800-541-5555.