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    v1.0.30
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyMedStar Family Choice DME Policy Update | OpenPaye…
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    CurrentMedStar Family Choice MarylandPolicy N/A

    Durable Medical Equipment Capped Rental Private Duty Nursing Service

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    This policy governs reimbursement, billing modifiers, rental limits, repair billing, and private duty nursing unit limits for MedStar Family Choice Maryland providers. It applies to covered DME, prosthetic and orthotic repairs, and medically necessary private duty nursing services.

    Policy Summary
    PayerMedStar Family Choice Maryland
    PolicyDurable Medical Equipment Capped Rental Private Duty Nursing Service
    Policy CodePolicy N/A
    Change TypePolicy update
    Effective DateNovember 25, 2025
    Next Review DateN/A
    Key ActionDetermine whether the prescriber's estimated duration of medical necessity is at least ten months, then bill the DME item as a purchase or rental accordingly.
    SourceLink
    POLICY UPDATE CHANGES

    Prospective pre-payment reviews were updated to include additional payment edits based on Maryland Department of Health and CMS coverage policy guidance.

    DME capped-rental billing requirements were revised to specify rental-to-purchase conversion, modifier use, and monthly and ten-month rental limits.

    DME repair billing rules were revised to apply prosthesis repair unit limits and deny certain repair services billed with oxygen equipment or capped-rental equipment.

    Private duty nursing billing rules were revised to limit or adjust units based on member age and daily or weekly service volume.

    10 monthsCapped-rental purchase conversion

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    1 per monthAdditional capped rentals
    12 units/yearProsthesis repair limit
    8 units/dayPrivate duty nursing under age 21
    240 units/weekPrivate duty nursing age 21 or older

    Coverage Criteria

    DME Capped-Rental Coverage and Billing Criteria

    Covered DME capped-rental items are subject to the following purchase, rental, modifier, and billing-limit requirements:

    ALL of the following

    • Equipment eligibility and rental-versus-purchase classification

      • The item is covered Durable Medical Equipment (DME) for which Medicare has established a purchase price.
      • The provider determines whether the item is purchased or rented based on the prescriber's best-faith estimate of the member's duration of medical necessity.
      • When medical necessity is expected to last ten (10) or more months, the provider charges for purchase.
      • When medical necessity is expected to last less than ten (10) months, the provider charges monthly rental for the duration of medical necessity.
      • After ten (10) monthly rental payments, the item is considered purchased.
      • If the item remains medically necessary after ten (10) months and is purchasable, the tenth rental payment is the final rental payment and the item is considered purchased.

    • Billing modifiers and rental limits

      • New equipment must be billed with modifier NU (New Equipment) or UE (Used Durable Medical Equipment); claims for new or used DME without NU or UE, or with the modifier field blank, will be denied.
      • Modifier RR must be used to indicate that a DME item is being rented rather than purchased and is typically billed monthly.
      • When billing each DME capped-rental code, the provider must use the appropriate modifier and report units accurately per month and across months without exceeding allowed limits.
      • Additional capped rentals are limited to one (1) per month and ten (10) per ten-month period.
      • When modifier RR is billed with LT or RT and units exceed the allowed maximum during a ten (10)-calendar-month period, the additional units will be denied.
      • An additional rental rate in the same calendar month is allowed when modifier RR with RT and LT is billed for the same HCPCS code on separate lines.

    • Purchase and rental billing exclusions

      • The same code must not be billed with both rental and new-purchase modifiers within the restricted timeframe.
      • A claim billed with modifier RR is denied as previously purchased when the same code was previously billed with modifier NU or UE on the same date of service or within the previous ten (10) calendar months.

