CurrentColorado Rocky Mountain Health PlansPolicy N/A

Durable Medical Equipment (DME) rental and purchase reimbursement

Governs UnitedHealthcare Community Plan Medicaid reimbursement for rental and purchase of certain DME, prosthetics, and orthotics billed on CMS-1500 (and when specified UB04) affecting network and non-network physicians, qualified health care professionals, and DME vendors.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyDurable Medical Equipment (DME) rental and purchase reimbursement

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionReport monthly rentals on CMS-1500 with the appropriate HCPCS code, rental modifier and one unit per calendar month including From/To dates.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

monthlyrental reimbursed once per calendar month (one rate)

RR, KH, KI, KJ, KR, LLrental modifiers required

≤13rent-to-purchase cap

6 monthsmaintenance frequency

A9900/A9901/L9900non-reimbursable supply codes

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Coverage and Reimbursement Criteria

inv-01: DME Rental and Purchase Criteria

Coverage and reimbursement rules

Applies to UnitedHealthcare Community Plan Medicaid products and services billed on CMS-1500 or electronic equivalent to Same Specialty Physicians, Other Qualified Health Care Professionals, and DME/Prosthetic/Orthotic vendors.

Items eligible for rental or purchase must be reported with the appropriate modifier; rental-only items must be reported with a rental modifier to be considered for reimbursement.

Monthly rental reimbursement: Monthly rental of DME, Orthotics, or Prosthetics reported with rental modifier RR and/or KH, KI, KJ, KR, or LL is reimbursed once per Calendar Month to the Same Specialty Physician or Other Qualified Health Care Professional. UnitedHealthcare Community Plan will reimburse only one monthly rate per Calendar Month per HCPCS code unless an exception applies.

Exceptions allowing additional monthly rates

RT and LT modifiers: An additional rental rate will be allowed in the same Calendar Month when codes are reported with RT and LT on separate lines (separate lines per side).
Codes with 'extension/flexion', 'supination/pronation', or 'each' in the description: Up to two rental rates per side (up to four total) will be considered when appropriate modifiers/units are submitted.
Second ventilator: One additional rental rate will be allowed for a second ventilator (HCPCS E0465, E0466, or E0467) when reported with rental modifier and modifier KX and medical policy requirements are met.

Daily rental: Daily rental is allowed for specified items (HCPCS E0935 reimbursed daily consistent with CMS); other devices allowed per CMS/PDAC or state requirements.

Reporting requirements: Monthly rental must be reported on CMS-1500 (or electronic equivalent) with the appropriate HCPCS code and rental modifier, one unit for each Calendar Month time span, and 'From' and 'To' dates for each monthly span; submitting multiple months on one line will result in reimbursement of only one unit.

inv-02: DME rental/purchase/maintenance coverage criteria

Coverage and billing criteria:

Report monthly rental on a CMS-1500 (or electronic equivalent) using the appropriate HCPCS code and rental modifier with one unit per Calendar Month and include From and To dates for each monthly span; claims that aggregate multiple months on one line will reimburse only one unit.

Daily rental: HCPCS E0935 is reimbursed daily consistent with CMS guidelines; other daily rentals follow CMS, PDAC, or state requirements.

Rental-to-purchase and rental cap: Rental fees from a single vendor are payable up to the lesser of the purchase price or the vendor contract's maximum rental months (not to exceed 13 months); vendor must stop billing when the contract maximum is reached; oxygen and ventilators are exempt from these rental limits.

Maintenance and service: Reimbursed once every six months when billed with the appropriate HCPCS code and modifier MS; the MS modifier must be on a separate line to be considered for separate reimbursement. Maintenance/service does not apply to Orthotics or Prosthetics.

inv-03: State-specific DME coverage notes (partial)

State-specific DME coverage and billing rules summarized (partial).

State summaries (partial)

Mississippi: Per state regulation, MS CAN covers rental up to ten months or up to purchase price whichever is less; allows daily rental for code E0202 when billed with RR or KR; HCPCS A4253 only allowed with SC modifier.
Missouri: Exempt from monthly rental limit; allows modifier TW with E0465 (back-up equipment) but not with E0466; does not allow modifier KX with E0465 or E0466; uses customized purchase/rental/repair code lists.
Nebraska: Allows multiple units to be reimbursed as daily rental when KR modifier is billed for listed codes; allows A9900 as supply kit with breast pumps and apnea monitors; E0604 purchase not covered and has a 12-month rental cap; allows RB modifier for listed codes.
New York: State-specific mapping lists for purchase or rental codes are maintained (examples include B9002 and E0261 series mapping entries).

