CurrentColorado Rocky Mountain Health PlansPolicy 2026R9012A

Durable Medical Equipment, Prosthetics, Orthotics & Supplies (DMEPOS) reimbursement on CMS-1500

Defines UnitedHealthcare Medicare Advantage reimbursement rules for items billed on the CMS-1500 (1500) form, including rental vs purchase, modifiers, rental limits, maintenance/repair/replacement, place-of-service restrictions, and special rules (daily rental, second ventilator). Applies to network physicians, qualified health care professionals and DME/PO vendors billing Medicare Advantage plans.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyDurable Medical Equipment, Prosthetics, Orthotics & Supplies (DMEPOS) reimbursement on CMS-1500

Policy CodePolicy 2026R9012A

Change TypeClarified (administrative/resource updates)

Effective Dateas written

Next Review Date

Key ActionReport DME/PO items on CMS-1500 with the correct rental or purchase modifier and submit monthly rentals as a single claim line with one unit and a calendar month date span.

SourceLink

POLICY UPDATE CHANGES

Resource section updated and anniversary review updated in 2026 version; application section updated and prior history entries archived in 2025.

5rental modifiers listed

5purchase modifiers listed

1/momonthly rental reimbursement frequency

once/6mo

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Reimbursement Eligibility & Limits

Reimbursement eligibility for rental vs purchase and monthly rental limits

Rules used to determine when rental or purchase reimbursement is allowed and limits on monthly rental payments.

ALL of the following

Claim must be submitted on CMS-1500 (or electronic equivalent) and report correct rental or purchase modifier (rental: RR, KH, KI, KJ, KR; purchase: NU, UE, NR, KM, KN).
For items eligible for rental, reimbursement is limited to either the purchase price or the maximum number of rental months (cap), whichever is less; cap rental periods are determined by provider contract and CMS rules.
Monthly rental reimbursement is allowed once per calendar month to the Same Specialty Physician or Other Qualified Health Care Professional; multiple claims with From dates in the same calendar month for the same item/provider will result in only one payment.One monthly rental reimbursement per calendar month per same specialty physician/qualified provider per HCPCS code (unless RT/LT on separate lines or allowed second ventilator exception).
Modifiers RT and LT allow an additional monthly rental rate in the same calendar month when used on separate lines for right and left side respectively.
Exception: oxygen equipment and ventilators are not subject to standard capped-rental limits; a second ventilator is allowed once per month when HCPCS code E0465 or E0466 is reported with a rental modifier plus modifier KX.
Daily rental is allowed only for specified items (example: HCPCS E0935) consistent with CMS guidelines.

Note

Monthly rentals should be reported on a single claim line with one unit and a single calendar month date span per NUBC/NUCC guidance.
If two claims are submitted with From dates in the same calendar month for the same item from the Same Specialty Physician or Other Qualified Health Care Professional, only one monthly rental payment will be allowed and the second claim will not be covered.

Maintenance, repair and replacement reimbursement rules

Conditions for payment of repair, maintenance, replacement and limits/exclusions.

ALL of the following

Repairs to beneficiary-owned DME are covered when necessary to make equipment serviceable; repairs are not applicable to equipment previously denied or items in the frequent and substantial servicing category.
Replacement of owned or capped rental items is allowed for loss or irreparable damage; replacement for irreparable wear considers reasonable useful lifetime; use RA modifier for replacement.
Maintenance/service is reimbursable once every six months with the appropriate HCPCS code appended with modifier MS on a separate line; maintenance does not apply to orthotics or prosthetics.Maintenance/service reimbursable once every 6 months
Payment for repair/maintenance excludes parts and labor covered under manufacturer or supplier warranty.

Place of service (POS) restriction for DME reimbursement

DME reimbursement limited to qualifying home POS codes; items intended for non-home POS are not reimbursable on CMS-1500.

ALL of the following

DME suppliers must report the POS where the device is intended to be used; reimbursable home POS codes: 01, 04, 09, 12, 13, 14, 16, 33, 54, 55, 56, 65.
Devices not intended for home use (e.g., certain implantable devices) are not reimbursable with a home POS.
Purchase of certain DME/PO reported by physician on CMS-1500 in POS 19, 21, 22, 23 or 24 will not be separately reimbursed when reported with purchase modifiers (NU, UE, NR, KM, KN) or no modifier, consistent with CMS PPS/APC rules.

