Prior authorization and billing flags (legend)

Effective 6.01.26 legend: Prior Authorization (PA) Required and Modifier Required / POS Required flags are shown in the document legend and apply to listed DME/OXY items; payment rate and pricing example links (AAC+% and CHIA 101 CMR 322.00) are noted in the legend.

• Refer to legend flags: PA Required, Modifier Required, POS Required (effective 6.01.26).
• Pricing and payment rate references (AAC+% and CHIA 101 CMR 322.00) appear in the legend.

DME code list and MUE note

The DME/OXY listing includes HCPCS code lines with unit definitions and a CMS MUE note (CMS MUE = 300) referenced for applicable items.

• HCPCS lines specify 1 unit definitions (e.g., 1 unit = each) and per-period quantity limits.
• NOTE: CMS MUE is 300 as shown in the document.

MUE applicability

Some code lines explicitly state that the MUE limit is not applicable for that HCPCS; providers should follow the per-line MUE applicability notes when billing.

• Lines such as the intermittent urinary catheter entries include the statement 'MUE limit not applicable.'

Documentation requirement for irrigation kit

For the Manual Transanal Irrigation System kit (1 Kit every 90 days), provider documentation must identify the number of catheters required on the request.

• A Manual Transanal Irrigation System kit includes up to 90 catheters; documentation of the number of catheters requested must be provided.

Use ICD-10 to support medical necessity

Providers must include applicable ICD-10 diagnosis codes to demonstrate medical necessity when billing for tracheostoma/HME products and related items.

• Claim lines for tracheostoma filters and related supplies must be supported by the applicable ICD-10 that determines medical necessity.

HCPCS restriction note

MassHealth restricts which HCPCS may be used for Non-Invasive PAP devices; only the specified HCPCS entry may be used for MassHealth members.

• The lithium ion battery line states: 'For MassHealth members, only this HCPCS can be used for Non Invasive PAP device.'

Medical necessity / diagnosis coding required

Several device and supply lines require an applicable ICD-10 code on the claim to establish medical necessity; providers must use the diagnosis code(s) that determine medical necessity for those products.

• Examples include transtracheal oxygen/suction catheters and tracheostomy inner cannulae — claims must include applicable ICD-10(s).

Rental payment limitation

When items are designated rental, rental is for short-term use and the rental paid amount cannot exceed the purchase price; this rental payment limitation applies across multiple rental lines.

• Battery/charger and other replacement items note: 'Rental is for short term use, rental paid amount can not exceed purchase price.'
• Apply rental payment cap when billing rental items.

DME item entries and rental note

DME item entries list HCPCS codes with per-period unit definitions and quantity limits; many entries also note the rental rule that rental paid amount cannot exceed the purchase price.

• Item lines include 1 unit definitions and specified frequency limits (e.g., 1 per 12 months, per wound per month).
• Replacement parts for patient-owned equipment are listed with replacement frequencies and rental/payment notes.

Bundling/billing exclusion

Certain small items are bundled into larger HCPCS and cannot be billed separately; for example, A4358 is included in A5112 and must not be submitted as a separate line.

• A4358 inclusion: 'A4358 is included in A5112 and can not be billed separately.'

Conditional coverage and quantity limits

Many supply and dressing entries are marked 'Sometimes' (conditional coverage); each line specifies the unit definition and quantity limit (often per month or per wound) and coverage is conditional on clinical necessity.

• Examples: foam dressings and gauze dressings show per-month or per-month-per-wound limits and are listed as 'Sometimes' covered.
• Providers must follow the per-line quantity limits when requesting/rending supplies.

Medical necessity documentation for custom compression garments

Custom compression and burn garments require provider documentation of medical necessity; providers must supply the applicable ICD-10 code(s) that determine medical necessity for these custom items.

• Custom garments (A6502–A6513, A6550) list frequency limits and state: 'Providers are to use applicable ICD-10 that determines the Medical Necessity of this product.'

Medical necessity documentation

Providers must include applicable ICD-10 diagnosis code(s) to demonstrate medical necessity for specified tracheostomy/laryngectomy tubes and related products.

• Tracheostomy/laryngectomy tube entries (e.g., A7520) explicitly state: 'Providers are to use applicable ICD-10 that determines the Medical Necessity of this product.'