    DME and Prosthesis Repair Criteria

    DME and prosthesis repair services are subject to the following coverage and billing criteria:

    ALL of the following

    • Prosthesis repair is limited to twelve (12) units per calendar year, with one (1) unit equal to fifteen (15) minutes, as indicated on the MDH DME/DMS fee schedule.<= 12 units per calendar year
    • The annual limitation reflects the expected frequency of prosthetic repairs under normal wear and use conditions.
    • Routine maintenance and repairs typically do not require labor charges exceeding one (1) unit (15 minutes) per year unless unusual circumstances exist, such as extensive damage, complex fittings, or acute changes in the member's medical condition affecting prosthesis use.
    • Repair or non-routine service codes for non-oxygen DME are denied when billed with oxygen equipment codes.

    Private Duty Nursing Criteria

    Private duty nursing is covered when medically necessary and subject to member-age, licensure, and unit limits:

    Members under age 21

    • The member is under twenty-one (21) years of age.
    • The nursing service is medically necessary for the member to benefit from educational or early intervention services.
    • The service is performed by a licensed nurse: a registered nurse (RN) or licensed practical nurse (LPN).
    • For private duty nursing services provided by an RN or LPN, billed units greater than eight (8) in a day will be adjusted.<= 8 units per day

    Shift nursing services for members age 21 or older

    Coding and Billing Limits

    DME equipment and rental modifiersModifierCovered
    NUNew equipment modifier
    UEUsed durable medical equipment modifier
    RRRental modifier for DME billed as a rental arrangement
    LTLeft-side modifier used with rental billing when applicable
    RTRight-side modifier used with rental billing when applicable
    Repair HCPCS codes with capped-rental incompatibilityHCPCSNot Covered
    K0739DME repair HCPCS code subject to denial when billed with a DME code containing modifier RR
    L4205DME repair HCPCS code subject to denial when billed with a DME code containing modifier RR
    L7520DME repair HCPCS code subject to denial when billed with a DME code containing modifier RR
    Capped-Rental Purchase Conversion
    Rental-to-purchase conversionAfter 10 monthly rental payments, the DME item is considered purchased.
    Final rental paymentThe 10th rental payment is final when the item remains medically necessary and purchasable.
    Payment basisThe conversion applies to covered DME items for which Medicare has established a purchase price.
    Additional Capped Rentals
    Monthly limitAdditional capped-rental billing is limited to 1 rental per month.
    Ten-month limitAdditional capped-rental billing is limited to 10 rentals per 10 calendar months.

    Provider Billing Actions

    Billing Rule

    Determine Rental Versus Purchase

    Use the prescriber's best-faith estimate of the member's expected duration of medical necessity to determine whether to bill the covered DME item as a purchase or rental.

    • Ten months or more: bill for purchase.
    • Less than ten months: bill rental for the duration of medical necessity.
    • After ten monthly rental payments, a purchasable item is considered purchased; the tenth rental payment is the final rental payment.
    Billing Rule

    Apply Required DME Modifiers

    Apply the modifier that accurately identifies the DME status on every applicable claim. Required modifier fields must not be left blank.

    • NU: new equipment.

