CurrentMedicarePolicy N/A
Durable Medical Equipment, Prosthetics, Orthotics, Parenteral and Enteral Nutrition, and Supplies (DMEPOS)
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Guidance on billing, coverage definitions, payment, and documentation requirements for DME, prosthetics/orthotics, PEN, and related supplies for Medicare providers and suppliers; applies to A/B MACs and DME MACs and entities that bill Medicare for these items.
Policy Summary
PayerMedicare
PolicyDurable Medical Equipment, Prosthetics, Orthotics, Parenteral and Enteral Nutrition, and Supplies (DMEPOS)
Policy CodePolicy N/A
Change TypeNo material coverage changes
Effective DateJan 1, 2024
Next Review DateN/A
Key ActionDo not submit Certificates of Medical Necessity or DME Information Forms with claims for dates of service on or after Jan 1, 2023; attached forms may be rejected.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
CMN/DIF not required after 2023-01-01CMN/DIF policy change
$150Inexpensive DME threshold
A/B MACs & DME MACApplies to
6 monthsPEN initial certification
15 monthsCapped rental period
Coverage & Payment Criteria
Coverage & Payment Criteria
Consolidated coverage and payment criteria for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS). Includes definitions, payment classes, billing responsibilities, documentation requirements, and special rules for oxygen, PEN/TPN, home dialysis, used equipment, delivery/service charges, upgrades, and capped rentals.
DME definition and general coverage: DME is covered under Part B when it meets the statutory definition: can withstand repeated use; primarily and customarily used to serve a medical purpose; not generally useful in absence of illness/injury; appropriate for use in the home. All elements must be met before coverage.
Coverage table and contractor actions: Reimbursement for rental or purchase is allowed only when conditions in the DME Coverage Table are met; A/B MACs and DME MACs perform the review actions specified (see local MAC instructions). A supplier must maintain and provide, upon request, the physician's detailed written order or CMN when required.
Payment classes and fee schedule: DMEPOS are assigned to payment classes (inexpensive/routinely purchased; items requiring frequent/substantial servicing; certain customized items; other P&O devices; capped rental items; oxygen and oxygen equipment). Payment is made on the DMEPOS fee schedule (oxygen on its fee schedule). Fee schedule applies according to bill type and provider (see Application of DMEPOS Fee Schedule).
Used equipment and purchase after rental: Used equipment is treated as routinely purchased DME; when a beneficiary rents new equipment then purchases it, the purchase allowed amount is the purchase fee schedule less prior rental payments or the actual charge, whichever is lower, but not to exceed actual charge. UE modifier rules apply (see 30.1.1.2).
Rental vs purchase reporting and modifiers: Claims must indicate rented vs purchased and whether equipment is new or used. If an assigned claim fails to indicate new/used, MAC assumes used. Use HCPCS modifiers (e.g., -NU, -UE, -RR, -BR, -BP, -NR, KH/KI/KJ historical) to indicate status.
Power-operated vehicles/wheelchairs: Payment is the lesser of actual charge or fee schedule amount (including medically necessary accessories). CMN required for initial POV claims; MACs must not broadly require additional documentation beyond CMN except for audits/investigations.
Delivery and service charges: Separate delivery/service charges are normally included in the fee schedule and are not payable separately except in rare/unusual documented circumstances (e.g., delivery outside supplier's normal area, extraordinary expenses). When allowed, MACs base amount on relevant local circumstances and actual expenses; suppliers must fully document unusual circumstances.
Repair parts and RB modifier: Repair parts billed with RB modifier are paid as lump sum purchase. For competitive bidding items, payment follows single payment amounts or contractor discretion per regulation.
Deluxe features and ABN/beneficiary charges: Deluxe or aesthetic features not medically necessary are not payable. If beneficiary requests upgrades, supplier may collect excess charges only with a valid ABN. When upgrades are furnished, suppliers must bill two line items (upgraded item with GA and non-upgraded item with GK) or use GL when charging Medicare for the non-upgraded item while furnishing an upgraded item with no charge to beneficiary.
CMN and documentation requirements: As of 01-01-2023, CMNs and DIFs are not required to be submitted with claims for dates of service on/after that date; however CMN content and physician attestation elements remain authoritative for items that require certification and MACs may request supporting documentation in reviews. CMN elements and completion rules remain in effect where CMNs are required.
PEN (Parenteral and Enteral Nutrition) documentation and coverage: Initial PEN claims must be supported by a properly completed PEN CMN with medical and prescription information entered by the attending/ordering physician (or employee authorized and reviewed/signed by physician). Initial certification is valid for six months; recertification schedule is case-by-case. DME MACs will deny initial assigned claims without appropriate documentation or with deficiencies (e.g., missing/inappropriate diagnosis, duration <90 days, supplies provided before onset date, stamped signatures).
PEN pump payment limits and supplies: Rental of parenteral/enteral pumps limited to 15 months during a period of medical need; once limit reached, no additional rental payments unless prescription changes between parenteral/enteral. DME MACs do not start a new 15-month period when supplier changes; new supplier entitled to remaining balance. PEN supply kits are all-inclusive for monthly administration; payment tied to method of administration documented on CMN; inappropriate kit billed without documentation may be denied or paid at gravity-fed allowance when pump documentation absent.
Oxygen coverage and NCD changes: For services on/after 09-27-2021, home oxygen claims must meet NCD 240.2 criteria; the CED NCD for cluster headache was removed effective 09-27-2021 and MACs adjudicate such claims under 1862(a)(1)(A) when no NCD applies. All initial certifications with >4 LPM require MAC review before payment.
Oxygen fee adjustments and contents fees: Monthly stationary oxygen fee is reduced by 50% if prescribed <1 LPM. Volume adjustment (+50%) applies when stationary >4 LPM. Portable add-on applies if portable oxygen is prescribed; if both apply use the higher add-on; QF modifier effective 04-01-2017 must be used when both stationary and portable codes billed. Contents-only fee payable when beneficiary owns stationary gaseous or liquid system (not for owned concentrators); portable contents fee payable in certain ownership/rental combinations.
Pre-discharge delivery for fitting/training: Pre-discharge delivery of DME/P&O (not supplies) is appropriate when all conditions are met: item medically necessary for home use, physician order with initial date no later than discharge, delivery solely for fitting/training, delivery within two days of discharge, supplier ensures item goes home with beneficiary or delivers to home on discharge date, no intent to shift facility responsibility, no claims prior to discharge date, no separate charges for redelivery, and discharge to a qualified place of service.