Modifier requirement for dual eligibles

For Medicare dually eligible members, CAPPED rental modifiers must be used when billing rental items as specified across multiple rental entries.

• High frequency chest wall oscillation vest and numerous bed/mattress lines include the parenthetical: 'CAPPED rental modifiers must be used for all Medicare dually eligible members.'

Documentation requirement for UC modifier

Use of the UC modifier for gastrostomy/jejunostomy tubes in adults (>21) requires that providers have documentation of medical justification in the member’s record before supplying or billing with the UC modifier.

• The gastrostomy/jejunostomy tube entry notes UC modifier use for children under specific circumstances and requires documentation of medical justification for >21 years prior to billing.

Infusion pumps and rental rules

Enteral and parenteral infusion pumps are listed with replacement frequency limits (1 per 3 years) and rental rules; when rented, the rental paid amount cannot exceed the purchase price.

• Enteral nutrition infusion pumps (B9002/B9004/B9006) show 1 unit = each, 1 per 3 years and note rental payment limitation.

Parenteral solution unitization and code grouping

Parenteral nutrition homemix solutions are unitized with 1 unit = 500 mL and are included in grouped billing statements; some codes (e.g., B4216) can be billed separately within groupings.

• Multiple B41xx/B42xx entries define 1 unit = 500 ml and note grouped inclusion with an explicit statement that certain codes (B4216) can be billed separately.

Medicare dual-eligible rental modifier requirement

CAPPED rental modifiers are required for Medicare dually eligible members on numerous rental lines; the document repeats this modifier requirement for dual eligibles.

• Multiple item lines state: 'CAPPED rental modifiers must be used for all Medicare dually eligible members.'

Rental payment limitation

Rental entries reiterate that rentals are for short-term use and the rental paid amount cannot exceed the purchase price; apply this rule when billing rental-designated items.

• Rental lines consistently state: 'Rental is for short term use, rental paid amount can not exceed purchase price.'

Code inclusion and utilization note

Certain accessory HCPCS are included in the initial purchase of larger E0xxx items; consult the per-line inclusion notes before billing accessories separately (click-through guidance is provided for some procedure codes).

• Accessory inclusion examples: A4636, A4637, E0155, E0159 are included in E0141/E0143/E0147/E0148/E0149 on initial purchase as noted.
• Some procedure code lines include a 'NOTE When Utilizing this procedure code CLICK HERE' instruction—follow the click-through for utilization guidance.

Rental and capped modifier guidance

Rental guidance: rental is short-term, rental paid amount cannot exceed purchase price, and capped rental modifiers must be used for Medicare dually eligible members where specified.

• Several walker, commode and bed lines restate rental payment cap and capped modifier requirements for Medicare duals.

Bundle/inclusion note

Certain small accessories (for example E0167 pail/pan) are included in the initial purchase of larger commode codes (E0163/E0165/E0168) and cannot be billed separately for MassHealth members.

• Line note: '[E0167 included in initial purchase of E0163/E0165/E0168] (MassHealth members only).'

Prior Authorization Renewal

Prior authorization renewals are required every 30 days for powered air flotation beds (E0193) and air fluidized beds (E0194); PA renewal must be requested on the stated schedule.

• E0193 and E0194 lines: 'PA renewal every 30 days.'
• E0193/E0194 cannot be used with E0277/E0371/E0372/E0373 as noted.

Rental modifier and payment rule

For many rental-designated items across beds, transfer benches and other equipment, capped rental modifiers must be used for Medicare dually eligible members and rentals are limited so the rental paid amount cannot exceed the purchase price.

• Lines for E0186/E0188/E0193/E0194/E0247/E0248 and others include both rental payment cap language and the capped-modifier requirement for Medicare duals.

Procedure code note (click-through)

The document contains 'NOTE When Utilizing this procedure code CLICK HERE' on several hospital bed and procedure code lines — follow the click-through instruction for utilization details when submitting these codes.

• Procedure codes such as E0250/E0251/E0255/E0265 include a 'CLICK HERE' note for additional utilization instructions.

Rental modifier requirement for dually eligible members

The rental modifier requirement for dually eligible members is reiterated in multiple entries: when billing rental items for Medicare dual-eligible members, use the CAPPED rental modifiers as indicated.

• Hospital bed lines and other rental items restate: '(CAPPED rental modifiers must be used for all Medicare dually eligible members).'