CurrentColorado Rocky Mountain Health PlansPolicy N/A

Durable Medical Equipment (DME) rental and purchase reimbursement

Reimbursement policy describing how UnitedHealthcare Community Plan Medicaid products reimburse rental and purchase of certain durable medical equipment, prosthetics, and orthotics for providers billing on CMS-1500/UB04 forms.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyDurable Medical Equipment (DME) rental and purchase reimbursement

Policy CodePolicy N/A

Change TypeMinor/revision updates to attachments and code lists

Effective DateN/A

Next Review DateN/A

Key ActionReport monthly rental on CMS-1500 or electronic equivalent with one unit per calendar month, From/To dates, and appropriate rental modifier.

SourceLink

POLICY UPDATE CHANGES

State Exceptions Section: Kentucky updated

Attachment Section: Medicaid DME Policy Modifier Required Code list updated

Policy: Codes with Flexion, Extension, Pronation or Supination in Description list updated

13max rental months

onemonthly rental allowed

6 monthsmaintenance frequency

3non-reimbursable delivery codes

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E0935daily rental example

DME Rental and Purchase Coverage Criteria

Reimbursement criteria for DME, prosthetics, and orthotics.

Items may be eligible for rental or purchase; codes eligible for both must be reported with the appropriate rental or purchase modifier from the Modifier Required Code List to be considered for reimbursement.

Some DME items are rental-only and must be reported with an appropriate rental modifier to be considered for reimbursement.

Monthly rental is reimbursed once per Calendar Month when reported with a rental modifier (RR and/or KH, KI, KJ, KR, LL); Calendar Month is determined by the 'From' date on the claim.

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

Policy applies to Same Specialty Physicians and Other Qualified Health Care Professionals, including DME, prosthetic and orthotic vendors, renting or selling DME, prosthetics or orthotics under UnitedHealthcare Community Plan Medicaid products.

DME rental and reimbursement criteria

Coverage conditions and billing rules:

Monthly rental must be billed on a CMS-1500 (or electronic equivalent) with the appropriate HCPCS and rental modifier; submit one unit for each Calendar Month time span and include From and To dates for each month to receive correct reimbursement.

If a rental code is submitted with units greater than 1 or multiple times in the same Calendar Month, UnitedHealthcare Community Plan will reimburse only one monthly rate per Calendar Month to the Same Specialty Physician or Other Qualified Health Care Professional except where specifically noted.

Rental fees are payable up to the lesser of the purchase price or the vendor contract maximum rental months (not to exceed 13 months); when the rental cap is reached the item is considered purchased and rental billing must stop.

Maintenance and service are reimbursable once every six months when billed with modifier MS on a separate line; MS reimbursement is separate from rental or purchase and does not apply to orthotics or prosthetics.

MI / MS rental and modifier rules

Mississippi and Michigan rental rule excerpts and Mississippi modifier specifics

Several states (including Michigan and Mississippi) limit rental duration to a maximum period of ten (10) months or until purchase price is reached as specified by the state; state rules may supersede general policy limits.

Mississippi (MSCAN) specifically allows daily rental for code E0202 when billed with modifier RR or KR and restricts HCPCS code A4253 to use only with the SC modifier per state regulation.

State-specific modifier and rental rules (e.g., Michigan and Mississippi) are detailed in the Attachment 'Modifier List' and must be followed for reimbursement in those states.

Missouri modifier and code lists

Missouri: state-specific modifier and code requirements

Missouri Medicaid is exempt from the general monthly rental limit due to state requirements and maintains state-specific rules that may override the general policy.

Per Missouri regulations: TW (back-up equipment) is allowed with HCPCS E0465 but not with E0466; Missouri does not allow KX on E0465/E0466 and does not allow modifier MS; repair (RB) is not allowed with any rental modifier because repair is covered if equipment is not being rented.

Missouri uses customized DME code lists that require specific modifiers (NU for purchase, RR for rental, RB for repair) and maintains purchase/rental/repair code mappings in the Attachments; providers must use the state lists for Missouri reimbursements.

Nebraska and assorted state rules

Nebraska allows multiple units to be reimbursed as daily rental when the KR modifier is billed with specific codes (see Nebraska KR list in Attachments).

Nebraska allows A9900 to be billed as a supply kit with breast pumps and apnea monitors; Nebraska does not cover purchase of HCPCS E0604 and imposes a 12-month rental cap for certain items where purchase is not allowed.

