Billing for Durable Medical Equipment (DME)

Not all DME and P&O items are covered. For benefit information, call the Provider Helpline.

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.
  
• Services billed with code 99070, unlisted supplies, will be denied.

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.  Unlisted codes from the following categories may be billed:

• 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