OAR 436-009-0080
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
(1)
Durable medical equipment (DME), such as Transcutaneous Electrical Nerve Stimulation (TENS), Microcurrent Electrical Nerve Stimulation (MENS), home traction devices, heating pads, reusable hot/cold packs, etc., is equipment that:(a)
Is primarily and customarily used to serve a medical purpose,(b)
Can withstand repeated use,(c)
Could normally be rented and used by successive patients,(d)
Is appropriate for use in the home, and(e)
Is not generally useful to a person in the absence of an illness or injury.(2)
A prosthetic is an artificial substitute for a missing body part or any device aiding performance of a natural function. Examples: hearing aids, eye glasses, crutches, wheelchairs, scooters, artificial limbs, etc. The insurer must pay for the repair or replacement of prosthetic appliances damaged as a result of a compensable injury, even if the worker received no other injury. If the appliance is not repairable, the insurer must replace the appliance with a new appliance comparable to the one damaged. If the worker chooses to upgrade the prescribed prosthetic appliance, the worker may do so but must pay the difference in price.(3)
An orthotic is an orthopedic appliance or apparatus used to support, align, prevent or correct deformities, or to improve the function of a moveable body part. Examples: brace, splint, shoe insert or modification, etc.(4)
Supplies are materials that may be reused multiple times by the same person, but a single supply is not intended to be used by more than one person, including, but not limited to incontinent pads, catheters, bandages, elastic stockings, irrigating kits, sheets, and bags.(5)
When billing for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS), providers must use the following modifiers, when applicable:(6)
Unless otherwise provided by contract or sections (7) through (11) of this rule, insurers must pay for DMEPOS according to the following table: {See attached table.}(7)
Unless a contract establishes a different rate, the table below lists maximum monthly rental rates for the codes listed (do not use Appendix E or section (6) to determine the rental rates for these codes): {See attached table.}(8)
For items rented, unless otherwise provided by contract:(a)
The maximum daily rental rate is one thirtieth (1⁄30) of the monthly rate established in sections (6) and (7) of this rule.(b)
After a rental period of 13 months, the item is considered purchased, if the insurer so chooses.(c)
The insurer may purchase a rental item anytime within the 13-month rental period, with 75 percent of the rental amount paid applied towards the purchase.(9)
For items purchased, unless otherwise provided by contract, the insurer must pay for labor and reasonable expenses at the provider’s usual rate for:(a)
Any labor and reasonable expenses directly related to any repairs or modifications subsequent to the initial set-up; or(b)
The provider may offer a service agreement at an additional cost.(10)
Hearing aids must be prescribed by the attending physician, authorized nurse practitioner, or specialist physician. Testing must be done by a licensed audiologist or an otolaryngologist. The preferred types of hearing aids for most patients are programmable behind the ear (BTE), in the ear (ITE), and completely in the canal (CIC) multichannel. Any other types of hearing aids needed for medical conditions will be considered based on justification from the attending physician or authorized nurse practitioner. Unless otherwise provided by contract, insurers must pay the provider’s usual fee for hearing services billed with HCPCS codes V5000 through V5999. However, without approval from the insurer or director, the payment for hearing aids may not exceed $7000 for a pair of hearing aids, or $3500 for a single hearing aid. If the worker chooses to upgrade the prescribed hearing aid, the worker may do so but must pay the difference in price.(11)
Unless otherwise provided by contract, insurers must pay the provider’s usual fee for vision services billed with HCPCS codes V0000 through V2999.(12)
The worker may select the service provider. For claims enrolled in a managed care organization (MCO) the worker may be required to select a provider from a list specified by the MCO.(13)
Except as provided in section (10) of this rule, the payment amounts established by this rule do not apply to a worker’s direct purchase of DMEPOS. Workers are entitled to reimbursement for actual out-of-pocket expenses under OAR 436-009-0025 (Worker Reimbursement).(14)
DMEPOS dispensed by a hospital (inpatient or outpatient) must be billed and paid according to OAR 436-009-0020 (Hospitals).
Source:
Rule 436-009-0080 — Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), https://secure.sos.state.or.us/oard/view.action?ruleNumber=436-009-0080.