Durable medical equipment (DME), Prosthetics and Orthotics

DME rental caps

• Ventilator rentals are never capped.
• DME rental is limited to 10 months for most plans.
• Medicare DME rentals are capped at 13 months.
• Medicare oxygen equipment rental is capped at 36 months. See more below.

DME rental agreements, Priority Health Medicare Advantage

For reference, see Chapter 20 of the Medicare Claims Processing Manual, Chapter 20.

Note: Section 10.3, "Beneficiaries Previously Enrolled in Managed Care Who Return to Traditional Fee for Service (FFS)", does not apply to Priority Health Medicare Advantage plan members.

Medicare plan members with no current rental agreement

DME supplier may create a new rental agreement.

New to Priority Health Medicare with a current rental agreement

If a member has an existing rental agreement with the supplier under another company's 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.

Medicare oxygen and oxygen equipment rental

• Priority Health Medicare follows Medicare rules.
• Oxygen equipment rental is limited to 36 months, at which point Priority Health Medicare will cover maintenance and repair as allowed by Medicare.
• Providers are responsible for tracking rental and should not submit bills for any month beyond 36.

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.
• For Priority Health Medicare Advantage plan members, follow CMS billing rules.

DME obtained from DME provider

A prescription is required for all DME and P&O when items are obtained from licensed DME providers.

Do not use code 99070, supplies & materials, when an item, device or piece of equipment is not represented by a specific HCPCS code. Instead, use unlisted codes from the following categories:

• 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.

For Priority Health Medicare Advantage members

Follow the modifier rules in Chapter 14 of the NGS Supplier Manual for Jurisdiction B (enter "DME modifiers" in Search).

For members of all other plans

Modifiers:

• NU = New
• RR = Rental

Use this guide to determine if a HCPCS code requires a modifier.

• A codes – Modifiers are 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

DME clinical edits

Several DME, PO and supplies HCPCS codes require the use of modifiers to identify that anatomical, laterality, functional or support policy criteria is met. Claims reported without the required modifiers will be denied. Those reported with modifiers that do not support medical necessity may be denied to member liability. Please note that this does not replace the need for NU, RR, UE, etc. associated with DME items.

Capped Rental Modifiers

Reminder – Capped rentals have to include RR modifier to identify capped rental along with modifiers to identify the period of capped rental with modifiers KH, KI, or KS

• KH (DMEPOS item, initial claim, first month rental) is only to be used for the initial claim of the capped rental period
• KI (DMEPOS item, second- or third-month rental) is only to be used for the second and third months of the capped rental period
• KJ (DMEPOS item, parenteral enteral nutrition (PEN) pump or capped rental, months 4 to 15) is only to be used for the fourth through final month of the capped rental period

Functional Modifiers K0-K4

Functional Modifiers have been developed to define ability (DME Medical Review Policy). When a lower limb prosthesis is billed without one of the functional modifiers, the prosthesis will be denied.

• Modifier K0 indicates the prosthesis does not enhance the member’s quality of life or mobility and medical policy (or for Medicare, LCD) will drive coverage when modifier is appended.
• Modifier K1 identifies the prosthesis creates a functional level of 1 (see HCPCS for modifier definition)
• Modifier K2 identifies the prosthesis creates a functional level of 2 (see HCPCS for modifier definition)
• Modifier K3 identifies the prosthesis creates a functional level of 2 (see HCPCS for modifier definition)
• Modifier K4 identifies the prosthesis creates a functional level of 2 (see HCPCS for modifier definition)

HCPCS codes below require modifier K2, K3 or K4

• HCPCS Codes - L5972 (Flexible keel foot)
• HCPCS Codes - L5978 (Multiaxial ankle/foot)
• HCPCS Codes - L5982-L5986 (Axial rotation unit)

HCPCS codes below require K3 or K4

• HCPCS Codes - L5610, L5613, L5614, L5722-L5780, L5814, L5822-L5840, L5848, L5856-L5858, L5859 (Fluid, pneumatic or electronic knee)
• HCPCS Codes - L5961, L5973 (Endoskeletal ankle foot system)
• HCPCS Codes - L5976, L5979-L5981, L5987 (All lower extremity prosthesis, foot system)

HCPCS code below requires K3

• HCPCS Code - L5859

HCPCS code below requires K4

• HCPCS Code - L5930

Modifier KF

According to CMS policy, external defibrillator (E0617, K0606) and osteogenesis stimulators (E0747-E0748, E0760, E0766) are classified as class III devices which must be submitted with modifier KF.

