Chapter 28: Supplies, Materials, and Bundled Services


Billing & Payment Policies for Healthcare Services provided to Injured Workers and Crime Victims



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Effective July 1, 2012

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Look for possible updates and corrections to these payment policies

 

Table of contents

Definitions

Payment policies:
Acquisition cost policy
Casting materials
Catheterization
Hot or cold therapy DME
Miscellaneous supplies
Services and supplies
Surgical dressings dispensed for home use
Surgical trays and supplies used in the physician’s office

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Related topics



Definitions

Acquisition cost: The acquisition cost equals:

  • The wholesale cost, plus
  • Shipping and handling, plus
  • Sales tax.

Bundled:

A bundled procedure code isn’t payable separately because its value is accounted for and included in the payment for other services.  Bundled codes are identified in the fee schedules.

Pharmacy and DME providers can bill HCPCS codes listed as bundled in the fee schedules.  This is because, for these provider types, there isn’t an office visit or a procedure into which supplies can be bundled.

Link: For the legal definition of “bundled,” see WAC 296-20-01002 .

HCPCS and local code modifiers mentioned in this chapter:

–NU

New purchased DME

Use the –NU modifier when a new DME item is to be purchased.

–RR

Rented DME

Use the –RR modifier when DME is to be rented.

–1S

Surgical dressings for home use

Bill the appropriate HCPCS code for each dressing item using this modifier –1S for each item.  Use this modifier to bill for surgical dressing supplies dispensed for home use.

Primary surgical dressings:

Therapeutic or protective coverings directly applied to wounds or lesions on the skin or caused by an opening on the skin.  These dressings include items such as:

  • Telfa, and
  • Adhesive strips for wound closure, and
  • Petroleum gauze.

Secondary surgical dressings:

Secondary surgical dressings serve a therapeutic or protective function and secure primary dressings.  These dressings include items such as:

  • Adhesive tape, and
  • Roll gauze, and
  • Binders, and
  • Disposable compression material.

Supplies:

Supplies include, but aren’t limited to:

  • Drugs administered in a provider’s office, and
  • Medical and surgical supplies, and
  • Prefabricated orthotics.

Payment policy: Acquisition cost policy

(See definition of acquisition cost in “Definitions” at the beginning of this chapter.)

Note: This policy doesn’t apply to hospital bills.

Link: For the “Hospital acquisition cost policy,” see the Hospitals chapter.

Requirements for billing

Billing acquisition cost

The total acquisition cost should be billed as one charge.  The acquisition cost equals:

  • The wholesale cost, plus
  • Shipping and handling, plus
  • Sales tax.

Note: Supply codes without a fee listed will be paid at their acquisition cost.

Sales tax and shipping and handling charges aren’t paid separately and must be included in the total charge of the supply.  An itemized statement showing net price (cost) plus tax may be attached to bills, but isn’t required.

Wholesale invoices

Providers must keep wholesale invoices for all supplies and materials in their office files for a minimum of 5 years.

A provider must submit a hard copy of the wholesale invoice to the insurer:

  • When billing for a supply item that costs $150.00 or more, or
  • Upon request.

Note: The insurer may delay payment of the provider’s bill if the insurer hasn’t received this information.

Payment policy: Casting materials

Services that can be billed

Bill for casting materials with HCPCS codes Q4001-Q4051.

Services that aren’t covered

No payment will be made for the use of a cast room.  Use of a cast room is considered part of a provider’s practice expense.


Payment policy: Catheterization

Link: For more information about catheterization to obtain specimen(s) for lab tests, see the “Specimen collection and handling” payment policy in the Pathology and Laboratory Services chapter.

Services that can be billed

Separate payment is allowed for placement of a temporary indwelling catheter when:

  • Performed in a provider’s office, and
  • Used to treat a temporary obstruction.

Payment limits

Separate payment isn’t allowed when placement of a temporary indwelling catheter is performed:

  • On the same day as a major surgical procedure, or
  • During the postoperative period of a major surgical procedure that has a follow up period.

Payment policy: Hot or cold therapy durable medical equipment (DME)

Note: This policy is identical to the “Hot or cold therapy DME” payment policy that appears in the Durable Medical Equipment (DME) chapter.

Services that can be billed

Ice cap or collar (HCPCS code A9273) is payable for DME providers only and is bundled for all other provider types.

Services that aren’t covered

Hot water bottles, heat and/or cold wraps aren’t covered.

Hot or cold therapy DME isn’t covered.

Examples include heat devices for home use, including heating pads.  These devices either aren’t covered or are bundled.

Link: For more information, see WAC 296-20-1102 .

Payment limits

Application of hot or cold packs (CPT® code 97010) is bundled for all providers.

Note: See definition of bundled in “Definitions” at the beginning of this chapter.

Link: For more information, see Appendix A: Bundled Services, Appendix B: Bundled Supplies, and Appendix F: Noncovered Codes and Modifiers, as well as the payment policy for “Hot and cold therapy DME” in the Durable Medical Equipment (DME) chapter.


Payment policy: Miscellaneous supplies

(See definition of supplies in “Definitions” at the beginning of this chapter.)

