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    v1.0.30
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyMedStar Family Choice DME Policy Update | OpenPaye…
    Ask Trek AI about this page
    CurrentMedStar Family Choice MarylandPolicy N/A

    Durable Medical Equipment and Supplies Reimbursement Policy

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    This policy governs prospective payment review and billing requirements for durable medical equipment, orthotics, prosthetics, and supplies billed by providers to MedStar Family Choice Maryland, including Maryland Medicaid medically unlikely edits, required modifiers, and National Correct Coding Initiative edits.

    Policy Summary
    PayerMedStar Family Choice Maryland
    PolicyDurable Medical Equipment and Supplies Reimbursement Policy
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateAugust 26, 2025
    Next Review DateN/A
    Key ActionUse the Maryland Department of Health Durable Medical Equipment and Supplies Medicaid Medically Unlikely Edits to determine the allowable quantity for each covered item and whether billing should use a single date of service or a date span.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    ProspectivePayment review type
    MDH MUEQuantity-limit standard
    Claim line deniedOutcome when MUE is exceeded
    AU, AV, AW

    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.

    Required tape modifiers
    Same provider, member, dateNCCI edit criteria

    Payment Review and Coverage Criteria

    MDH MUE and date-span requirements

    A DME claim must comply with the applicable Maryland Medicaid MUE and required date-of-service format.

    ALL of the following

    • Billed DME units do not exceed the applicable Maryland Department of Health (MDH) MUE for the item on a single date of service.

      If units exceed the applicable MUE, the claim line will be denied; this requirement applies exclusively to DME providers.

    • When billing a date span, the span does not include future dates of service.

      The MDH MUE determines whether billing should use a single date of service or a date span.

    Tape modifier requirement

    Waterproof and non-waterproof tape supplies must include the modifier applicable to the type of supply.

    ALL of the following

    • The billed supply is applicable urological, ostomy, tracheostomy, prosthetic, orthotic, or surgical dressing tape or another applicable tape supply.
    • The claim includes the applicable modifier: AU, AV, or AW.

      If the required modifier is not included, the claim will deny.

    NCCI code-pair reimbursement rules

    Code pairs billed by the same provider for the same member on the same date are subject to NCCI correct-coding edits.

    ALL of the following

    • The code pair is billed by the same provider for the same member on the same date of service.

    • ONE of

      • The code pair is separately reimbursable under correct-coding principles.
      • An appropriate clinical circumstance supports use of an NCCI bypass modifier.

        Modifiers that may be used when appropriate include E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI, 24, 25, 57, 58, 78, 79, 27, 59, 91, XE, XS, XP, and XU.

    Coding and Modifier Requirements

    Covered CPT CodesModifierCovered
    AUModifier for specified urological supplies
    AVModifier for specified ostomy supplies
    AWModifier for specified other applicable supplies, including tracheostomy, prosthetic, orthotic, or surgical dressing supplies as applicable
    NCCI Edit Bypass ModifiersModifier
    E1-E4Anatomic modifiers
    FAAnatomic modifier
    F1-F9Anatomic modifiers
    TAAnatomic modifier
    T1-T9Anatomic modifiers
    LTAnatomic modifier
    RTAnatomic modifier
    LCAnatomic modifier
    LDAnatomic modifier
    RCAnatomic modifier
    1–10 of 25
    1/3
    MDH MUE Quantity Limit
    Applicable standardMaryland Department of Health Medicaid Medically Unlikely Edit (MDH MUE)
    Quantity requirementDo not exceed the applicable MDH MUE for the billed DME item on a single date of service.
    Exceeding the limitThe claim line will be denied when DME units exceed the applicable MDH MUE.
    NCCI Edit Matching Conditions
    Code relationshipThe billed services must be evaluated as a code pair.
    ProviderThe code pair is billed by the same provider.

    Provider Billing Actions

    Denial Risk

    Apply MDH MUE quantity limits

    Use the Maryland Department of Health Durable Medical Equipment and Supplies Medicaid Medically Unlikely Edits (MUE) to determine the allowable quantity for each covered item and whether billing requires a single date of service or a date span. If billed units exceed the applicable MDH MUE for a single date of service, the claim line will be denied.

    Billing Rule

    Avoid future dates in date spans

    Do not submit future dates of service when billing a date span for durable medical equipment and supplies. Follow the applicable MDH MUE to determine whether the item should be billed with a single date of service or a date span.

    Key Definitions

    Maryland Medicaid DME MUE
    DefinitionMedically Unlikely Edits are quantity limits used by Maryland Medicaid for covered DMEPOS items.
    PurposeThey limit the frequency with which DMEPOS items are dispensed to an eligible member.
    Billing useProviders use the applicable MDH MUE to determine the allowable quantity for each covered item and whether billing requires a single date of service or a date span.
    Excess unitsA DME claim line is denied when billed units exceed the MDH MUE for a single date of service.
    NCCI Manual Policy
    What NCCI edits evaluateNCCI edits evaluate code pairs billed by the same provider on the same day for the same member.
    Policy Summary
    PayerMedStar Family Choice Maryland
    PolicyDurable Medical Equipment and Supplies Reimbursement Policy
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateAugust 26, 2025
    Next Review DateN/A
    Key ActionUse the Maryland Department of Health Durable Medical Equipment and Supplies Medicaid Medically Unlikely Edits to determine the allowable quantity for each covered item and whether billing should use a single date of service or a date span.
    SourceLink
    On This Page
    Payment Review and Coverage CriteriaCoding and Modifier RequirementsProvider Billing ActionsKey Definitions
    MemberThe code pair is billed for the same member.
    Date of serviceThe code pair is billed on the same date of service.
    Denial Risk

    Use required tape modifiers

    Bill waterproof and non-waterproof tapes with the modifier applicable to the type of supply. If the required modifier is not included, the claim will deny.

    • AU: specified urological supplies
    • AV: specified ostomy supplies
    • AW: other applicable supplies, including tracheostomy, prosthetic, orthotic, or surgical dressing supplies
    Denial Risk

    Apply NCCI bypass modifiers only when appropriate

    Use an appropriate NCCI modifier only when supported by the clinical circumstances to bypass an NCCI procedure-to-procedure edit. When codes are submitted for the same date of service, same member, and same provider, one code may be denied as not separately reimbursable under correct coding principles.

    • Anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI
    • Global surgery modifiers: 24, 25, 57, 58, 78, 79
    • Other modifiers: 27, 59, 91, XE, XS, XP, XU
    Correct-coding guidanceThe NCCI Manual includes combinations of correct-coding edits not present in the NCCI procedure-to-procedure column 1 and column 2 edits.
    Separate reimbursementOne of the codes may be denied as not separately reimbursable when the codes are submitted under these matching conditions.
    Bypass standardAn NCCI procedure-to-procedure edit may be bypassed only with an appropriate modifier supported by the clinical circumstances.