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Relevant HCPCS / Modifier Examples

Rental modifiersModifier

RR	Rented, supplier retains ownership
KH	Rental modifier
KI	Rental modifier
KJ	Rental modifier
KR	Rental modifier (partial month allowed by code but paid monthly by payer)

Purchase modifiersModifier

NU	New equipment, purchase
UE	Used durable medical equipment
NR	Not otherwise specified purchase modifier
KM	Purchase modifier
KN	Purchase modifier

Other modifiers referencedModifier

RT	Right side
LT	Left side
KX	Requirements met modifier (used with second ventilator rule)
RA	Replacement of DME
RB	Replacement parts for repair (beneficiary-owned DME)
MS	Maintenance/service fee

HCPCS/DME examples referencedHCPCS

E0465	Ventilator, chronic use, home ventilator (example referenced for second ventilator rule)
E0466	Ventilator, other type (example referenced for second ventilator rule)
E0935	Portable oxygen concentrator — example of daily rental reimbursement (daily rental allowed per CMS guidelines)

Billing, Documentation & Operational Requirements

Billing Rule

Use correct modifiers and claim form

Report DME/PO items on the CMS-1500 (or electronic equivalent) with the appropriate rental (RR, KH, KI, KJ, KR) or purchase (NU, UE, NR, KM, KN) modifier. Monthly rentals must be reported on a single claim line with one unit and a calendar month date span. Maintenance/service (MS) must be billed on a separate line.

Clinical & Administrative Context

This policy defines UnitedHealthcare Medicare Advantage reimbursement rules for services billed on the CMS-1500 (1500) form related to Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS). It applies to network physicians, other qualified health care professionals and DME/PO vendors who rent or sell DME, prosthetics or orthotics and describes when items should be billed as rental versus purchase, required modifiers, limits on monthly rental payments, maintenance/repair/replacement rules, place-of-service restrictions, and specific exceptions such as daily rental items and the second ventilator rule.

This reimbursement policy is specific to UnitedHealthcare Medicare Advantage plans and follows applicable CMS guidelines and coding conventions. Providers remain responsible for submitting accurate claims and should verify member-specific benefits and any prior authorization requirements via the member ID card or customer service, as this policy does not enumerate prior authorization requirements.

Scope: the policy applies to all Medicare Advantage products and services reported using the CMS-1500 form (or electronic equivalent) and to all network physicians and other qualified health care professionals. It directs billing and coding practices—such as use of the appropriate rental (e.g., RR, KH, KI, KJ, KR) or purchase (e.g., NU, UE, NR, KM, KN) modifiers—and limits reimbursement for monthly capped rentals to one monthly rental per calendar month to the same specialty physician or other qualified health care professional, subject to CMS exceptions (for example, oxygen equipment, ventilators, and specified daily rental items).

Key Terms

Key Definitions

Durable Medical Equipment (DME)Medical equipment that can withstand repeated use, is not disposable, is used to serve a medical purpose, is generally not useful in the absence of sickness or injury, and is appropriate for use in the home.

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

ProstheticA device that replaces all or part of an internal body organ or all or part of the function of a permanently inoperative or malfunctioning internal body organ.

Same Specialty Physician or Other Qualified Health Care ProfessionalPhysicians and/or other health care professionals of the same group and same specialty reporting the same Federal Tax Identification number.

Policy Updates

2026-05-01Policy Version ChangeLatest

Resource section updated and anniversary review conducted as part of the 2026 policy version change.

2025-06-01Policy Version Change

Application section updated and history entries prior to 2023 archived.

2017-08-01Policy Implemented

Thresholds & At-a-Glance Rules

Thresholds and Quick Stats

Monthly rental frequencyOne monthly rental reimbursement per calendar month to the Same Specialty Physician or Other Qualified Health Care Professional per HCPCS code (unless separate RT/LT lines or allowed second ventilator exception).

Maintenance frequencyMaintenance/service reimbursable once every 6 months; appropriate HCPCS code must be appended with modifier MS on a separate line.

Rental modifiers (summary)RR, KH, KI, KJ, KR — report these to indicate an item is rented.

Purchase modifiers (summary)NU, UE, NR, KM, KN — report these to indicate an item is purchased (new/used/status as required).

Home POS codes (qualifying)Place-of-service codes that qualify as the member's home: 01, 04, 09, 12, 13, 14, 16, 33, 54, 55, 56, 65.