Method II home dialysis elimination: Method II was eliminated for dates of service on/after 01-01-2011; home dialysis claims must be billed by ESRD facilities and paid under ESRD PPS for those dates. For pre-2011 DOS, Form CMS-382 selection rules applied.
Frequency and sequencing of claims: Suppliers bill monthly for DME/oxygen unless another policy allows different frequency. Claims for continuous services should be sequential; when break in service occurs (e.g., inpatient stay) resume sequential billing and adjust anniversary date for capped rentals when discharge changes 'from' date.
Appeals of duplicate claims: DME MACs only afford appeal rights for initial determinations; duplicate claim denials have limited appeal rights only to the issue of duplication. Specific MSN and remittance messages must be used for duplicate denials.
Fee schedule application and patient liability: Allowable amount is lower of fee schedule or billed charge. For non-nominal providers, payment = (lower of billed charge or fee schedule - unmet Part B deductible) * 80%. Patient liability rules and bill types determine fee schedule application.
Maintenance & servicing and installation: Maintenance and servicing included in rental payments; for purchased equipment reasonable servicing is payable. Use modifiers (-MS for capped rental servicing, -RP for replacement/repair) or revenue codes as specified. Installment purchases report total price on first bill; monthly amounts equal rental fee until purchase price or actual charge reached.
Supplies and drugs billing: Supplies necessary for effective use of DME and associated drugs are billed to DME MAC (HHAs use revenue code 0294). NDCs and HCPCS rules apply; MACs must accept NDCs in specified formats and return claims with invalid NDC as unprocessable.
Lymphedema compression treatment: Effective 01-01-2024 CAA 2023 establishes benefit for standard/custom compression garments and items; frequency and quantity limits apply (e.g., up to 3 daytime garments and 2 nighttime per body area with replacement rules and RA modifier for replacements); payment made as lump sum at national Medicare allowed payment amount, beneficiary pays 20% coinsurance after deductible when applicable.
Home infusion and HIT transitional payments: Temporary transitional categories and payment rules apply to home infusion drugs and associated professional G-codes; claims must include associated J-code on same or recent claim or professional claim will recycle/deny per CWF rules.
Billing for P&O and customized items: Providers bill appropriate MACs per setting; specialty licensing/certification codes are required when state law applies. Customized items without specific HCPCS use E1399 and are billed to DME MAC.
Special collection limits and PRA: DME MACs must adhere to PRA limits on collection of information; except during audits/investigations they must not require additional documentation beyond CMN for POV claims, nor require make/model or functional ability documentation on all claims beyond CMN/Section C capture.
Operational notes: MACs provide local instructions and bulletins; suppliers must retain documentation and support claims; claims with CMNs for pre-2023 dates follow prior rules; suppliers must ensure proper modifiers, ABNs, and documentation to avoid denials.
HCPCS, Modifiers & Code Tables
HCPCS coding and jurisdictionHCPCS
| HCPCS | HCPCS codes describe DMEPOS categories; jurisdiction updated quarterly; spreadsheet of DME MAC jurisdiction posted on CMS website |
DMEPOS payment class codesmixed
| IN | Inexpensive/routinely purchased DME payment class |
| FS | Frequency Service payment class |
| CR | Capped Rental payment class |
| OX | Oxygen and Oxygen Equipment payment class |
| OS | Ostomy, Tracheostomy and Urologicals / Prosthetics & Orthotics category |
| SU | Supplies payment class |
| TE | TENS payment class |
ModifiersModifier
| UE | Modifier for purchase of used equipment (used equipment purchase) |
| -BP | Beneficiary elected to purchase |
| -BR | Beneficiary elected to rent |
| -BU | Beneficiary did not inform supplier after 30 days |
| -KH | Initial claim, purchase or first month rental |
| -KI | Second or third month rental |
| -KJ | PEN pump/capped rental months four to fifteen |
| -NR | New when rented |
| -NU | New equipment |
| -RR | Rental |
1–10 of 11
1/2
CPM device code exampleHCPCSCovered
| E0935 | Continuous passive motion device |
Modifiers and condition codes for oxygen clinical trialsModifier | ICD-10
| QR | Modifier indicating item/service provided in a Medicare-specified study (used for oxygen clinical trials) |
| 30 | Condition code indicating qualified clinical trial |
| Z00.6 | ICD-10 code referenced for oxygen home therapy trial (second diagnosis position) |
Replacement-part modifier (RB)ModifierCovered
| RB | Modifier denoting replacement of a part of a DMEPOS item furnished as part of repair (paid as lump sum purchase) |
Enteral nutrient HCPCS categoriesHCPCSCovered
| B4150 | Enteral nutrient, category I |
| B4152 | Enteral nutrient, category II |
| B4153 | Enteral nutrient, Category III (hydrolyzed protein/amino acids) |
| B4154 | Enteral nutrient, Category IV (defined formulas for special metabolic needs) |
| B4155 | Enteral nutrient, Category V (modular components) |
| B4156 | Enteral nutrient, Category VI (standardized nutrients) |
HCPCS exclusions from DMEPOS fee schedule by bill type/providerHCPCSCovered
| A4214, A4310-A4455, A4481, A4622, A4623, A4625, A4626, A4629, A5051-A5149 | HCPCS codes excluded from the fee schedule when billed by an HHA to its A/B MAC (HHH) under specified bill types |
| A4214, A4310-A4330, A4338-A4359, A5102-A5114 | HCPCS codes excluded from the fee schedule when billed by a non-OPPS hospital with an ASC service under specific bill types |
Retail pharmacy drug identificationNDC
| NDC | National Drug Codes must be transmitted in the NCPDP standards for retail pharmacy drug transactions to DME MACs |
Modifiers for ABN/upgrades guidanceModifierCovered
| GA | Waiver of Liability - ABN on file (used to indicate beneficiary signed ABN for upgraded items) |
| GZ | Item or Service not Reasonable and Necessary - no ABN on file |
| GK | Reasonable and necessary item/service associated with GA or GZ modifier |
| GL | Medically Unnecessary Upgrade Provided Instead of Non-upgraded Item, No Charge, No ABN |
Referenced HCPCS, Modifiers, and special codesHCPCS | Modifier | mixed
| GA | Waiver of Liability - ABN on file |
| GZ | Item or Service not Reasonable and Necessary - no ABN on file |
| GK | Reasonable and necessary item/service associated with GA or GZ modifier |
| GL | Medically Unnecessary Upgrade Provided Instead of Non-upgraded Item, No Charge, No ABN |
| E1399 | Miscellaneous DME (used for customized items without specific HCPCS) |
| QE | Oxygen modifier - prescribed <1 LPM (reduce monthly payment by 50%) |
| QG | Oxygen modifier - prescribed >4 LPM (increase monthly payment by 50%) |