    Key Definitions

    Durable Medical Equipment Capped Rental
    Covered equipmentCapped rental applies to covered durable medical equipment items.
    Established priceThe equipment must be an item for which Medicare has established a purchase price.
    Reimbursement methodThe item is reimbursed as a monthly rental until the capped-rental purchase rules are met.
    Duration of Medical Necessity
    Determining factorThe prescriber’s best-faith estimate of how long the member will medically need the DME determines whether it is billed as a purchase or rental.
    Purchase billingWhen the estimated duration is 10 months or more, the provider charges for a purchase.
    Policy Summary
    PayerMedStar Family Choice Maryland
    PolicyDurable Medical Equipment Capped Rental Private Duty Nursing Service
    Policy CodePolicy N/A
    Change TypePolicy update
    Effective DateNovember 25, 2025
    Next Review DateN/A
    Key ActionDetermine whether the prescriber's estimated duration of medical necessity is at least ten months, then bill the DME item as a purchase or rental accordingly.
    SourceLink
    On This Page
    Coverage CriteriaCoding and Billing LimitsProvider Billing ActionsKey Definitions
    Repair HCPCS codes K0739, L4205, or L7520 are denied when billed with any DME HCPCS code with modifier RR.
    The member is twenty-one (21) years of age or older.
  1. Billed shift nursing services do not exceed 240 units in a week.<= 240 units per week
  2. Units exceeding 240 in a week will be denied for exceeding the maximum allowed units.
    3. Excess unitsWhen RR is billed with LT or RT, units above the allowed maximum during a 10-calendar-month period deny.
    Prosthesis Repair Limit
    Annual limitProsthesis repair is limited to 12 units per calendar year.
    Unit durationEach repair unit equals 15 minutes.
    ReferenceThe limitation is indicated on the Maryland Department of Health DME/DMS fee schedule.
    Routine Prosthesis Repair Labor
    Routine repair expectationRoutine maintenance and repairs typically do not require labor charges exceeding 1 unit per year.
    Unit durationOne unit equals 15 minutes.
    ExceptionsAdditional labor may be appropriate in unusual circumstances, including extensive damage, complex fittings, or acute changes in the member’s medical condition affecting prosthesis use.
    Private Duty Nursing Under Age 21
    Age requirementThe adjustment applies when the member is under age 21.
    Daily thresholdPrivate duty nursing units greater than 8 in a day are adjusted.
    Qualified servicesThe services must be medically necessary and performed by a licensed RN or LPN.
    Private Duty Nursing Age 21 or Older
    Age requirementThe denial applies when the member is age 21 or older.
    Weekly thresholdPrivate duty or shift nursing units greater than 240 in a week are denied.
    Denial basisUnits above 240 are denied for exceeding the maximum allowed units.
  3. UE: used durable medical equipment.
  4. RR: equipment being rented, typically billed monthly.
  5. Claims for new or used DME billed without NU or UE will be denied.
    6. Denial Risk

    Observe Capped-Rental Unit Limits

    Observe the capped-rental limits when billing modifier RR, including applicable LT or RT combinations. Units exceeding the allowed limits will deny.

    • Allow one additional capped rental per month.
    • Allow no more than ten rentals in a ten-month period.
    • For RR billed with LT or RT, additional units beyond the allowed maximum in a ten-calendar-month period will deny.
    • An additional rental rate in the same calendar month is allowed when RR with RT and LT is billed on separate lines for the same HCPCS code.

    Unsupported block type: denial_risk stateresponse?

    Denial Risk

    Avoid Incompatible DME Repair Billing

    Do not combine prohibited DME repair or non-routine service billing with incompatible equipment or rental claims.

    • Repair HCPCS codes K0739, L4205, and L7520 billed with any DME HCPCS code carrying modifier RR will be denied.
    • Repair or non-routine service codes for non-oxygen DME billed with oxygen equipment codes will be denied.
    Billing Rule

    Bill Private Duty Nursing for Members Under 21

    For members under age 21, private duty nursing must be medically necessary to enable the member to benefit from educational or early intervention services and must be provided by a licensed RN or LPN.

    • When RN or LPN private duty nursing exceeds eight units in a day for a member under 21, billed units will be adjusted.
    Denial Risk

    Observe Adult Private Duty Nursing Limits

    For members age 21 or older, shift nursing units exceeding the weekly maximum will be denied.

    • Units above 240 per week are denied for exceeding the maximum when the member is age 21 or older.
    Rental billingWhen the estimated duration is less than 10 months, the provider charges rental for the duration of medical necessity.
    RR Rental Modifier
    ModifierRR indicates that DME is being rented rather than purchased.
    Billing purposeThe modifier identifies the rental arrangement for correct reimbursement.
    Billing frequencyDME billed with RR is generally billed monthly.
    Private Duty Nursing Under Age 21
    Member ageThe service applies to members under age 21.
    Medical necessityNursing must be medically necessary for the member to benefit from educational or early intervention services.
    Qualified personnelThe service must be performed by a licensed registered nurse (RN) or licensed practical nurse (LPN).