inv-04: Medicaid DME state exceptions and billing criteria

State-specific coverage and billing criteria for Medicaid DME in this excerpt

Selected state-specific rules and exceptions

Texas: A4253 allowed 2 units/month for insulin-dependent diabetics and 1 unit/month for non-insulin dependent; combined A4253+A9275 limits apply; E0956 billed purchase-only; E0471 is a monthly rental with no purchase price and no limit on rental months; Texas does not accept KX to indicate a second ventilator for E0465/E0466.
Virginia: Exempt from the monthly rental unit limit and reimburses in daily rather than monthly units.
Washington State: Requires modifier U2 (not KX) for a second ventilator (E0465/E0466); allows POS 99 for DME providers; E0600 reported with RR or TW is deemed purchased after 12 months of rental.
Washington DC: Rental maximum is six months; HCPCS E0936 is not covered.

HCPCS / Modifiers / Unit & Duration Rules

Rental-only DME examplesHCPCSCovered

E0424

DME items eligible for rental only (maps to multiple codes listed)

Codes with 'each' or side-specific descriptorsHCPCSCovered

E0743

Codes with Each in Description (examples paired mapping listed)

Non-separately reimbursable supply/delivery codesHCPCSNot Covered

A9900	Delivery, set-up and supplies (not separately reimbursable)
A9901	Delivery, set-up and supplies (not separately reimbursable)
L9900	Delivery, set-up and supplies (not separately reimbursable)

Daily rental codesHCPCS

E0935

Daily rental reimbursed consistent with CMS guidelines

Modifiers for rental and maintenanceModifier

RR	Rental modifier required for monthly/daily rental reporting
MS	Maintenance and service modifier; must be on separate line

MO Medicaid purchase or rental codes (partial)HCPCSCovered

E0154	Listed mapping entries (purchase/rental list - Missouri)
E0194	Listed mapping entries (purchase/rental list - Missouri)

MO Medicaid purchase/rental/repair and rental-only lists (partial)HCPCSCovered

A9270	MO mapping entries for purchase/rental/repair
B9004	MO rental codes list

NY Medicaid purchase or rental codes (partial)HCPCSCovered

B9002	NY Medicaid purchase or rental mapping entries (partial)
E0261	NY Medicaid mapping entries (partial)

State-specific HCPCS notesHCPCS

A4253	Insulin administration supplies — state-specific monthly unit limits (TX: 2 units/month insulin-dependent; 1 unit/noninsulin)
A9275	Supply code — combined monthly limit with A4253 in TX
E0956	Billed for purchase only in TX
E0471	Monthly rental with no purchase price; no limit on rental months in TX
E0465	Ventilator — TX does not accept KX for second ventilator; WA requires U2 for second ventilator
E0466	Ventilator — same as E0465
E0600	Deemed purchased after 12 months of rental (WA note)

Monthly rental unit limit — one monthly rental rate per calendar month; exceptions

Standard ruleOne monthly rental rate reimbursed per Calendar Month per HCPCS code when reported with RR or other specified rental modifiers; multiple units on a single line will reimburse only one monthly rate.

RT/LT exceptionAn additional monthly rental rate is allowed in the same Calendar Month when RT and LT modifiers are submitted on separate lines for the same HCPCS code.

'Each' / multi-part codesCodes with 'extension/flexion', 'supination/pronation' or 'each' allow up to two rental rates per side (up to four total) in the same Calendar Month when appropriately billed.

maximum_rental_months_contract_limit — maximum rental months varies by contract; rent-to-purchase cap not to exceed 13 months

Claims Submission, Billing & State-specific Provider Rules

Billing Rule

Claims submission and applicability

You are responsible for submission of accurate claims. This policy follows CPT/CMS and other coding guidelines and applies to services billed on the CMS-1500 (or electronic equivalent). Submit the HCPCS/CPT code(s) that correctly describe services provided and follow NUCC/NUBC claim form guidance. UnitedHealthcare Community Plan may apply reasonable discretion when interpreting this policy; state regulatory requirements, provider contracts, benefit design, and other policies may supersede or modify reimbursement rules.

Submit accurate claims using CPT/CMS or other coding guidance.
This policy applies to CMS-1500 claims and electronic equivalents.

Billing Rule

Maintenance/service billing

Maintenance and service (preventive maintenance or repairs) are reimbursable once every six months to the Same Specialty Physician or Other Qualified Health Care Professional. Report the appropriate HCPCS code with modifier MS on a separate line to be considered for separate reimbursement from rental or purchase.