| QF | Oxygen modifier - >4 LPM with portable prescribed (increase by higher of 50% or portable add-on); must be used with both stationary and portable codes |
Oxygen-related HCPCS codes referencedHCPCS
| E0424 | Gaseous stationary oxygen concentrator (stationary monthly payment example) |
| E0439 | Liquid stationary oxygen (stationary monthly payment example) |
| E0431 | Portable oxygen add-on (example code referenced) |
| E0434 | Portable oxygen add-on (example code referenced) |
| E0441 | Gaseous oxygen content fee |
| E0442 | Liquid oxygen content fee |
| E0443 | Portable contents fee (example) |
| E0444 | Portable contents fee (example) |
| E1377 | Concentrator stationary monthly payment (example series) |
Insulin supply modifiers for DMEHCPCSCovered
| JK | One month supply or less of drug or biological (insulin via DME) |
| JL | Three month supply of drug or biological (insulin via DME) |
DME purchase/rental and new/used modifiersModifierCovered
| -BP | Beneficiary elected to purchase |
| -BR | Beneficiary elected to rent |
| -BU | Beneficiary did not inform supplier after 30 days |
| -KH | Initial claim, purchase or first month rental |
| -KI | Second or third month rental |
| -KJ | PEN pump or capped rental months four to fifteen |
| -NR | New when rented |
| -NU | New equipment |
| -RR | Rental |
| -UE | Used durable medical equipment |
Home infusion therapy HCPCS and related J-codesHCPCSCovered
| G0068 | Professional services for administration of infusion drug in home; each 15 minutes |
| G0069 | Professional services for administration of subcutaneous immunotherapy in home; each 15 minutes |
| G0070 | Professional services for administration of chemotherapy in home; each 15 minutes |
| J7799 | Compounded infusion drug, not otherwise classified (example transitional J-code grouping reference) |
| J7999 | Compounded infusion drug, not otherwise classified (example transitional J-code grouping reference) |
Lymphedema compression treatment itemsmixed
| No codes listed |
Home IVIG administration code (Q2052)HCPCSCovered
| Q2052 | Services, Supplies, and Accessories used in the Home for the Administration of Intravenous Immune Globulin (billable per visit) |
Home IVIG administration guidanceHCPCSCovered
| Q2052 | Home IVIG items and services payment code (visit administration) — report in 15-minute increments; only one Q-code unit payable per infusion date |
IVIG product codes (J-codes)HCPCSCovered
| J-code (IVIG product) | IVIG product J-code must appear on same claim or within 30 days prior in claims history to support payment of Q2052 |
HCPCS correctionHCPCS
| A4217 | HCPCS code referenced for correction in transmittals list |
Coverage table requirement
Column A (coverage condition)Reimbursement permitted when all conditions listed in Column A are met (see Coverage Table for DME Claims).
Column B (contractor action)Column B indicates actions A/B MACs and DME MACs will take to establish that the Column A conditions have been met (development, documentation requests, etc.).
Key policy effectReimbursement requires both Column A clinical/coverage conditions and contractor verification actions in Column B before payment is made.
Inexpensive DME purchase price threshold
Inexpensive DME price thresholdEquipment whose purchase price does not exceed $150 is categorized as Inexpensive DME.
Billing implicationItems meeting this threshold are billed under the Inexpensive/Other Routinely Purchased DME payment class to the DME MAC (or A/B MAC per setting).
Reference effective ruleDefinition and billing guidance appear in sections defining payment classes and billing for inexpensive/routinely purchased DME.
Routinely purchased DME purchase frequency threshold
Purchase-frequency thresholdAn item is considered 'other routinely purchased DME' if acquired at least 75% of the time by purchase.
Included examplesCategory includes certain accessories and, effective Oct 1, 2015, speech generating devices and accessories necessary for their use.
Billing impactItems in this category follow the inexpensive/routinely purchased billing instructions to the DME MAC (or A/B MAC per setting).
Capped rental fee percentages
First 3 months rental percentageFor capped rental items, monthly rental for first 3 months is limited to 10% of the average allowed purchase price (base period adjusted).
Remaining months percentageFor each remaining rental month after the first three, monthly rental is limited to 7.5% of the average allowed purchase price.
15-month capAfter 15 months of rental payments, no further rental payment may be made except for a 6-month maintenance and servicing fee.
Arterial oxygen partial pressure threshold for trial payment (PaO2 / SpO2)
Arterial oxygen trial thresholdFor specified oxygen home therapy clinical trials, DME MACs shall pay claims when arterial oxygen partial pressure (PaO2) measures are 56–65 mmHg.
Oxygen saturation alternativeClaims also payable when oxygen saturation (SpO2) is at or above 89% in the trial context as described.
Associated codingClaims for clinical trials should include QR modifier and condition code 30 where applicable per trial instructions.
PEN initial certification validity
Initial PEN certification validityAn initial certification for parenteral/enteral nutrition (PEN) must accompany the initial claim and is valid for six months.
RecertificationDME MACs establish recertification schedules on a case-by-case basis; a period of medical need ends when nutrients are not medically necessary for two consecutive months.
Documentation requirementInitial CMN must include supplier and beneficiary identifiers and be completed/signed by the attending physician or authorized employee.
Lipids monthly unit threshold
Lipid monthly unit thresholdThe attending physician must document the reason for using more than 12 units (at 500 mL per unit) of lipids per month in the PEN CMN.
Parenteral CMN specificsParenteral CMN must state infusion frequency, route, components, and justification for special formulas or dextrose concentrations <10%.
Review and denial riskDME MACs review initial PEN certifications and may deny claims without adequate clinical documentation or inappropriate/missing information.
Enteral calorie guidance
Enteral calorie documentation guidanceGenerally 750–2,000 calories/day is considered sufficient; the attending physician must document the reason if prescribing <750 or >2000 calories/day.
Administration methodEnteral CMN must state nutrient product/category, calories/day (100 cal = 1 unit), frequency, administration method (syringe, gravity, pump), and reason for pump when used.
Higher-category justificationIf prescribing higher category formulas, document unfavorable events or medical need prompting the higher category selection.
Pre-discharge delivery window
Pre-discharge delivery timingSupplier may deliver a medically necessary DME/P&O item no earlier than two days before hospital discharge for fitting/training when the item will be taken home at discharge.