• External defibrillator (E0617, K0606)
• Osteogenesis stimulators (E0747-E0748, E0760, E0766)

Wheelchair Modifiers

• KX Modifier – Modifier should be appended to indicate that policy criteria has been met for all wheelchair DME items (includes base, seating, power devices, and additional accessories). Claims reported without KX modifier will deny as non-payable per medical policy. (Commercial, Medicaid products)
• KX, GA, GY, GZ Modifiers – Per CMS local coverage determinations, one of these modifiers are required for claim processing all wheelchair DME items (includes base, power bases, seating, and additional accessories). Please review applicable LCD for additional guidelines. (Medicare)
• RT, LT Modifiers – Laterality modifiers should be utilized to identify the right or left side when a bilateral accessory is supplied. Missing modifiers will result in a claim denial.

Pressure Reducing Support Surfaces (Groups I, II, III)

• KX Modifier – Modifier should be appended to indicate that policy criteria has been met. Claims reported without KX modifier will deny as non-payable per medical policy. (Commercial, Medicaid products)
• KX, GA, GY, GZ Modifiers – Per CMS local coverage determinations, one of these modifiers are required for claim processing. Please review applicable LCD for additional guidelines. (Medicare)
• Group I - E0181, E0182, E0184-E0189, E0196-E0199
• Group II - E0193, E0277, E0371- E0373
• Group III - E0194

Oxygen and Associated Equipment

• KX Modifier – Modifier should be appended to indicate that policy criteria has been met. Claims reported without KX modifier will deny as non-payable per medical policy. (Commercial, Medicaid products)
• KX, GA, GY, GZ Modifiers – Per CMS local coverage determinations, one of these modifiers are required for claim processing. Please review applicable LCD for additional guidelines. (Medicare)

Respiratory Assist Devices, Airway Pressure Devices, and Oral Appliance or Devices

• KX Modifier – Modifier should be appended to indicate that policy criteria has been met. Claims reported without KX modifier will deny as non-payable per medical policy. (Commercial, Medicaid products)
• KX, GA, GY, GZ Modifiers – Per CMS local coverage determinations, one of these modifiers are required for claim processing. Please review applicable LCD for additional guidelines. (Medicare)

Glucose Monitors

• KS Modifier – reported to identify if member is treated with insulin when billing for home glucose monitors. Claims without applicable modifier will be denied.
• KX Modifier – reported to indicate if member is insulin dependent and policy criteria is met. Claims without applicable modifier will be denied.

Prosthetics and Orthotics

• KX Modifier – Modifier should be appended to indicate that policy criteria has been met. Claims reported without KX modifier will deny as non-payable per medical policy. (Commercial, Medicaid products)
• KX, GA, GY, GZ Modifiers – Per CMS local coverage determinations, one of these modifiers are required for claim processing. Please review applicable LCD for additional guidelines. (Medicare)

Orthotic Footwear

• KX Modifier – Modifier should be appended to indicate that policy criteria has been met. Claims reported without KX modifier will deny as non-payable per medical policy. (Commercial, Medicaid products)
• KX, GA, GY Modifiers – Per CMS local coverage determinations, one of these modifiers are required for claim processing. Please review applicable LCD for additional guidelines. (Medicare)
  Diabetic shoes/inserts HCPCS A5500-A5507 or A5512-A5514 – KX or GY
• RT or LT Modifier (Diabetic shoes/inserts) HCPCS A5500 - A5514

Surgical Dressing

• Modifiers A1-A9 are utilized to identify surgical dressings used for primary or secondary dressing on surgical and debrided wounds. These modifiers also indicate the number of wounds in which the surgical supply is utilized (total number based on wounds with dressings)
• Modifiers A1-A9
• A6010-A6011, A6021-A6024, A6196-A6224, A6228-A6248, A6251-A6259, A6261-A6262, A6266, A6402-A6404, A6407, A6441-A6456, A4461, A4463, A6154 and miscellaneous surgical dressings (A4649) when applicable

Other DME related supplies

• Modifier KX – HCPCS codes A4310-A4328, A4332-A4360, or A5102-A5114 (Commercial and Medicaid)
• Modifier KX – HCPCS codes A6550, A7000 or E2402 (Urological supplies) (Commercial and Medicaid)
• Modifiers GA, GY, GZ or KX – HCPCS codes A4310-A4328, A4332-A4360, or A5102-A5114 (Medicare)
• Modifiers GA, GY, GZ or KX – HCPCS codes A6550, A7000 or E2402 (Medicare)

ESRD Supplies

• When ESRD items are utilized for non-ESRD treatment, HCPCS codes should be reported with AY modifier
• HCPCS codes - A4215-A4218, A4244-A4248, A4450-A4452, A6204, A6215-A6216, A6250, A6260, A6402, E0210