DME items have a reasonable useful lifetime per DMERC of 5 years. This makes it extremely important to check with patients prior to giving any DME item to see if they have been given anything similar previously. If they have an item that will work for the current issue, they are to use it again. DMERC’s automated line has option to check for same/similar equipment and gives the HCPCS code and date purchased. You simply put in the patient’s information and then the HCPCs code for the item currently being issued.
In certain cases of loss or irreparable damage, replacement may be considered with proper documentation. Replacement refers to giving an identical or nearly identical item. DME owned by the patient may be replaced in cases of loss or irreparable damage. Irreparable damage refers to a specific accident or to a natural disaster (e.g., fire, flood, etc.). If lost in fire, fire report is to be in patient’s file. If stolen, the police report is to be in the patient file. If replacing because item is irreparably damaged, the assessment of the original item to support this statement and any supporting fire/police/insurance reports are to be kept in the patient’s file. DMERC may request this proof before considering payment of the new item or my audit after payment to be sure all proper documentation was on file.
Irreparable wear (wear and tear) refers to deterioration sustained from day-to-day use over time and a specific event cannot be identified. For DMERC, this is not sufficient for replacement of the same or similar equipment prior to the reasonable useful lifetime. In these cases, the patient will have to sign an ABN and pay for the replacement themselves. No replacement will be paid by DMERC for wear and tear until 5 years from the purchase of the original item.
To bill DMERC for a replacement item, the claim must have the RA modifier on it to identify it is a replacement item. Claims must also have a claim note to identify why the equipment is being replaced. The note must also include the date the patient received the original equipment that is being replaced. The following format is suggested by DMERC for reporting the proper information:
- HCPCS code of the original item;
- A notation that this is patient owned item and
- The date the patient obtained this equipment.
Example 1 – patient lost original cam walker paid under L4360 in a fire in 2016. Now patient is being issued L4361 off the shelf cam walker for a new condition. Claim bills as L4361RA with claim note of “FIRE L4360 042316”
Example 2 – patient had cam walker in 2012 and now is eligible for a replacement. Claim still bills as L4361RA but note would be L4360 RUL 021212. (RUL means reasonable useful lifetime.)