Date-of-service determinationPre-discharge deliveries intended for use at home are considered provided on the date of discharge (date of service deemed date of discharge) if the supplier leaves the item and beneficiary takes it home or fitting/training requirements are met.
Supplier responsibilitiesSupplier must ensure the item is taken home on discharge (or re-deliver on that date) and must not bill for days prior to the date of discharge; failure to re-deliver means date of service is actual delivery date.
Inexpensive DME price threshold (duplicate)
Inexpensive DME price threshold (duplicate)Equipment with purchase price not exceeding $150 is classified as inexpensive or other routinely purchased DME.
Category billingItems in this category are billed under the Inexpensive/Other Routinely Purchased DME rules to the DME MAC (or A/B MAC per setting).
Effective policy citationSee sections defining payment classes and billing for inexpensive/routinely purchased DME for detailed instructions.
Flow rate thresholds for modifier assignment
Flow rate modifier thresholdsPrescribed stationary oxygen <1 LPM use modifier QE/QA to reduce monthly payment by 50%; >4 LPM use QG/QR to increase payment by 50%.
>4 LPM with portableIf >4 LPM and portable oxygen is prescribed use QF/QB; payment increase equals the higher of 50% stationary adjustment or the portable add-on; QF must be used on both stationary and portable codes.
Revenue code mappingHHAs use revenue codes 0602 (QE), 0603 (QG/QR), 0604 (QF) for analogous payment adjustments when billing A/B MAC (HHH).
G-code claim recycling limit
G-code recycle limitG-code claims (G0068/G0069/G0070) will recycle up to three times with a 30-day lookback each (total 15 business days) if the associated transitional J-code is not found; after that the G-code claim will be denied.
Lookback requirementThe appropriate transitional J-code must be on the same claim or in claims history within prior 30 days to avoid recycling/denial.
Unit reportingG-codes are reported in 15-minute units with specified rounding thresholds for time-to-units conversion.
Time-to-units rounding thresholds (units 1-10)
Time-to-units rounding (units 1-10)Rounding table: Unit 1 = <23 min; Unit 2 = 23–<38 min; Unit 3 = 38–<53 min; Unit 4 = 53–<68 min; Unit 5 = 68–<83 min; Unit 6 = 83–<98 min; Unit 7 = 98–<113 min; Unit 8 = 113–<128 min; Unit 9 = 128–<143 min; Unit 10 = 143–<158 min.
Applicable servicesApplies to time-based G-codes for Home Infusion Therapy and to IVIG Q-code visit unit rounding (15-minute increments) as specified.
Claim processing noteClaims must report visit length per these thresholds to determine payable units; improper reporting may lead to adjustments or denials.
Allowed garment quantities per body area
Allowed garment quantitiesFor lymphedema, allowed quantity per body area is up to 3 daytime garments/wraps and up to 2 nighttime garments per body area.
Replacement frequencyReplacement allowed once every 6 months for daytime garment/wrap and once every 2 years for nighttime garment unless medical need/loss/theft/irreparable damage justifies earlier replacement.
Payment methodPayment made as lump-sum per item; supplier paid 80% of the lesser of actual charge or national Medicare allowed amount.
IVIG visit unit rounding
IVIG visit unit roundingReport IVIG visit length in 15-minute increments (15 minutes = 1 unit) and apply the rounding table (e.g., <23 min = 1 unit; 23–<38 = 2 units; etc.).
One Q-code per infusion dateOnly one Q-code unit (Q2052) is payable per infusion date of service; multiple administrations on same date require separate Q-code lines per date.
J-code pairing requirementAn eligible IVIG J-code must be billed on the same claim or be present in claims history within 30 days prior to avoid recycling/denial of the Q-code claim.
Q-code lookback/recycle
Q-code recycle/lookbackHome IVIG Q-code claims will recycle up to three times with a 30-day look back each (total 15 business days) if a matching IVIG J-code is not found; after 15 business days the Q-code claim is denied.
CWF process similarityThis recycle/lookback policy mirrors the G-code/CWF recycling process used for transitional Home Infusion Therapy professional service claims.
Supplier responsibilitySuppliers must ensure the IVIG product J-code is billed with the visit or within the prior 30 days to prevent recycling or denials.
CWF look-back and recycle limit
CWF look-back and recycle limitCWF recycling uses a 30-day look back per recycle, up to 3 recycles (total 15 business days) before denial if the matching J-code is not found in claims history.
Applies to multiple programsPolicy explicitly applies to transitional HIT G-codes and home IVIG Q-code claims where a matching drug J-code must be present.
Operational consequenceAfter the third recycle/15 business days without a matching J-code, the professional visit or Q-code claim will be denied by the CWF.
Supplier & Provider Billing Actions
Documentation Required
Documentation requirement for DME
A supplier must maintain and, upon request, make available to the MAC the detailed written order from the treating physician or, when previously required, the Certificate of Medical Necessity (CMN). Written orders/C MN information need not be submitted with claims with dates of service on or after 2023-01-01, but must remain in the supplier's records and be producible to the MAC on request.
- Suppliers must keep the written order/CMN or equivalent documentation in the beneficiary file and provide it to the MAC upon request.
- Do not attach CMNs/DIFs to electronic claims with DOS on/after 2023-01-01 — such claims may be rejected.
Billing Rule
Supplier change and responsibility
A change of supplier does not create a new rental episode. The new supplier is entitled to the remaining monthly rental payments up to the 15-month capped rental period; the supplier providing the item in the 15th month is responsible for supplying the equipment and for maintenance/servicing thereafter.
- If supplier change occurs after month 8, the new supplier is entitled to the remaining 7 months (15 - 8).
- Supplier in the 15th rental month must assume maintenance and servicing responsibility after the 15-month period.
Billing Rule
Modifications or Substitutions of Equipment — review and rental period implications
When equipment is changed or modified, DME MACs/A/B MACs may review medical necessity. If review finds the beneficiary's medical needs substantially changed and new equipment is necessary, a new 15-month rental period may begin. If the change is to different but similar equipment without a substantial change in needs, remaining months continue to count against the original 15-month rental period and payment is based on the least expensive medically appropriate configuration.
- Modifications that add medically necessary features (e.g., special back added to wheelchair) may trigger a new 15‑month rental period for the added equipment while continuing the original period for the base equipment.
- If a new 15-month period is not warranted and the 15-month cap already expired, no additional rental payments will be made.
Billing Rule
Change in Suppliers — rental entitlement and remaining responsibilities
If a beneficiary changes suppliers during an active capped rental period, the rental entitlement and payment responsibility transfer consistent with the remaining months of the original rental episode; the new supplier is paid for the remaining rental months and the supplier providing the item in the 15th month has ongoing obligations for supply, maintenance, and servicing.