Key Definitions and Modifier Glossary

Calendar Month — period definition and rental reimbursement determined by From date reported

DefinitionCalendar Month is the period from a day of one month to the corresponding day of the next month; rental reimbursement is determined by the 'From' date reported on the claim.

Reporting implicationReport one unit per Calendar Month time span with the rental initiation date in the 'From' field and the end date in the 'To' field on CMS-1500 or electronic equivalent.

Multiple claims ruleIf two claims with From dates in the same Calendar Month are submitted for the same item to the Same Specialty Physician or Other Qualified Health Care Professional, only one claim will be allowed for that month.

Modifiers — rental vs purchase modifiers and other allowance modifiers

Rental modifiersKH, KI, KR (partial month), LL (apply rental against purchase price), RR — used to identify monthly rental status.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyDurable Medical Equipment (DME) rental and purchase reimbursement

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionReport monthly rentals on CMS-1500 with the appropriate HCPCS code, rental modifier and one unit per calendar month including From/To dates.

SourceLink

On This Page

Supply/delivery codes: HCPCS codes A9900, A9901, and L9900 (delivery, set-up and supplies) are included in item payment rates and will not be reimbursed separately when submitted alone or with another service.

Place-of-service limitation: Reimbursement of certain DME items is limited to qualifying home POS codes (01, 04, 09, 12, 13, 14, 16, 31, 32, 33, 54, 55, 56, 65); DME dispensed for use in a non-home POS are not reimbursable.

Identification of rented vs purchased: Whether equipment was rented or purchased must be documented by use of the applicable rental or purchase modifier from the Modifier Required Code List.

Texas: State-specific allowances include A4253 unit limits (2 units/month insulin-dependent, 1 unit/month non-insulin), combined limits with A9275, E0956 billed for purchase only, E0471 monthly rental with no purchase price and no limit on rental months; Texas does not accept KX for second ventilator on E0465/E0466.

Washington DC: Rental maximum is 6 months; HCPCS E0936 is not covered under DC Medicaid.

Wisconsin: Monthly rental unit limits do not apply; daily unit limits are allowed; certain codes (e.g., L8614) allowable in POS 22, 23, 24; WI exempts certain DME from home POS requirements and requires LT/RT for laterality on specified codes rather than modifier 50.

General billing/reporting reminders: A Calendar Month is the period from a day in one month to the corresponding day in the next month; rentals should be reported on a single claim line with one unit and a single Calendar Month date span; repair codes (K0462, K0739, K0740) are included in rental payment and are not separately reimbursed during rental periods.

If two claims with From dates in the same Calendar Month are submitted for the same item from the same specialty provider, only one claim will be allowed for that month.

Contract variabilityMaximum number of rental months used for rent-to-purchase comparison varies by vendor contract and must follow the contract terms.

13-month statutory capRent-to-purchase comparison shall not exceed 13 months — rentals payable up to the lesser of purchase price or contract-specified maximum months (not to exceed 13 months).

Vendor obligationVendor must stop billing for rental once the contract maximum rental months is reached; identification of rented vs purchased must be documented with applicable modifiers.

rental duration limits — examples of state-specific maximums (6, 10, 12 months)

Washington DCRental maximum is 6 months for Washington DC Medicaid.

Typical state examplesSome states reference limits around 10 months (e.g., Mississippi/Michigan notes) and 12 months for deemed purchase in specific codes or situations (e.g., WA E0600 deemed purchased after 12 months).

State variation summaryRental duration limits vary by state — examples include 6 months (DC), ~10 months (several state entries), and 12 months (deemed purchase notes).

rental unit limits — state approaches to monthly vs daily units and examples

Monthly vs daily unitsSome states reimburse monthly rental units (typical policy) while others reimburse daily units or exempt monthly limits (e.g., Virginia reimburses daily units; Wisconsin does not apply monthly rental limits).

Texas exampleTexas applies monthly unit limits for certain supply codes (A4253/A9275 combined limits per month).

Wisconsin exampleWisconsin permits daily unit limits instead of monthly units and exempts some items from home POS requirements.

Modifier MS required and must be on a separate line.
TennCare: providers should report base wheelchair code + MS for CRT visit tracking (informational; no payment).

Billing Rule

Mississippi rental/modifier rules

Mississippi Medicaid (MS CAN) rules: rental covered up to ten (10) months or up to the purchase price, whichever is less. Per state regulation, daily rental is allowed for HCPCS E0202 when billed with RR or KR. HCPCS A4253 is only payable when billed with SC modifier.

