Billing for DME

When billing for durable medical equipment (DME), use the appropriate HCPCS code and modifier(s) to describe the items being billed. Also include an ICD-9/ICD-10 diagnosis code indicating the medical condition for which the item has been prescribed. 

Note: Pharmacies participating with HMSA's medical plan will generally dispense only small items such as braces, glucometers, nebulizers, or walkers.

Modifiers

In addition to an appropriate HCPCS code for the DME item, many HCPCS codes require a modifier. The modifiers are used to provide more information about the item. For example, the modifier may tell HMSA that an item is new, used, or rented on a capped basis. For capped rentals, modifiers distinguish which month's rental is being billed. If these modifiers are used incorrectly or missing, the claim may be denied. To expedite processing of your claims, please indicate first month rental by including the appropriate modifier code, and bill your claims in sequential order.

Common modifiers

• RR - Rental
• NU - Purchase of new equipment
• UE - Purchase of used equipment

Modifiers RR, NU and UE should be used for the following categories:

• Inexpensive or Routinely Purchased (IRP)  Item
• Capped Rental item
• Items Requiring Frequent and Substantial Servicing
• Oxygen Equipment (not contents)

For capped rentals, use RR and one of these additional modifiers to indicate rental period:

• KH – Initial claim, first-month rental
• KI – Second and third capped rental months
• KJ – Fourth to 13th capped rental months

Maintenance and Servicing

MS – Six-month maintenance and servicing fee for reasonable and necessary parts and labor that are not covered under any manufacturer or supplier warranty.  This is covered for capped rental items prior to Jan. 1, 2006.  Payment is not made for maintenance and servicing of capped rental items in which the first month occurs on or after Jan. 1, 2006.  Maintenance and services payments will be made for oxygen equipment every six months, starting six months after the member first owns the equipment.

Replacement and Repair

• RA – Replacement of a DME item due to loss, irreparable damage, or theft. This is used on the first-month rental claim for a replacement item.
• RB – Replacement of a part of DME as part of a repair

KX Modifier – Documentation on File

KX – The KX modifier should be added to the code to indicate that specific required documentation is on file to support the medical necessity of the item.  (Refer to page 2 of the November 2014 HealthPro News edition [PDF] for more information).  The KX modifier is allowed for the following categories:

• AFO/KAFO
• Cervical traction unit
• Commodes
• CPAP
• External infusion pumps
• Hospital Beds
• Manual wheelchair bases (except K0004, K0005, K0009)
• Nebulizers
• Orthopedic footwear
• Patient lifts
• Pre-fabricated knee orthoses
• Pressure-reducing support surfaces
• Walkers
• Wheelchair options/accessories (except E1399,K0108)
• Wheelchair seating (except E1399, K0108)

Right and Left

• RT – Right
• LT – Left

RT and LT modifiers should be used for the following categories:

• AFO/KAFO
• External breast prosthesis
• Eye prosthesis
• Lower limb prosthesis
• Orthopedic footwear
• Therapeutic shoes for persons with diabetes
• Wheelchair options/accessories

Used with complex power wheelchairs only:

• BP – Member has elected to purchase
• BR – Member has elected to rent

Note: Modifiers are not needed when billing for medical supplies (e.g., syringes, ostomy bags).

Example

For example, use the following code and modifiers to bill for CPAP, capped rental, first month, documentation available to support medical necessity:

• HCPCS code E0601
• Modifiers -
  • RR - rental
  • KH - Initial claim, first month rental
  • KX - documentation available to support medical necessity

Revision History