- Example: Change after month 8 → new supplier entitled to 7 additional months of rental payment (15 − 8).
- Supplier in month 10 must still offer the purchase option (see purchase-option rules).
Note
Clinical trial modifiers and condition codes for oxygen home therapy
DME MACs and A/B MACs recognize clinical trial reporting codes for oxygen home therapy: use the QR modifier for CMS‑identified clinical trials and condition code 30 (with appropriate diagnosis code) for qualified clinical trials. Claims meeting the trial criteria are payable under the trial rules.
- QR modifier: denotes item/service provided in a Medicare‑specified study; recognized for oxygen home therapy clinical trials identified by CMS.
- Condition code 30 + ICD-9 V70.7 or ICD-10 Z00.6 in the second diagnosis position denotes a qualified clinical trial for oxygen home therapy and may permit payment when arterial blood gas/oximetry values meet trial thresholds.
Billing Rule
Replacement part billing and payment (RB modifier)
Replacement parts furnished as repair parts must be billed with the RB modifier and are paid on a lump‑sum purchase basis. Payment rules differ in competitive bidding areas versus non‑competitive areas; contractors have discretion when parts correspond to competitive bidding HCPCS but are used to repair non‑competitive base equipment.
- All repair part claims with RB are paid as lump sum purchases.
- In competitive bidding areas, payment for repair parts follows the applicable single payment amount; in non‑competitive areas, payment follows contractor consideration per regulation.
Denial Risk
Delivery and service charge billing — generally disallowed except rare circumstances
Separate delivery and service charges are ordinarily disallowed because such costs are assumed to be included in the DME fee schedule; DME MACs may only allow separate delivery/service charges in rare, documented, unusual circumstances (for example, delivery outside the supplier's normal service area when no local supplier is available).
- Document unusual circumstances fully when billing a separate delivery/service charge.
- If a supplier routinely itemizes delivery charges, DME MACs may consider such charges included in the equipment fee and deny separate payment.
Documentation Required
Written order prior to delivery
A written order from the physician is required prior to delivery. See the Medicare Program Integrity Manual, Chapter 5 for supplier written order requirements. HHAs billing certain bill types should follow Chapter 6 instructions where applicable.
- Suppliers must retain the physician's signed order in files and produce it to the MAC on request.
- HHAs: follow the specific written‑order requirements in the Program Integrity Manual Chapter 6 for bill types 32x/33x/34x.
Documentation Required
PEN certification and recertification requirements
PEN (parenteral and enteral nutrition) initial certification must accompany the initial claim and is valid for six months. DME MACs set the recertification schedule thereafter. A change in prescription after the initial certification does not restart the certification period; services not required for two consecutive months end the period and recertification begins anew.
- Initial PEN certification: submit with initial claim; valid 6 months.
- Recertification schedules are determined by the DME MAC on a case‑by‑case basis.
- Revised certifications are required for certain prescription changes (e.g., >1 liter change in daily volume, change from home‑mix to pre‑mix, method of infusion changes).
Prior Authorization
ABN use and claim submission for upgrades
When using an ABN for an upgraded DMEPOS item, suppliers must submit two claim lines on the same claim: the upgraded item (with GA modifier if ABN signed) and the reasonable‑and‑necessary item (with GK modifier). If furnished but charging only for the non‑upgraded item, bill the non‑upgraded HCPCS with modifier GL and include detailed description of the actual upgraded make/model and rationale.
- Line 1: upgraded item — bill HCPCS for item furnished; include GA modifier if ABN obtained (or GZ/GK per instructions where applicable).
- Line 2: reasonable/necessary item — bill HCPCS & charge for non‑upgraded item with GK modifier.
- If charging beneficiary only for non‑upgraded item (no charge for upgrade), use modifier GL and document make/model and why item is an upgrade.
Billing Rule
No‑charge upgraded item billing (GL modifier)
If the supplier furnishes an upgraded item but chooses to bill Medicare only for the non‑upgraded item (no charge to beneficiary for the upgrade), bill the HCPCS for the non‑upgraded item accompanied by modifier GL and document the upgraded make/model and justification. Medicare pays based on the non‑upgraded item's payment amount.
- Include details of the upgraded item (make/model) and explanation in Item 19 or attachment when using GL.
- MSN message 8.51: beneficiary is not liable for additional charge when GL is used.
Billing Rule
Use of HCPCS modifiers and revenue codes / claim handling
Use of HCPCS modifiers and revenue codes is required for oxygen and other payment adjustments. Examples: QE (prescribed stationary oxygen <1 LPM), QG (>4 LPM), QF (>4 LPM with portable prescribed). HHAs and hospitals must use the appropriate revenue codes when billing for stationary or portable oxygen and for maintenance/servicing.
- QE, QG, QF modifiers adjust monthly stationary oxygen payments; HHAs use revenue codes 0602/0603/0604 as applicable.
- Improper combinations (e.g., QG plus a recently paid portable add‑on) can render claims unprocessable and returned with CARC/RARC messages.
- For maintenance/servicing: suppliers use -RP modifier; HHAs use revenue code 0299; hospitals use revenue code 0274 with specified HCPCS codes.
Billing Rule
Billing actions for capped rental anniversary date and maintenance
For capped rental anniversary date or when a beneficiary is discharged from an institution, suppliers must submit a new capped rental claim with the discharge date as the new 'from' date when applicable. The CWF rejects DME MAC claims with DOS that fall within an inpatient stay and processes claims with 'from' date equal to the discharge date. Maintenance/servicing claims with the 'MS' modifier are payable regardless of inpatient status.
- When inpatient stay overlaps anniversary date and beneficiary not in facility entire month, use discharge date as new 'from' date and submit new claim.
- Annotate claims to indicate the patient was institutionalized to establish a new anniversary date.
- CWF: rejects claims with DOS during inpatient stay; accepts claims with 'from' date equal to discharge date; 'MS' modifier identifies maintenance/servicing claims.
Denial Risk
CWF edit and recycling/denial process (G/Q‑codes and matching drug J‑codes)
Certain home infusion and IVIG Q/G‑code claims are subject to Common Working File (CWF) edits that recycle the professional/administration line if a matching J‑code is not found on the same claim or in claim history within the lookback window; after three cycles (15 business days) the recycled claim will be denied if no matching drug J‑code appears.
