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Provider Handbook
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Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Pricing
Payment of Home Infusion Drug Pricing
Modifiers |
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Durable Medical Equipment, Prosthetics,
Orthotics, and Supplies Pricing |
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Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) prices are established by using fee schedules, reasonable charges, or average wholesale pricing. Most payments of (DME) are based on a fee schedule established for each DMEPOS item by state. The services and/or supplies are coded using HCPCS Level II codes that begin with the letters:
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- A (medical and surgical supplies)
- B (enteral and parenteral therapy)
- E (durable medical equipment)
- K (temporary codes)
- L (orthotics and prosthetic procedures)
- V (vision services)
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Inclusion or exclusion of a fee schedule amount for an item or service does not imply TRICARE coverage.
In addition to the DMEPOS schedule, Parenteral and Enteral Nutrition (PEN) items and services and fees are also included. DMEPOS pricing information is available at the Noridian web site.
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Payment of Home Infusion Drug Pricing |
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Home infusion drugs are reimbursed the lesser of the billed amount or 95 percent of the Average Wholesale Price (AWP). This change affects claims processed on or after June 6, 2006.
Home infusion drugs are those drugs (including chemotherapy drugs) administered by other than oral means, e.g., the drug must be administered either intramuscularly, subcutaneously, intravenously, or infused through a piece of durable medical equipment (DME). DME verification is not required.
Claims for home infusion will be identified by place of service and the Centers for Medicare and Medicaid Services Common Procedure Coding System, National Level II Medicare “J” codes, along with a specific National Drug Code (NDC). The CMAC for these drugs will be reimbursed at 95 percent of AWP as retrieved from the National Drug Blue Book.
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Modifiers |
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Providers should use applicable modifiers that fit the description of the service, and the claim will be processed accordingly. The CPT and HCPCS publications contain lists of modifiers available for describing services. If a provider believes a claim was incorrectly denied, the provider should follow the Allowable Charge Review process explained under “TRICARE Claim Appeals” in the Claims Processing and Billing Information section of this handbook. |
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