Loading...Loading...Policy No: 131
Originally Created: 02/01/2017
Section: Administrative
Last Reviewed: 10/01/2024
Last Revised: 10/01/2022
Approved: 11/14/2024
Effective: 12/01/2024
Policy Applies To: Medicare Advantage
This policy applies only to physicians and other qualified health care professionals, including DMEPOS Suppliers.
Custom Durable Medical Equipment (DME) – Custom Items are rarely necessary and are rarely furnished. Must be uniquely constructed or substantially modified for a specific beneficiary according to the description and orders of a physician and be so different from another item used for the same purpose that the two items cannot be grouped together for pricing purposes. Items that are measured, assembled, fitted, or adapted in consideration of a patient’s body size, weight, disability, period of need, or intended use (i.e., custom fitted items) do not meet the definition of customized items. An example of a genuine custom item would be a wheelchair that is modified to allow conjoined twins to use it in such a way that no other beneficiary could ever use it. An example of an item that is not a custom item would be a compression garment that comes in a variety of sizes, even if the beneficiary’s leg were measured for the item to determine which preset size they would be getting. This compression garment example would be a custom fitted item, not a Custom DME item.
Durable medical equipment (DME) – DME is equipment that:
- Can withstand repeated use.
- Is primarily and customarily used to serve a medical purpose.
- Generally, is not useful to a person in the absence of an illness or injury; and
Is appropriate for use in the home.
All requirements of the definition must be met before an item can be considered durable medical equipment.
Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) are classified by the Centers for Medicare & Medicaid (CMS) into 12 categories below:
- IN - Inexpensive and Other Routinely Purchased Items
- FS - Frequently Serviced Items
- CR - Capped Rental Items
- OX - Oxygen and Oxygen Equipment
- OS - Ostomy, Tracheostomy & Urological Items
- PO - Prosthetics & Orthotics
- SD - Surgical Dressings
- SU - Supplies
- TE - Transcutaneous Electrical Nerve Stimulators
- TS - Therapeutic Shoes
- IL - Intra Ocular lens
- SC - Splinting and Casting
Purchase and Rental Limitations:
DME claims must indicate whether the item(s) is rented or purchased. Purchased equipment must specify whether it is new or used. If the claim does not indicate whether the item is new or used, the item may be denied for the appropriate modifier. The following table indicates the Healthcare Common Procedure Coding System (HCPCS) modifiers used to indicate status. Other modifiers may be used in addition to those listed below to increase specificity.
Modifer and status
LL - Lease/rental (use when DME equipment rental is to be applied against the purchase price)
NR - New when rented (use when an item that was new at the time of rental is subsequently purchased)
NU - New equipment
RR - Rental (use when DME is to be rented)
UE - Used durable medical equipment
In addition to this policy, claims payments are subject to other plan requirements, including, but not limited to, requirements of medical necessity and reasonableness.
A DME item that has been purchased, may not be purchased, or rented again within a 60-month period. Back-up, upgrade, and replacement may be allowable as indicated on Centers for Medicare & Medicaid (CMS) Guidelines – Durable Medical Equipment Upgrades, Replacements and Duplicates.
A DME item that has been categorized by CMS on the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule as a capped rental (CR) item will be considered purchased and owned by the member after 13 continuous rental months have been paid for the item. Rental charges received for the item after the 13th continuous month will be denied.
A DME item that has been categorized by CMS on the DMEPOS Fee Schedule as a Transcutaneous Electrical Nerve Stimulation (TE) item will be considered purchased and owned by the member after three (3) continuous months have been paid for the item. Charges received for the item after the 3rd continuous month will be denied.
A DME item that has been categorized by CMS on the DMEPOS Fee Schedule as an Oxygen Equipment (OX) item reimbursement will be limited to 36 monthly rental payments. This allowance applies to both stationary and portable items. Only charges submitted with modifier MS to indicate maintenance and servicing may be considered for additional payment beyond the 36-month rental period for parts and labor which are not covered under any manufacturer or supplier warranty.
Reimbursement:
Medicare Advantage reimbursement of DMEPOS codes will be at the lesser of billed charges or 100% of current DMEPOS fee schedule amount published by CMS.
Parenteral and Enteral Nutrition (PEN) codes will be reimbursed at the lesser of billed charges or 80% of the current DMEPOS fee schedule published by CMS.
Our health plan reserves the right to set a fee schedule amount for a DMEPOS code which is different from the amount published in the CMS DMEPOS fee schedule. For codes which do not have CMS fees, we may assign a payment rate that is the lesser of billed charges, a fee schedule amount or 150% of wholesale invoice cost.
Centers for Medicare & Medicaid Services (CMS), Medicare Claims Processing Manual, Chapters 15, 17 and 20
Centers for Medicare & Medicaid Services (CMS), Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule
Electronic Code of Federal Regulations, Title 42, Public Health, Part 414, Payment for Part B Medical and Other Health Services, Subpart B, Physicians and Other Practitioners, 414.202, 414.210, 414.229, 414.232
Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.