- G‑ or Q‑code claims for professional/administration services will recycle up to three times (30‑day lookback windows) if the associated J‑code is not found, then deny.
- Suppliers must ensure the associated drug J‑code is billed on the same claim or within the lookback window (usually 30 days) to avoid denial.
Billing Rule
Requirement to bill matching J‑code for administration/visit claims
Ensure an eligible J‑code for the drug (or IVIG product) is billed on the same claim as the professional/administration G‑ or Q‑code or within the allowed lookback period (generally 30 days). Failure to bill the matching J‑code will cause recycling and, ultimately, denial of the professional/administration claim.
- For home infusion G‑codes and home IVIG Q2052: only one administration unit payable per infusion date; report visit time in 15‑minute units.
- If multiple visits occur same date, bill only one visit and the highest paying visit with applicable drug.
Denial Risk
Pre‑payment auto‑denial edits for oxygen equipment
DME MACs have implemented pre‑payment auto‑denial edits in applicable states for oxygen and oxygen equipment suppliers. Suppliers should be aware that these pre‑payment edits may cause claims to be auto‑denied prior to payment and must ensure compliance with the documentation and coding requirements to avoid denials.
- Transmittals established pre‑payment auto‑denial edits for oxygen suppliers in applicable states; consult DME MAC transmittals and local guidance.
- Maintain required documentation and report appropriate modifiers and NPIs to reduce risk of pre‑payment denials.
Key Definitions & Terms
Durable Medical Equipment (DME) definition
DME definition (four criteria)Durable Medical Equipment (DME) is equipment that: (a) can withstand repeated use; (b) is primarily and customarily used to serve a medical purpose; (c) is generally not useful in the absence of illness or injury; and (d) is appropriate for use in the home.
Coverage prerequisiteAll elements of the definition must be met before an item can be considered DME for Part B coverage.
Reference for detailsSee the Medicare Benefit Policy Manual, Chapter 15 for detailed coverage requirements and definitions related to DME.
Prosthetic Devices definition
Prosthetic devices definitionProsthetic devices (other than dental) are devices that replace all or part of an internal body organ or replace function of a permanently inoperative or malfunctioning internal body organ; replacements/repairs covered when furnished incident to physician services or on physician's order.
Coverage referenceSee Medicare Benefit Policy Manual, Chapter 15 and NCD Manual for specific prosthetic device coverage guidance.
Physician order requirementReplacements or repairs are covered when furnished incident to physician services or on a physician's order.
Prosthetics and Orthotics (P&O) definition
P&O definitionProsthetics and Orthotics (P&O) include leg, arm, back, and neck braces, trusses, and artificial limbs/eyes covered when furnished incident to physician services or on a physician's order; chapter uses 'P&O' interchangeably for related sections.
Brace descriptionA brace supports a weak or deformed body member or restricts motion in a diseased or injured part of the body.
Cross-referenceRefer to Medicare Benefit Policy Manual, Chapter 15 for detailed coverage and replacement/adjustment rules.
P&O (alternate) definition
P&O term usageThe chapter uses the term 'P&O' to refer to prosthetic and orthotic devices under sections §1861(s)(8) and (9) interchangeably for payment and policy discussion.
ScopeApplies except where specific exceptions (e.g., IOLs) are noted.
Billing implicationPayment for prosthetics and orthotics is made on the basis of the DMEPOS fee schedule regardless of billing to A/B MAC or DME MAC.
DMEPOS payment classes
Payment classes listDMEPOS payment classes include: Inexpensive/other routinely purchased DME; Items requiring frequent and substantial servicing; Certain customized items; Other prosthetic and orthotic devices; Capped rental items; Oxygen and oxygen equipment.
CMS assignmentCMS determines the category for each HCPCS code and issues instructions when changes are appropriate.
Fee schedule basisDME, including oxygen and prosthetics/orthotics, is paid on the DMEPOS fee schedule.
Inexpensive DME
Inexpensive DME definitionInexpensive DME is defined as equipment whose purchase price does not exceed $150.
Category applicationEquipment meeting this price threshold is billed under the inexpensive/other routinely purchased DME rules to the DME MAC (or appropriate A/B MAC per setting).
Related billing sectionSee section 130.2 and related billing instructions for implementation details.
Other routinely purchased DME
Other routinely purchased DME definitionDefined as equipment acquired at least 75% of the time by purchase; includes certain accessories and, effective Oct 1, 2015, speech generating devices and accessories.
Billing instructionSuppliers and providers (other than HHAs) bill these items to the DME MAC; HHAs bill A/B MAC (HHH) or DME MAC as appropriate.
Category examplesIncludes accessories used with nebulizers, aspirators, and certain ventilator-related devices.
Used equipment
Used equipment definitionUsed equipment is equipment purchased or rented previously by someone before the current purchase transaction, including trial/demo equipment and equipment used without a commercial transaction.
Purchase-after-rental ruleIf beneficiary rented brand-new item and then purchases it, allowed purchase may be adjusted so combined rental+purchase equal fee schedule for new equipment, not to exceed actual charge.
Payment examplesExamples illustrate adjustments to purchase allowances when prior rental months were paid.
Customized item
Customized item definition (CFR)A customized item (per 42 CFR 414.224) must be uniquely constructed or substantially modified for a specific beneficiary per physician description/orders so it cannot be grouped with other items for pricing.
ExclusionsItems that are custom fitted, assembled, or supplier-assembled but not uniquely constructed do not meet the customized item definition.
Payment approachMACs make lump-sum purchase payments based on reasonable costs and may require detailed documentation of construction/fabrication costs and labor.
Items requiring frequent and substantial servicing
Items requiring frequent and substantial servicing definitionEquipment for which MACs pay fee schedule amounts on a rental basis until medical necessity ends; purchase is not permitted for these items.
Payment basisMACs continue rental payments while medically necessary; purchase disallowed.
Examples and guidanceSee section on items requiring frequent and substantial servicing for examples and rental policy details.
Payment rule for power-operated vehicle/wheelchair
Power-operated vehicle payment ruleAllowed payment amount for a power-operated vehicle usable as a wheelchair is the lower of the actual charge or the fee schedule amount (including medically necessary accessories).
Coverage implicationPayment follows fee schedule limits; supplier billing must reflect actual charge and fee schedule comparisons.
Applicable codesFollow DMEPOS fee schedule HCPCS mapping for power-operated vehicle codes.
Oxygen fee adjustments
Oxygen fee adjustments overviewOxygen payment adjustments include volume adjustments for stationary oxygen >4 LPM (+50%) and reduction for <1 LPM (−50%); portable add-on applies when portable oxygen prescribed.