Nebraska permits reimbursement of claims billed with the RB (repair) modifier if the codes are on the NE Medicaid fee schedule; some items (A4604 & A8000) do not require rental or purchase modifiers for reimbursement.

New York coverage rules

New York: rental duration, purchase mappings, and POS/maintenance notes

New York Medicaid covers rental of equipment up to a maximum period of ten (10) months or until the purchase price is reached; state-specific purchase/rental code mappings are provided in the Attachments.

Maintenance (modifier MS) is not covered by New York Medicaid; POS is limited to the home (allowed POS: 01, 04, 12, 13) per state rules.

When the anticipated need is six months or less the item is treated as rented; if anticipated need exceeds six months the item may be rented or purchased per state guidance, but once rental is initiated a subsequent prior approval for purchase will be denied.

Other state-specific coverage notes

Tennessee law requires TennCare MCOs to provide coverage for repairs by authorized complex rehabilitation technology suppliers and at least one preventative maintenance visit annually; TennCare requires providers to use base wheelchair code + MS modifier for informational tracking only.

Texas Medicaid: A4253 unit limits differ by diabetic status (2 units/month insulin-dependent; 1 unit/month non-insulin-dependent; combined limits with A9275 apply); E0956 is billed for purchase only; E0471 is monthly rental with no purchase price and no limit on rental months.

Washington DC limits rental max to 6 months and excludes coverage for E0936 per DC regulations.

Wisconsin Medicaid: monthly rental unit limits do not apply (daily unit limits are allowed instead); HCPCS L8614 is allowable in POS 22, 23, 24; WI is exempt from certain home POS restrictions and does not allow modifier 50 for specified procedure codes (LT/RT must be used for laterality).

DME Rental and Repair Coverage Rules

Monthly rental billing and payment rules

Monthly rental must be reported on a single claim line with one unit and a single Calendar Month date span; do not report multiple months on the same line.

If two claims for the same item from the same provider show From dates in the same Calendar Month, only one claim will be allowed; the second claim for that month will not be covered.

When modifier KR (partial-month) is used, UnitedHealthcare Community Plan pays a single full monthly rental rate once per Calendar Month to the same vendor (no proration), except for items listed in the 'Daily Rental' section which are reimbursed daily.

Repair codes (e.g., K0462, K0739, K0740) are included in the rental payment and are not separately reimbursed during rental periods; repair may be allowed for purchased (patient-owned) items.

Wisconsin State Exceptions

Wisconsin-specific exceptions and modifier rules

Wisconsin Medicaid does not apply monthly rental unit limits; daily unit limits are allowed instead of monthly units for rental reporting in Wisconsin.

HCPCS code L8614 is allowable in Wisconsin in Place of Service 22, 23 and 24 as a state exception.

Modifier 50 is not allowed with procedure codes A6504-A6508, A6530-A6538, A6545, A6549, S8420-S8429 in Wisconsin; use LT/RT laterality modifiers when billing these codes.

Wisconsin Medicaid is exempt from certain DME items being limited to home Place of Service requirements; consult the WI state-specific section for details.

HCPCS / Modifiers / Coding Guidance

Representative HCPCS and modifier guidanceHCPCS

E0424	DME item mapping to E0431/E0433/E0434/E0439/E1392/K0738 per listing
E1130	Example HCPCS used to illustrate monthly rental reporting
E0465	Ventilator HCPCS eligible for second ventilator exception with KX
E0935	HCPCS reimbursed daily consistent with CMS guidelines

Representative Rental Modifiers (Medicaid)Modifier

KH	Rental modifier - monthly rental indicator
KI	Rental modifier - monthly rental indicator
KR	Partial month rental modifier
LL	Use when DME equipment rental is to be applied against the purchase price
RR	Rental modifier - monthly rental indicator

Representative Purchase Modifiers (Medicaid)Modifier

KM	Purchase modifier
KN	Purchase modifier
NR	Use when DME which was new at time of rental is subsequently purchased
NU	Purchase modifier
UE	Purchase modifier

Other Allowable DME ModifiersModifier

MS	Six month maintenance and servicing fee modifier

Codes with 'each' or flexion/extension/supination/pronation in descriptionHCPCS

E0743	Listed in 'Codes with Each in Description' mappings (see document list)
E0967	Listed in 'Codes with Each in Description' mappings (see document list)
E1017	Listed in 'Codes with Each in Description' mappings (see document list)
E2214	Listed in 'Codes with Each in Description' mappings (see document list)
E2224	Listed in 'Codes with Each in Description' mappings (see document list)
E2365	Listed in 'Codes with Each in Description' mappings (see document list)
E2389	Listed in 'Codes with Each in Description' mappings (see document list)
K0017	Listed in 'Codes with Each in Description' mappings (see document list)
K0043	Listed in 'Codes with Each in Description' mappings (see document list)
K0069	Listed in 'Codes with Each in Description' mappings (see document list)