Services that can be billed

HCPCS billing code E1399 can be billed for a miscellaneous supply that meets both of these criteria:

  • The supply (or DME item) doesn’t have a valid HCPCS code assigned, and
  • The item must be appropriate relative to the injury or type of treatment being received by the worker.

Services that aren’t covered

The insurer won’t pay CPT® code 99070, which represents miscellaneous supplies and materials provided by the provider.

Requirements for billing

All bills for E1399 items must have:

  • Either the –NU or –RR modifier, and
  • A description must be on the paper bill or in the remarks section of the electronic bill.

These specific miscellaneous supplies must be billed using HCPCS code E1399:

  • Therapy putty and tubing, and
  • Antivibration gloves.

Payment policy: Services and supplies

(See definition of supplies in “Definitions” at the beginning of this chapter.)

Requirements for billing

Services and supplies must be medically necessary and must be prescribed by an approved provider for the direct treatment of an accepted condition.

Providers must bill specific HCPCS or local codes for supplies and materials provided during an office visit or with other office services.

For covered medical and surgical supplies that pay by report, providers must bill their usual and customary fees.

Note: Also see “Payment limits” for by report medical and surgical supplies, below.  See definition of by report in “Definitions” at the beginning of this chapter.

Links: For more information on billing “usual and customary” fees, see WAC 296-20-101 (2).

To find out which codes pay by report, see the Medical and Surgical Supplies section of the Professional Services Fee Schedule, available at www.feeschedules.Lni.wa.gov.

Services that aren’t covered

The insurer won’t pay CPT® code 99070, which represents miscellaneous supplies and materials provided by the provider.

Payment limits

Under the fee schedules, some services and supply items are considered bundled into the cost of other services (associated office visits or procedures) and won’t be paid separately.

These include:

  • Supplies used in the course of an office visit, and
  • Fitting fees, which are bundled into the office visit or into the cost of any DME.

For medical and surgical supplies that pay by report, the insurer will pay 80% of the billed charge.

Note: Also see “Requirements for billing” for by report medical and surgical supplies, above.  See definition of bundled in “Definitions” at the beginning of this chapter.

Link: To see which billing codes are bundled, see L&I’s Professional Services Fee Schedule; in the dollar value column, such items show the word bundled (instead of a dollar amount). The fee schedule is available at www.feeschedules.Lni.wa.gov .

Also, lists of bundled services and supplies are available in Appendix A: Bundled Services and Appendix B: Bundled Supplies.


 

Payment policy: Surgical dressings dispensed for home use

(See definitions of primary surgical dressings and secondary surgical dressings in “Definitions” at the beginning of this chapter.)

Requirements for billing

Providers must bill the appropriate HCPCS code for each dressing item, along with the local billing code modifier –1S for each item.

Payment limits

Primary surgical dressings and secondary surgical dressings dispensed for home use are payable at acquisition cost when all of these conditions are met:

  • They are dispensed to a patient for home care of a wound, and
  • They are medically necessary, and
  • The wound is due to an accepted work related condition.

Note: See definition of acquisition cost in “Definitions” at the beginning of this chapter, and also the payment policy for “Acquisition cost policy” earlier in this chapter.

The cost for surgical dressings applied during a procedure, office visit, or clinic visit is included in the practice expense component of the RVU (overhead) for that provider.  Separate payment isn’t allowed.

Items such as elastic stockings, support hose, and pressure garments aren’t secondary surgical dressings and must be billed with the appropriate HCPCS code.

Surgical dressing supplies and codes billed without the local modifier –1S are considered bundled and won’t be paid.

Note: See definition of bundled in “Definitions” at the beginning of this chapter.


Payment policy: Surgical trays and supplies used in the physician’s office

Payment limits

L&I follows CMS’s policy of bundling HCPCS codes for surgical trays and supplies used in a physician’s office.  Surgical trays and supplies won’t be paid separately.

Note: See definition of bundled in “Definitions” at the beginning of this chapter.


If you’re looking for more information about… Then go here:
Administrative rules
for topics relevant to this chapter
Washington Administrative Code (WAC) 296-20-1102:
http://apps.leg.wa.gov/wac/default.aspx?cite=296-20-1102
WAC 296-20-01002:
http://apps.leg.wa.gov/wac/default.aspx?cite=296-20-01002
Becoming an L&I provider L&I’s website:
www.Lni.wa.gov/ClaimsIns/Providers/Becoming/default.asp
Billing instructions and forms Chapter 2:
Information for All Providers
Fee schedules for all healthcare
facility services (including ASCs)
L&I’s website:
www.feeschedules.Lni.wa.gov
Lists of bundled services and supplies Appendix A: Bundled Services
Appendix B: Bundled Supplies
Payment policies for
catheterization to obtain specimens for lab tests
Chapter 22:
Pathology and Laboratory Services
Payment policies for
durable medical equipment (DME)
Chapter 9:
Durable Medical Equipment
Payment policies for hospital
acquisition cost policy
Chapter 35:
Hospitals

Need more help?  Call L&I’s Provider Hotline at 1-800-848-0811.


CPT® codes and descriptions only are © 2011 American Medical Association

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