Rental cap: 10 months or purchase price, whichever is less.
E0202: daily rental allowed with RR or KR.
A4253: requires SC modifier.

Billing Rule

Missouri rental/modifier rules

Missouri Medicaid rules: Missouri is exempt from the standard monthly rental limit. State-specific modifier and code constraints apply: modifier TW (backup equipment) is allowed with E0465 but not with E0466. Modifier KX is not allowed with E0465 or E0466. Missouri does not allow the RB modifier to be billed with any rental modifier because repair is covered when equipment is not rented. Missouri maintains a customized DME Repair Code list and a state-specific list of codes that require NU (purchase) or RR (rental) modifiers for reimbursement.

TW allowed with E0465; TW not allowed with E0466.
KX not accepted with E0465 or E0466.
RB cannot be combined with rental modifiers; repairs covered when equipment not rented.
State-specific NU/RR lists govern purchase vs rental coding.

Billing Rule

TennCare maintenance/repair billing

TennCare maintenance/repair requirements: TennCare law requires MCOs to cover and reimburse repairs provided by authorized complex rehabilitation technology (CRT) equipment suppliers and to reimburse at least one preventive maintenance visit annually for CRT equipment. TennCare requires providers to report the base wheelchair code plus modifier MS for informational tracking (UPRV will apply base code + MS to CRT visit types for data tracking; no payment for that informational reporting).

MCOs must cover/reimburse repairs by authorized CRT suppliers.
At least one preventive maintenance visit annually must be covered and reimbursed.
Report base wheelchair code + MS for informational tracking (no payment).

Billing Rule

Texas and Washington DC rules

Texas and Washington DC state rules (selected highlights): Texas Medicaid: A4253 — 2 units/month for insulin-dependent diabetics (1 unit/month for non-insulin-dependent); combined A4253 + A9275 limit of 2 units/month (insulin-dependent) or 1 unit/month (non-insulin-dependent). E0956 is purchase-only. E0471 is monthly rental with no purchase price and no month limit. KX is not accepted on E0465/E0466 to reflect a second ventilator (Texas does not accept KX for those codes). Washington DC: rental maximum is 6 months; HCPCS E0936 is not covered.

Texas: A4253 and A9275 combined monthly unit limits by diabetic type.
Texas: E0956 purchase only; E0471 monthly rental with no purchase price or month cap.
Texas: KX not accepted to denote second ventilator on E0465/E0466.
DC: rental max 6 months; E0936 not covered.

Billing Rule

State-specific billing modifier/unit rules

State-specific billing modifier/unit rules — selected examples to avoid denials: Washington (WA) requires modifier U2 (not KX) on E0465/E0466 to indicate a second ventilator. Virginia is exempt from monthly rental unit limits and reimburses in daily units. E0600 billed RR or TW is deemed purchased after 12 months of rental in WA. Some states (e.g., NE) allow daily rental multiple units when KR is billed for specific codes; others require specific modifiers (SC, KR, RR, MS, NU, RB) per their state lists. Always consult the state-specific attachments and the plan's customized code lists for allowed modifier/code combinations.

WA: use U2 for second ventilator (E0465/E0466); POS 99 allowed for DME providers in WA.
Virginia: exempt from monthly rental limit; reimburses daily.
E0600 RR/TW deemed purchased after 12 months in WA.
Nebraska: KR allows multiple units as daily rental for specific codes; NE allows A9900 as supply kit with breast pumps and monitors.
Consult state-specific attachments for NU/RR/RB/MS/KR/SC modifier rules.

KM, KN, NR (when item new at time of rental is subsequently purchased), NU, UE — indicate item purchased.

Maintenance/service modifierMS — identifies six-month maintenance and servicing fee; must be billed on a separate line.

Monthly rental — definition

DefinitionMonthly rental — reimbursement of DME, Orthotics, or Prosthetics when billed with a rental modifier (RR and/or KH, KI, KJ, KR, LL) is paid once per Calendar Month to the Same Specialty Physician or Other Qualified Health Care Professional.

Claiming detailSubmit the applicable HCPCS code with rental modifier and one unit per Calendar Month; include From and To dates to define each Calendar Month span.

Unit aggregation warningReporting multiple months on one line (e.g., 3 units with From/To covering 3 months) will result in reimbursement of only one unit for that line.