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Non-reimbursable standalone 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 example codeHCPCSCovered

E0935

HCPCS reimbursed daily consistent with CMS guidelines

Monthly rental example codes/modifiersHCPCS | ModifierCovered

E1130	Example showing monthly rental reporting and unit/count pitfalls
RR	Rental modifier used to report monthly rental (one unit per Calendar Month time span)

Maintenance modifierModifierCovered

MS	Maintenance and Service modifier - required and must be reported on a separate line for reimbursement once every six months

Missouri purchase or rental mappings (sample)HCPCS

E0194	Listed in Missouri purchase/rental mapping (see MO list)
E0235	Listed in Missouri purchase/rental mapping (see MO list)

Missouri purchase/rental/repair mappings (sample)HCPCS

A9270	Mapped in Missouri purchase/rental/repair list (see MO list)
E0550	Mapped in Missouri purchase/rental/repair list (see MO list)

New York purchase or rental mappings (sample)HCPCS

E0316	Included in New York purchase/rental list (see NY list)
E0565	Included in New York purchase/rental list (see NY list)

State-specific HCPCS/procedure code notesHCPCS

L8614	HCPCS code allowable in POS 22, 23, 24 per Wisconsin Medicaid exception
A6504-A6508	Procedure codes where Modifier 50 is not allowed; LT/RT required for laterality

Monthly unit limits (rental)

Standard monthly limitGenerally 1 unit per Calendar Month will be reimbursed for rental when reported with RR or rental modifiers; multiple units on one line or multiple submissions in the same Calendar Month will reimburse only one monthly rate.

Extension/flexion/supination/pronation/each exceptionsUp to 2 rental rates allowed in the same Calendar Month for codes with 'extension/flexion', 'supination/pronation' or 'each' in the description; with RT and LT modifiers considered separately, up to 4 rental rates total may be reimbursed in the same Calendar Month.

Second ventilator exceptionOne additional monthly rental rate may be allowed in the same Calendar Month for a second ventilator (E0465/E0466/E0467) when KX or state-specific modifier rules apply (see state sections).

Billing, Reporting, and Vendor Responsibilities

Billing Rule

Modifier usage requirement

Providers must append the correct rental or purchase modifiers to claims to identify whether an item is rented or purchased. Use the Medicaid rental modifiers KH, KI, KR (partial month), LL (applied against purchase price), and RR for rentals. Use the purchase modifiers KM, KN, NR (for DME new at time of rental subsequently purchased), NU, and UE to indicate purchases. Accurate modifier use is required for proper reimbursement and to determine rental-to-purchase calculations.

Rental modifiers (Medicaid): KH, KI, KR (partial month), LL, RR
Purchase modifiers (Medicaid): KM, KN, NR, NU, UE
Identification of rental vs. purchase must be documented using the applicable modifier

Billing Rule

Maintenance and service billing

Maintenance and service (preventive maintenance/repair visits) may be reimbursed separately once every six months when billed to the Same Specialty Physician or Other Qualified Health Care Professional. The appropriate HCPCS code must be appended with modifier MS and must be reported on a separate claim line to be considered for separate reimbursement from the rental or purchase of the equipment.

Key Terms and Modifiers

Calendar Month (definition)

Calendar Month definitionA Calendar Month is the period from a day of one month to the corresponding day of the next month; it is determined by the 'From' date reported on the claim.

Use for rental billingMonthly rental reimbursement and unit reporting use the Calendar Month definition to set From/To date spans for each billed month.

RationaleCalendar Month is used (rather than fixed 30-day periods) because vendor billing cycles vary and claims are submitted with corresponding From/To dates per month.

Allowed modifiers

Rental modifiers (Medicaid)KH, KI, KR (partial month), LL (applied against purchase price), RR — used to indicate monthly rental.

Purchase modifiers (Medicaid)KM, KN, NR (use when DME rented new is subsequently purchased), NU, UE — used to indicate purchase.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyDurable Medical Equipment (DME) rental and purchase reimbursement

Policy CodePolicy N/A

Change TypeMinor/revision updates to attachments and code lists

Effective DateN/A

Next Review DateN/A

Key ActionReport monthly rental on CMS-1500 or electronic equivalent with one unit per calendar month, From/To dates, and appropriate rental modifier.

