CurrentAnthemPolicy C-19006

DME Modifiers - Professional

Defines allowable reimbursement modifiers and billing rules for durable medical equipment (DME), prosthetics, and orthotics for Anthem commercial professional claims; affects professional providers submitting DME-related claims.

Policy Summary

PayerAnthem

PolicyDME Modifiers - Professional

Policy CodePolicy C-19006

Change TypeNo material clinical or coverage changes

Effective Date01/01/2026

Next Review DateN/A

Key ActionAppend the appropriate reimbursement modifier in the primary/first modifier field; claims without the required modifier may be denied or subject to recovery.

SourceLink

01/01/2026effective date for current policy version

11+modifier descriptions listed

10/01/2025last approval/review date

DME/Prosth/Orthoservice types governed

DME Modifier Billing and Reimbursement Rules

DME modifier billing and reimbursement rules

Rules for using modifiers and reimbursement handling for DME, prosthetics, and orthotics:

Modifiers listed are reimbursement modifiers and must be billed in the primary or first modifier field to determine appropriate reimbursement.

Modifiers are appropriate for Durable Medical Equipment (DME), prosthetics, and orthotics and are inappropriate for supplies unless required under State guidelines; claims for supplies appended with a DME modifier may be denied.

When reporting daily rental items, append modifier RR.

Reimbursement for continuous/rent-to-purchase items is based on the plan's allowance for the monthly rental period; append a rental modifier such as BR, KI, KR, LL, or RR when the DME item is a continuous rental.

Policy Summary

PayerAnthem

PolicyDME Modifiers - Professional

Policy CodePolicy C-19006

Change TypeNo material clinical or coverage changes

Effective Date01/01/2026

Next Review DateN/A

Key ActionAppend the appropriate reimbursement modifier in the primary/first modifier field; claims without the required modifier may be denied or subject to recovery.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Reimbursement Modifiers and Coding Requirements

DME reimbursement modifiersModifierCovered

BP	Beneficiary elected to purchase the item (purchase election)
BR	Beneficiary elected to rent the item (rental election)
EX	Expatriate beneficiary
KC	Replacement of special power wheelchair interface
KI	DMEPOS item, 2nd or 3rd month rental
KR	Rental item, billing for partial month
LL	Lease/Rental applied against purchase price
MS	Six-month maintenance and servicing fee
NR	New when rented (subsequently purchased)
NU	New equipment (purchased)

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Modifier placement requirement

RequirementReimbursement modifiers must be billed in the primary or first modifier field to determine appropriate reimbursement.

ScopeModifiers listed apply to DME, prosthetics, and orthotics; they are inappropriate for supplies unless required under State guidelines.

ConsequenceClaims submitted without the appropriate reimbursement modifier may be denied or payment recovered.

Authorization, Documentation, and Denial Risks

Prior Authorization

Authorization and applicability — obtain required authorizations

Services must meet authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and the member's state of residence. Ensure any required prior authorization is obtained before rendering services to avoid claim denials or payment recovery.

Follow state and federal mandates and provider contract requirements that may supersede this policy.

Denial Risk

Denial risk for missing or incorrect modifiers

Claims submitted without the appropriate reimbursement modifier may be denied or payment may be recovered. Modifiers listed as reimbursement modifiers must be billed in the primary or first modifier field to determine appropriate reimbursement. Modifiers appropriate for DME, prosthetics, and orthotics are not appropriate for supplies unless state guidelines require them.

Missing or incorrect modifiers can lead to claim denial or recoupment.
Examples: RR for daily rental items; BR, KI, KR, LL, RR for continuous/rent-to-purchase rentals; KC, RA, RB for DME replacement reporting.

Documentation Required

Documentation requirement — maintain complete coding and medical record support

Use industry-standard CPT, HCPCS, and revenue codes on all claim submissions. All billed services must be fully supported by the medical record and/or office notes. Maintain documentation that supports the service, procedure, modifier usage, rental status, and any clinical justification for medical necessity. Failure to follow coding/billing guidelines or maintain adequate documentation may result in claim rejection, denial, or recovery of payment.

Bill services with appropriate CPT/HCPCS/revenue codes and append required reimbursement modifiers in the first modifier field.
Retain medical records and office notes that substantiate billed services, modifiers, and authorization.
Document rental status and applicable rental modifiers (e.g., RR, BR, KI, KR, LL) and replacement modifiers (KC, RA, RB) when billing DME.

Key Definitions

Durable Medical Equipment (DME)

DefinitionDurable Medical Equipment (DME): Equipment that provides therapeutic benefits, is primarily medical in purpose, can withstand repeated use, is generally not useful without illness/injury, appropriate for home use, and prescribed by a licensed practitioner.

Coverage noteHealth plan allows reimbursement for new, rented or used DME when appended with the appropriate modifier unless contract or mandate indicates otherwise.

Use limitationModifiers are appropriate for DME, prosthetics, and orthotics; claims for supplies appended with a DME modifier may be denied.

Purchase

DefinitionPurchase: Items that are generally not reusable (such as supplies), or are available for long-term use, and/or are customized.

ExamplesTypically applies to items intended to be owned permanently rather than rented; positive airway pressure devices submitted with a purchase modifier are not eligible for reimbursement.

ImplicationPurchase modifier indicates the item is billed as bought rather than rented; reimbursement rules and eligibility may differ per policy and contract.

Purchase/Rent to Purchase (P/RTP)

DefinitionPurchase/Rent to Purchase (P/RTP): Items not routinely purchased up-front; they are reusable, not service intensive, not customized, and/or may only be needed for short-term use.

Reimbursement basisReimbursement for continuous/rent-to-purchase items is based on the health plan's allowance for the monthly rental period; append a rental modifier when applicable.

When to useUse P/RTP designation when the item may initially be rented with intent to purchase later rather than purchased up front.

Continuous Rental

DefinitionContinuous Rental: Equipment which is never purchased and the rental reimbursement is not capped at a purchase price; also referred to as frequently serviced (FS) items.

Reimbursement handlingThese items are reimbursed as rentals for as long as medically necessary; append rental modifiers such as BR, KI, KR, LL, or RR when the DME item is a continuous rental.

DistinctionContinuous rental differs from daily rental in duration and reimbursement basis; it is ongoing rather than short-term.

Daily Rental

DefinitionDaily Rental: Items that are considered short-term rentals, generally rented for less than a month.

ModifierUse modifier RR to report daily rental items.

Reimbursement noteDaily rental reimbursement is handled under rental rules distinct from continuous rental and may be billed using the RR modifier.