Durable medical equipment (DME) billing
Not all DME and P&O items are covered. For benefit information, call the Provider Help Line.
DME rental agreements under Priority Health Medicare
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Priority Health Medicare members with no current rental agreement:
DME supplier may create a new rental agreement.
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New to Priority Health Medicare with a current rental agreement:
If a member has an existing rental agreement with the supplier under another Medicare Advantage plan, the DME supplier must continue that rental agreement until the capped rental is reached or the member has completed the rent-to-own number of months.
NOTE: Section 10.3 of Chapter 20 of the Medicare Claims Processing Manual, "Beneficiaries Previously Enrolled in Managed Care Who Return to Traditional Fee for Service (FFS)", does not apply to Priority Health Medicare members.
DME dispensed in provider office
- Durable medical equipment (DME) and prosthetics/orthotics (P&O) items dispensed in the provider's office must be billed using the appropriate HCPCS code and modifier (NU and RR: see "Accepted modifiers" section below).
- Coverage is available for standard orthotic/support devices only.
DME obtained from DME provider
- A prescription is required for all DME and P&O when item is being obtained from a licensed DME provider.
- Prior authorization is required for items over $500 (Priority Health Medicaid members), or $1,000 (for other Priority Health members). Check our list of DME items requiring prior authorization.
Miscellaneous/unlisted DME codes
Occasionally an item, device or piece of equipment is not represented by a specific HCPCS code.
Do not use code 99070, supplies & materials. Instead, use unlisted codes from the following categories:
- A4649, Surgical supply, miscellaneous
- A9999, Miscellaneous DME supply or accessory, not otherwise specified
- E1399, Durable medical equipment, miscellaneous
When billing with one of these codes, notes and invoice must accompany the claim. The notes may consist of a notation of the item in box 19 on the claim or may be an invoice or note describing the item, brand, model, quantity, size, etc.
Items billed under a miscellaneous code will not be paid if a more specific code is available.
Accepted DME modifiers
Use this guide for all products except Priority Health Medicare to determine if a HCPCS code requires a modifier. For Priority Health Medicare claims, follow Medicare guidelines for using HCPCS modifiers.
NU = New, RR = Rental
- A codes – Modifiers are not required
- B codes – Modifiers are not required
- E codes – NU and RR can be used
- J codes – Modifiers are not required
- K codes – NU and RR can be used
- L codes – NU only
- Q codes – Modifiers are not required
- S codes – Modifiers are not required
- T codes – NU only