Daily rental — definition

DefinitionDaily rental — reimbursement based on daily units for specified items (HCPCS E0935 is reimbursed daily consistent with CMS); other devices follow CMS/PDAC or state requirements.

State exceptionsSome states (e.g., Virginia, Mississippi entries) reimburse daily units or allow daily rental for specific codes when billed with appropriate modifiers (e.g., KR in NE).

Claiming practiceDaily rental items must be billed consistent with CMS/PDAC and any applicable state rules; check state lists for codes allowed as daily rental.

Maintenance and Service — definition and MS modifier guidance

DefinitionMaintenance and Service — reimbursement for reasonable and necessary parts and labor for maintenance/service, payable once every six months when billed with modifier MS on a separate line.

Modifier requirementMS modifier must be appended to the appropriate HCPCS code and reported on a separate line to be considered for separate reimbursement.

ScopeMaintenance and servicing reimbursement does not apply to Orthotics or Prosthetics.

Rental-to-Purchase — definition and vendor billing stop rules

DefinitionRental-to-Purchase — rental fees are payable up to the lesser of the purchase price or the contract-specified maximum rental months; once the maximum is reached the item is considered purchased and vendor must stop billing.

Contract determinationThe maximum rental months for rent-to-purchase comparison varies according to the vendor's contract and daily rental items may have separate limits.

ExemptionsThese rental limits do not apply to oxygen equipment or to ventilators (per policy text).

back-up equipment modifier — TW definition

DefinitionTW — back-up equipment modifier (state-specific use; e.g., Missouri allows TW with E0465 but not with E0466).

State noteApplication of TW is state-dependent; check state-specific sections for allowed combinations with ventilator codes.

rental modifiers (RR / KR) — monthly vs daily rental modifiers

RRMonthly rental modifier required to indicate monthly rental status (reimbursed once per Calendar Month).

KRUsed in some states to indicate daily rental or partial month billing (e.g., Nebraska allows multiple units reimbursed as daily rental when KR is billed).

Usage noteApplication of RR vs KR can be subject to state-specific rules — consult state modifier lists for allowed usages and exceptions.

purchase/repair/maintenance/requirement/supply/ventilator modifiers (NU, RB, MS, KX, SC, U2)

NUPurchase modifier indicating item purchased.

RBRepair modifier — note: some states (e.g., Missouri) do not allow RB with any rental modifier because repair is covered if equipment is not being rented.

MSMaintenance and Service modifier — used to identify maintenance billed once every six months (must be on separate line).

KXRequirement indicator modifier used to denote that medical policy requirements have been met (state-specific acceptance varies; e.g., Missouri does not allow KX with certain ventilator codes).

SCSupply code modifier (state-specific usages noted, e.g., Mississippi: A4253 only allowed with SC modifier).

U2State-specific ventilator modifier used in some states for second ventilator billing instead of KX (e.g., Washington requires U2 for a second ventilator).

Calendar Month definition (duplicate source)

Definition (duplicate)Calendar Month — the period from a day of one month to the corresponding day of the next month; rental reimbursement determined by the 'From' date reported on the claim.

Rationale noteCalendar Month definition is used to normalize rental billing periods regardless of month length; vendors should submit one unit per Calendar Month span.

Durable Medical Equipment (DME) definition

DefinitionDurable Medical Equipment (DME) — medical equipment which can withstand repeated use, is not disposable, serves a medical purpose, is generally not useful in the absence of sickness or injury, and is appropriate for use in the home.

ImplicationDME reimbursement rules in this policy apply to qualifying home-use equipment and are limited to specified home POS codes unless state exceptions apply.

Orthotic — definition

DefinitionOrthotic — an external appliance such as a brace or splint that prevents or assists movement of the spine or limbs; used to support weak or deformed body parts or to restrict/eliminate motion in a diseased or injured part of the body.

Billing noteMaintenance and servicing reimbursement does not apply to Orthotics per policy guidance.

Prosthetic — definition

DefinitionProsthetic — a device that replaces all or part of an external body organ or the function of a permanently inoperative or malfunctioning external body organ.

ScopeProsthetics are reimbursed under the same rental/purchase rules as applicable DME when billed with appropriate modifiers and codes.

Same Specialty Physician or Other Qualified Health Care Professional — definition

DefinitionSame Specialty Physician or Other Qualified Health Care Professional — physicians and/or other qualified professionals of the same group and same specialty reporting the same Federal Tax Identification number.

Reimbursement tieMonthly or daily rental reimbursement is paid to the Same Specialty Physician or Other Qualified Health Care Professional as defined here; billing must reflect that provider relationship.