Portable add-on interactionIf both >4 LPM and portable apply, use the higher of the 50% volume adjustment or the portable add-on; do not pay both add-ons.
Contents feesContents-only fees apply when beneficiary owns stationary liquid/gaseous oxygen equipment; rules differ for owned concentrators and portable systems.
PEN pump rental period
PEN pump rental periodRental of parenteral and enteral pumps is limited to payments for a total of 15 months during a period of medical need; period ends when nutrients not medically necessary for 2 consecutive months.
No additional rental after 15 monthsDME MACs do not allow additional rental payments after the 15-month limit unless attending physician changes prescription between parenteral and enteral nutrients.
Supplier responsibilitiesSupplier collecting the last rental month (15th) is responsible for ensuring patient has pump and for maintenance/servicing during therapy duration.
Mbi
Mbi (Medicare beneficiary identifier)The Medicare beneficiary identifier (Mbi) refers to a beneficiary's Medicare identification number and references both HICN and MBI during transition and for some business areas.
Use on CMNSupplier and beneficiary identifiers including the MBI must be entered on PEN certifications and CMNs to facilitate claims development.
Operational noteMbi usage described in CMN completion instructions for PEN and other certification forms.
RB modifier
RB modifier definitionRB modifier denotes replacement of a part of a DMEPOS item furnished as part of repair; repair part claims billed with RB are paid on a lump-sum purchase basis.
Competitive bidding impactPayment for repair parts described by HCPCS in competitive bidding areas is based on the single payment amount for the HCPCS code.
Non-competitive base equipmentPayment for parts used to repair non-competitive base equipment follows 42 CFR considerations and contractor discretion.
Delivery/service charges
Delivery/service charges ruleDelivery and service costs are ordinarily included in fee schedules and are generally not separately payable except in rare/unusual circumstances; DME MACs may allow separate charges only when justified and documented.
Allowable separate charge criteriaExtraordinary delivery charges may be allowed when supplier delivers outside normal area and beneficiary lacks reasonable access to local supplier; amount based on time/distance, actual expenses, customary charges, prevailing local charges.
Documentation requirementSuppliers must fully document unusual circumstances when billing separate delivery/service charges; routine itemization may be treated as included and denied.
Mbi (duplicate reference)
Mbi (duplicate)Medicare beneficiary identifier (Mbi) describes beneficiary's Medicare identification number and may reference both HICN and MBI during transition processes.
Use on certificationsMbi required on certifications such as PEN CMNs to identify beneficiary for claims processing.
Form completion guidanceSee CMN completion instructions for proper entry and use of MBI on forms.
Upin
UPIN requirementA handwritten original attending physician signature and identification including the Unique Physician Identification Number (UPIN) must appear on PEN certifications to allow DME MAC verification of prescriber authorization.
Signature rulesStamped physician signatures are not acceptable; forms must be dated to show reasonable association to active therapy dates.
Supplier IDPEN supplier identification (name, address, phone, PEN ID) must be on each certification to facilitate claims development.
EY modifier and ordering/referring NPI
EY modifier and Ordering/Referring NPISuppliers must use modifier EY and report their own name and NPI in the Ordering/Referring Provider fields on claims for DMEPOS items dispensed without a physician's order to secure a Medicare denial for COB purposes.
Separate claims when partial ordersIf some items have physician orders and others do not, suppliers must submit separate claims for items without an order.
Effective date noteThis reporting requirement effective May 23, 2008 for claims to secure denial when no physician order is present.
Upgrade
Upgrade definitionAn upgrade is an item with features that go beyond what is medically necessary for the beneficiary and may include excess components; upgrades may be within a single HCPCS code or between codes.
ABN requirementWhen supplier expects Medicare to reduce payment for non-medically necessary upgrades, the supplier must give an ABN for beneficiary signature to hold beneficiary liable for additional expense and submit claim with GA modifier on upgraded line.
Claim submissionSuppliers must submit two claim lines: upgraded item (GA) and the reasonable/necessary item (GK), and list upgrade features in ASC X12 837 professional format or CMS-1500 Item 19/attachment.
Claim formats and standards
Claim formats acceptedAccepted claim formats include ASC X12 837 (professional and institutional), Form CMS-1500, Form CMS-1450, and NCPDP for retail pharmacy transactions to DME MACs.
NCPDP usageRetail pharmacy drug claims to DME MACs must use NCPDP standards and transmit NDCs per NCPDP implementation guidance.
Electronic supportASC X12 formats support reporting of CMNs in FRM segments where applicable.
Upgrade (duplicate)
Upgrade (duplicate)Upgrade defined as item/features beyond medical necessity; ABN must be used when charging beneficiary for upgrade difference.
Billing detailUpgraded items require GA modifier when ABN signed; features must be listed on claim or attachment.
Denial basisDenials for upgrade charges should be based on medical necessity assessments.
Excess component
Excess component definitionAn excess component is an item feature or service that is additional to, more extensive, and/or more expensive than what is reasonable and necessary under Medicare coverage rules.
Upgrade relationExcess components are elements that can make an item an upgrade and may trigger ABN requirements.
Billing impactExcess components must be identified and justified; Medicare pays based on the non-upgraded allowed amount when GL modifier used for no-charge upgrades.
Inexpensive DME (duplicate)
Inexpensive/routinely purchased DME (repeat)Category includes equipment with purchase price ≤ $150 or determined to be acquired by purchase at least 75% of the time.
Billing guidanceSuppliers bill such items to the DME MAC (or A/B MAC for implanted items); see section 130.2 for full billing instructions.
Effective rulesUpdated definitions and inclusions (e.g., speech generating devices) effective Oct 1, 2015 per policy text.
Unit
Unit definitionOne month of service equals one unit for reporting DMEPOS monthly services (e.g., stationary oxygen rentals).
Billing implicationMonthly billing should report one unit per service month; fee schedule amounts apply per unit.
Use casesApplies to oxygen monthly rentals and other monthly rental fee schedule items.
HCPCS oxygen modifiers
HCPCS oxygen modifiers summaryQE/QA indicate prescribed stationary oxygen while at rest <1 LPM (payment reduced 50%); QG/QR indicate >4 LPM (payment increased 50%); QF/QB indicate >4 LPM with portable prescribed (special add-on rules apply).
Conserving device indicatorModifier QH indicates an oxygen conserving device is being used.
HHAs revenue code mappingHHAs use revenue codes 0602 (QE), 0603 (QG/QR), 0604 (QF) when billing A/B MAC (HHH) for analogous adjustments.
