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February 15, 2013

Temporary Replacement (HCPCS K0462) Claims – Documentation Requirement Change

Medicare allows payment for temporary replacement (HCPCS K0462) for beneficiary-owned equipment being repaired. Current documentation requirements for billing code K0462 require that the claim must include a narrative description of the equipment being used as a temporary replacement, including the manufacturer, brand name, model name or number of the temporary replacement item, and a statement of why the replacement is needed. CGS staff has noted that to properly process these claims, there are instances where additional information pertaining to the beneficiary-owned piece of equipment may also be needed. Such instances occur when Medicare has no record of the beneficiary-owned equipment on file or Medicare has records for multiple pieces of equipment on file. Based on Supplier feedback, in order to avoid the confusion and frustration of further development for this additional information after the claim has been filed, CGS is implementing a change in supplier documentation for code K0462.

Effective for claims received on or after April 1, 2013, suppliers billing temporary replacement equipment under HCPCS code K0462 must provide information pertaining to both the beneficiary-owned equipment and the temporary replacement equipment submitted with every claim. Claims must include a narrative description of the equipment being used as a temporary replacement, with the manufacturer, brand name, model name or number of the temporary replacement item, and a statement of why the replacement is needed. In addition, claims must include the HCPCS code and or manufacturer name, brand name, and model name or number of the beneficiary-owned piece of equipment and the date of purchase of the equipment. Claims without this information will be denied as not medically necessary.

For claims filed in the X12 837 version 5010A1 format, the information should be sent in the line level note (2400.NTE segment). Due to the 80 character limitation of this field, suppliers may submit additional information in the claim level note (2300.NTE segment) or utilize the PWK option.

An example of how the information might be shortened to fit the 80 character limitation is:

PWR WC LNR PRIDE JAZZY 614HD BAD DRIVE MOTOR - PARTS ON ORDER PT OWN K0824 8/09

For suppliers approved for paper filing, the information should be sent in Block 19 of the Health Insurance Claim Form – Form CMS-1500 (08-05).

The new instructions will be added to the Jurisdiction C Supplier Manual.

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