REIMBURSEMENT SERVICES - HELPFUL HINTS FOR FILING
HCPCS-E1399 Durable Medical Equipment (DME), Miscellaneous
Sometimes third-party payers believe an item provided to a customer is not “medically necessary” or “reasonable” for treating the patient’s condition. In this event, payment for the equipment may be denied. “Medical necessity” claims for equipment may be turned down because:
• Therapeutic function is questioned
• Equipment is believed to only provide partial therapeutic benefit
• The equipment substantially exceeds what is needed for treatment - or too expensive
Check for “Medical Necessity”:
A physician’s order and/or documentation of medical necessity is required to be completed and signed by the physician for every DME claim. The physician order and/or documentation of “medical necessity” should include, at a minimum, the following information or documentation:
• Patient’s diagnosis
• Patient’s prognosis
• Clinical need for the equipment
• Duration of medical need (six months or longer typically receives special review)
Include product literature as a description of the equipment and instructions for intended use and indications. Any available clinical studies are may be helpful in providing a detailed description of the clinical application of the item. Administrative information, such as suggested retail cost of the item, supplier ID, address, and telephone number are also necessary.
Check for “Reasonableness”:
Claims can be denied if any of the following statements are true:
• Product cost of the item outweighs the benefits
• A “clearly disproportionate” expense
• Alternative therapy is not medically appropriate and/or reasonably easy to provide
• The patient previously purchased a device that has the same purpose
USE HCPCS-E1399 When Submitting the SinuPulse Elite® Nasal/Sinus Irrigation System
Mix one teaspoon of SinuAir™ Powdered Saline or one teaspoonful of salt to one pint or 500 cc of warm water and stir until dissolved. Attach nasal tip.
• Adjust stream so it is about one inch high. Turn off at the handle.
• Place bulb end into nostril.
• Bend into the sink so you can see the drain or the nose is lower than the lips.
• Keep head straight, not side to side to have stream exit from the opposite nostril.
• Turn off at handle and do other side.
Use about 250 cc or 8 ounces for each side.
The following materials on the SinuPulse Elite® Advanced Sinus Irrigation System are available from Health Solutions Medical Products Corporation:
Nasal/Sinus Irrigation Instructions
Frequently Asked Questions about Pulsatile Irrigation
SinuPulse Elite® Sell Sheet and Product Description
Physician reference and bibliography
Note: Inclusion or exclusion of a procedure code for a specific product or supply does not imply any health insurance coverage or reimbursement policy. All referenced information and codes were taken from HCPCS.