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, RP, and RR: see Accepted Modifiers, 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 (self-funded ASO plan and PriorityMedicaid members), or $1,000 (for other Priority Health members). Effective 9/1/07, self-funded (ASO) plans will raise the purchase limit requiring prior auth to $1,000. 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 Modifiers
The following guide should be used for all products except PriorityMedicare^SM to determine if a HCPCS code requires a modifier. For PriorityMedicare claims, follow Medicare guidelines for using HCPCS modifiers.

• A codes – Modifiers are not required
• B codes – Modifiers are not required
• E codes – All modifiers (NU, RP and RR) can be used
• J codes – Modifiers are not required
• K codes – All modifiers (NU, RP 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

NU = New, RR = Rental, RP = Repair