SourceLink

On This Page

Delivery, set-up and supplies (A9900, A9901, L9900) are included in the payment rates for the item and are not separately reimbursable when submitted alone or with another service.

Reimbursement for certain DME items is limited to Place of Service codes that qualify as the patient's home (01, 04, 09, 12, 13, 14, 16, 31, 32, 33, 54, 55, 56, 65); devices dispensed for use in other POS are not reimbursable.

Rental months maximum / purchase comparison

Rental-to-purchase comparisonVendors may bill rental until the lesser of the purchase price or the contract maximum rental months is reached — the vendor must stop billing rental when that Rent-to-Purchase maximum is met.

13-month capThe maximum number of rental months used for comparison to purchase price shall not exceed 13 months (vendor contract maximum may be lower).

Vendor responsibilityThe vendor is responsible for complying with contract terms, including stopping rental billing when the rental cap or purchase price threshold is reached.

A4253 monthly unit limits

Insulin-dependent allowanceA4253: 2 units per month allowed for insulin-dependent diabetics (combined A4253 and A9275 limits apply).

Non–insulin-dependent allowanceA4253: 1 unit per month allowed for non-insulin-dependent diabetics (combined A4253 and A9275 limits apply).

Combined code limitA4253 and A9275 together have combined monthly unit limits as specified (see Texas Medicaid details in state sections).

Washington DC rental maximum

Washington DC rental capRental maximum for Washington DC Medicaid is 6 months.

Coverage notesCertain HCPCS (e.g., E0936) may be not covered in Washington DC per state regulations.

State-specific exceptionsProviders should consult DC-specific section for further state billing rules and excluded codes.

Rental reporting unit

Reporting unit definitionReport monthly rental with one unit per Calendar Month time span on the CMS-1500 (or electronic equivalent) — the From date determines the Calendar Month span for that line.

Single-line ruleDo not report multiple months on the same line; each Calendar Month must be billed on a separate line with its own From/To dates and one unit.

Duplicate claims in same monthIf two claims from the same specialty/provider show From dates in the same Calendar Month for the same item, only one will be allowed and the second will not be covered.

Maintenance and Service modifier: MS
MS must be on a separate line to receive separate reimbursement
Reimbursable once every six months to the same provider

Billing Rule

Place of service restrictions for DME

Reimbursement for many DME items is limited to places of service that qualify as the patient’s home. Report the place of service (POS) code where the device is intended to be used. Devices dispensed for use in a POS other than the patient's home are not reimbursable except where state-specific exemptions apply (see state rules).

Qualifying home POS codes: 01, 04, 09, 12, 13, 14, 16, 31, 32, 33, 54, 55, 56, 65
Report the intended POS on the claim
Certain states (e.g., WI) may be exempt from home-only POS restrictions for specific items

Billing Rule

Texas code billing constraints

State-specific billing constraints apply in Texas: E0956 must be billed for purchase only (no rental). HCPCS code E0471 is treated as a monthly rental with no purchase price and no limit on rental months. Also observe Texas-specific unit limits for supplies (e.g., A4253 and A9275 combinations) as applicable.

E0956 — billed for purchase only (Texas)
E0471 — monthly rental with no purchase price and no limit on rental months (Texas)
Follow Texas Medicaid unit rules for supply codes (A4253, A9275) where applicable

Other allowable modifiersMS — six-month maintenance and servicing fee; must be reported on a separate line when applicable.

Monthly rental — definition & guidance

DefinitionMonthly rental: reimbursement of DME, Orthotics, or Prosthetics billed with an appropriate rental modifier (RR or KH/KI/KJ/KR/LL) and one unit per Calendar Month line with From/To dates.

Billing guidanceSubmit each rented month on a separate CMS-1500 line with one unit and correct From/To dates; reporting multiple units or multiple months on a single line will reimburse only one unit for that Calendar Month.

Partial-month (KR) handlingWhen KR (partial month) is used, the plan pays a full monthly rental rate once per Calendar Month to the same vendor (no proration), except for items listed under Daily Rental.

Daily rental — definition & guidance

DefinitionDaily rental: reimbursement calculated on a daily basis for specific items designated as daily rental (e.g., HCPCS E0935), consistent with CMS guidance and state/PDAC requirements.