QH
QH modifierModifier QH indicates that an oxygen conserving device is being used with the oxygen delivery system.
Billing noteSuppliers and HHAs must indicate use of conserving device when applicable for proper processing.
Relation to adjustmentsQH is an indicator only and does not itself adjust payment like QE/QG/QF modifiers.
BU modifier
BU modifier meaningModifier BU indicates the beneficiary has been informed of purchase and rental options and after 30 days has not informed the supplier of a decision.
Use on claimsUse BU when beneficiary did not notify supplier after being informed; affects purchase/rental processing and modifier status reporting.
Related modifiersOther purchase/rental modifiers include BP (beneficiary elected purchase), BR (elected to rent), NR, NU, RR, UE per guidance.
JK/JL modifiers
JK/JL insulin supply modifiersJK identifies one-month (or less) supply and JL identifies three-month supply of insulin administered through DME; required on claims beginning July 1, 2023.
Claims requirementClaims for insulin administered through DME without these modifiers will be returned as unprocessable.
Policy purposeModifiers ensure appropriate coinsurance and deductible handling per statutory changes effective July 1, 2023.
HIT G-codes timing
HIT G-codes timingG0068/G0069/G0070 are reported in 15-minute units for home infusion professional services and must accompany or follow associated infusion drug J-code billing within the 30-day lookback window to avoid CWF recycling/denial.
Single payment per calendar dayA single unit of payment is made for HIT services provided in the individual's home during an infusion drug administration calendar day; if multiple drugs administered, payment equals highest category.
Rounding tableProviders should report visit length in 15-minute increments and apply the specified rounding thresholds to determine units.
Lymphedema compression treatment items definition
Lymphedema treatment items definitionLymphedema compression treatment items include standard/custom daytime garments, nighttime garments, wraps with adjustable straps, accessories, compression bandaging supplies, and related items prescribed by an authorized practitioner.
Payment approachPayment is a lump-sum per item with a national Medicare allowed payment amount updated annually; supplier paid 80% of the lesser of actual charge or national allowed amount.
Quantity and replacement limitsAllowable quantity: up to 3 daytime and 2 nighttime garments per body area; replacements subject to frequency limits or for loss/theft/irreparable damage.
Infusion drug administration calendar day
Infusion drug administration calendar dayA single unit of payment is assigned per infusion drug administration calendar day for home infusion therapy; G-codes represent professional services per 15-minute unit within that calendar day.
Claim pairing requirementG-code professional service claims must be accompanied by the associated infusion drug J-code on same claim or be present in claims history within prior 30 days to avoid recycling/denial.
Unit roundingReport visit length in 15-minute increments using the rounding thresholds to determine payable units.
Automatic mailing/delivery of DMEPOS
Automatic delivery prohibitionSuppliers may not automatically mail or deliver DMEPOS supplies; beneficiary, physician, or designated representative must specifically request refills before supplier dispenses.
Supplier dutySuppliers must not initiate refills without a specific request and must contact physician for renewals when needed; DME MAC review is post-pay.
Public noticeDME MACs must publish these procedures on their websites and bulletins annually.
'From' date / Anniversary date
'From' / Anniversary date definitionThe 'from' (date of delivery) on the first claim for capped rental DME becomes the anniversary date on all subsequent monthly claims; if that 'from' date falls during an institutional stay and beneficiary was not home that date, the discharge date becomes the new anniversary date.
Billing adjustment for institutional staysWhen a covered Part A stay overlaps the anniversary date and beneficiary not in stay for whole month, supplier must submit a new claim dated to discharge as new 'from' date and annotate the claim to indicate institutional stay.
CWF behaviorCWF rejects DME claims with DOS within inpatient stays but processes claims with 'from' date equal to inpatient discharge and validates crossover based on 'from' date only.
MS modifier
'MS' modifier definitionThe 'MS' modifier identifies maintenance and servicing claims for DME and allows payment for maintenance and servicing regardless of whether the beneficiary is in an institutional setting or at home.
Use caseApply MS modifier on maintenance/servicing claims to ensure payment even during inpatient stays where DME would otherwise be non-payable.
CWF handlingCWF approves payment for maintenance and servicing claims that contain the MS modifier irrespective of institutional status.
Q-code
Q-code (home IVIG) definitionQ2052 is the HCPCS payment code for home IVIG administration visits; billed per infusion date and reported in 15-minute units.
Billing pairing requirementQ-code must be billed on same claim as the IVIG J-code or within 30 days prior; otherwise Q-code claim will recycle up to 3 times (15 business days) then be denied.
Unit reportingReport visit length in 15-minute increments (15 minutes = 1 unit) and follow rounding table for unit determination.
J-code
J-code requirement for IVIGAn IVIG product J-code must be billed on the same claim as the Q-code or be present in claims history within the prior 30 days to validate Q-code payment and avoid CWF recycling/denial.
Single unit per dateOnly one Q-code unit is payable per infusion date of service regardless of multiple administrations listed on single claim line.
Claims returned as unprocessableClaims reporting multiple visits on the same line item date of service will be returned as unprocessable.
Pre-payment auto-denial edits
Pre-payment auto-denial editsTransmittals establish pre-payment auto-denial edits for DMEPOS suppliers of oxygen and oxygen equipment in applicable states (DME MACs only).
Transmittal reportingChapter transmittals list issued guidance including pre-payment auto-denial edits and CMN claim edits workload reporting entries.
Operational effectDME MACs may implement pre-payment edits to deny claims for oxygen/equipment that fail edit criteria prior to payment.
Certificate of Medical Necessity (CMN)
Certificate of Medical Necessity (CMN)CMNs are required for certain DME/PEN items and include specified elements; CMN claim edit workload reporting transmittals are published for tracking.
CMN completion guidanceCMN must include beneficiary identifiers (Mbi), supplier info, clinical and prescription details, and original physician signature; alterations (whiting out/pasting) cause denials.
Submission change noteFor claims with DOS on/after Jan 1, 2023, providers/suppliers no longer need to submit CMNs or DIFs with claims; attached forms may cause rejection (see separate policy sections).
Policy Summary
PayerMedicare
PolicyDurable Medical Equipment, Prosthetics, Orthotics, Parenteral and Enteral Nutrition, and Supplies (DMEPOS)
Policy CodePolicy N/A
Change TypeNo material coverage changes
Effective DateJan 1, 2024
Next Review DateN/A
Key ActionDo not submit Certificates of Medical Necessity or DME Information Forms with claims for dates of service on or after Jan 1, 2023; attached forms may be rejected.
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