Billing guidanceDaily rental items are exceptions to the monthly reimbursement rule and should be billed per the applicable daily-rate guidance and state rules.

ExamplesHCPCS code E0935 is reimbursed daily consistent with CMS guidelines; other devices allowed per CMS/PDAC or state requirements.

Rental-to-Purchase / Rental Cap

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

13-month statutory limitThe rental-to-purchase comparison shall not exceed 13 months when determining whether the lesser of purchase price or rental months has been met.

Vendor contractual complianceVendors must comply with contract terms, including ceasing rental billing when the rent-to-purchase maximum or rental cap is reached.

Maintenance and Service (MS) — what it covers

MS modifier purposeMS identifies a six‑month maintenance and servicing fee for reasonable and necessary parts and labor not covered under warranty.

Billing frequencyMaintenance and service billed with modifier MS is reimbursable once every six months and must be submitted on a separate claim line to be considered for separate reimbursement.

ScopeMaintenance/service reimbursement applies to DME but does not apply to orthotics or prosthetics (see policy state sections for exceptions).

Calendar Month (alternate reference)

Calendar Month definition (alt)A Calendar Month equals the period from a day in one month to the corresponding day in the next month; the Calendar Month is determined by the claim's From date.

ApplicationUsed to set billing From/To date spans for monthly rental lines and to determine reimbursement eligibility per Calendar Month.

Vendor billing cyclesThis approach aligns with vendor cycle billing practices where rentals are billed on corresponding monthly dates (e.g., 1/9 to 2/9).

Durable Medical Equipment — definition

DefinitionDurable Medical Equipment (DME): medical equipment that can withstand repeated use, is not disposable, serves a medical purpose, is generally not useful without sickness/injury, and is appropriate for home use.

Examples/characteristicsDME items are intended for repeated use, provide a medical benefit, and are commonly used in the patient's home setting as defined by POS rules.

Relation to rental/purchaseDME may be rented or purchased per code allowances and contract rules; rental/purchase status must be documented using appropriate modifiers.

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 motion.

FunctionOrthotics support or restrict motion and are used for therapeutic purposes; maintenance/service reimbursement does not apply to orthotics in general policy language.

Billing noteOrthotics follow DME reporting rules where applicable; consult code lists for rental vs purchase allowances and modifier requirements.

Prosthetic — definition

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

Use caseProsthetics restore function or form and are subject to purchase/rental rules and modifier documentation per the policy.

Billing noteProsthetics are generally not eligible for MS maintenance/service reimbursement and follow specific code-based coverage criteria.

Calendar Month (duplicate inventory entry)

Calendar Month fallbackIf questions arise, Calendar Month is the period from a day in one month to the corresponding day of the next month and is set by the 'From' date on the claim (used to adjudicate monthly rentals).

Claims impactClaims that bill multiple months on one line or that have duplicate From dates in the same Calendar Month may be underpaid or denied per the Calendar Month rule.

Example referenceSee Reporting Monthly Rental example (E1130) showing correct per‑month separate lines versus a single-line multi-month submission that reimburses only once.

Durable Medical Equipment (duplicate inventory entry)

DME definition (alt)Durable Medical Equipment: equipment that withstands repeated use, is not disposable, serves a medical purpose, is generally not useful without sickness/injury, and is appropriate for home use.

Policy applicationDME items are subject to rental and purchase rules, modifier documentation, and POS restrictions described in the policy.

Relation to maintenance/repairsRepair services may be included in rental payments and are not separately reimbursed during rental periods; repairs may be allowed for purchased items.

Orthotic / Prosthetic definition (combined)

Orthotic / Prosthetic combined definitionOrthotic: external appliance (brace/splint) to prevent or assist movement or to support/restrict motion. Prosthetic: device replacing all/part of an external body organ or its function.

Scope noteOrthotics and prosthetics follow code‑specific rental/purchase and modifier requirements; maintenance/service reimbursement generally does not apply to these items.

Provider actionProviders must document purchase vs rental with appropriate modifiers and follow reporting guidance for From/To dates and units.

Same Specialty Physician / Other Qualified Health Care Professional

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

Billing implicationMonthly rental reimbursement is paid to the Same Specialty Physician or Other Qualified Health Care Professional; duplicate claims from different providers in the same specialty/group may be evaluated against this rule.

DocumentationClaims should reflect the provider/group Federal Tax ID to establish Same Specialty Physician or Other Qualified Health Care Professional status when billing rental items.