Currentpriority healthPolicy 017

Miscellaneous Durable Medical Equipment (DME) billing and payment rules

Governs payment, coding, documentation, and allowable accessory/part billing for miscellaneous DME items for Priority Health commercial and Medicaid lines where specified.

Policy Summary

Payerpriority health

PolicyMiscellaneous Durable Medical Equipment (DME) billing and payment rules

Policy CodePolicy 017

Change TypeNo material change

Effective DateAug 1, 2024

Next Review Date

Key ActionSubmit documentation meeting CMS standard documentation requirements (see CMS Article A55426) with DME claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

up to 2wheelchair batteries allowed

150/6moalkaline hearing aid batteries

2/yrlithium hearing aid batteries

E0172 non-coveredtoilet seat lift

calendar-month spanrental billing rule

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DME coverage rules and limits

Item-specific coverage, bundling, and denial rules:

ALL of the following

Up to two batteries with codes E2359, E2361, E2363, E2365, E2371 or K0733 are allowed at any one time.
Non-sealed batteries with codes E2358, E2360, E2362, E2364 or E2372 will be denied.

ALL of the following

A single mode battery charger (E2366) is appropriate for charging a sealed lead acid battery.
A dual mode battery charger (E2367) provided as a replacement will be denied as not reasonable and necessary.

ALL of the following

Miscellaneous options, accessories or replacement parts for wheelchairs without a specific HCPCS code and not included in another code should be coded K0108.
Supporting documentation must be submitted with unlisted codes.

ALL of the following

Right (RT) and left (LT) modifiers must be used when applicable.
Column II codes are included in the allowance for the corresponding Column I code when provided at the same time and must not be billed separately.

ALL of the following

A powered seat cushion (E2610) is denied as not proven effective.
Pediatric seating system codes (E2291–E2294) may only be billed with pediatric wheelchair base codes.
A manual swing-away (E1028) should not be reported in addition to E0955, E0956 or E0960 for mounting hardware.

ALL of the following

An enclosed frame walker (E0144) is not medically necessary and will be denied.
Brakes provided with a walker are not separately payable; replacement brakes billed with E0159 for replacement only.
Column II codes are included in the allowance for the corresponding Column I code and must not be billed separately when provided at the same time.

ALL of the following

When mattress or bedside rails are provided at the same time as a hospital bed, use the single code that combines these items.

ALL of the following

Eligibility: member must have severe arthritis of the hip or knee, or a severe neuromuscular disease; the mechanism must be part of treating practitioner’s course of treatment and prescribed to improve or prevent deterioration.
Functional criteria: member must be completely incapable of standing up from any chair at home but able to ambulate once standing.
Ordering practitioner must document that all other therapeutic modalities have been tried and failed; the lift must operate smoothly and be controlled by the beneficiary (exclude spring-release mechanisms with sudden jolting motion).
A seat lift mechanism placed over or on top of a toilet (any type, E0172) is non-covered.
Electrically operated seat lift billed with E0627; manually operated seat lift billed with E0629.

ALL of the following

Commodes with a seat lift mechanism (E0170, E0171) are free-standing devices with an integrated seat and commode pan; toilet seat lifts attached to the toilet are coded E0172 (non-covered).
Raised toilet seat (E0244), bidets (A9270), and extra wide/heavy-duty commode chairs (E0168) are defined and coded as specified.
Column II codes are included in the allowance for corresponding Column I codes when provided at the same time and must not be billed separately.

ALL of the following

Specified frequency limits and per-device frequency allowances apply to hearing aid and cochlear implant components and accessories; see coding thresholds for per-device limits.
Authorization rules may apply to hearing aid and cochlear implant supplies; anatomical modifiers required for side.

ALL of the following

Applies to Commercial (except cochlear implant limits subject to Hearing Rider) and Medicaid (limits follow MDHHS).
Refer to separate DME place-of-service billing policy for POS billing requirements.

ALL of the following

Column II inclusion examples are provided across device types; Column II codes are included in the allowance for corresponding Column I codes when provided at the same time (must not be billed separately).

DME billing & frequency rules

Billing and reimbursement requirements and limits applicable when DME is covered by member benefits:

Modifier requirement: KX modifier must be appended to indicate policy criteria have been met for all wheelchair DME items and hospital bed DME items; applicable claims reported without KX will be denied (Commercial, Medicaid).

Additional modifier guidance: Per CMS local coverage determinations, one of KX, GA, GY, or GZ is required for claim processing of wheelchair DME items; see Provider Manual for details.

Rental billing span: Capped rental devices must be billed with a 'from' and 'to' date span that encompasses the month being billed; overlapping dates of service will result in denial. Supplies billed for a date span must follow the same 'From'/'To' guidelines. A calendar month is from a day of one month to the corresponding day of the next month.

Bilateral reimbursement: To receive separate reimbursement for bilateral items, appropriate laterality modifiers (RT, LT) must be used on separate lines for the same HCPCS code; up to one unit per side with a maximum of two rental rates within the same calendar month.

HCPCS / modifier / code-specific guidance

Wheelchair batteriesHCPCSCovered

E2359	Sealed or other battery (allowed up to two)
E2361	Battery (allowed up to two)
E2363	Battery (allowed up to two)
E2365	Battery (allowed up to two)
E2371	Battery (allowed up to two)
K0733	Battery (allowed up to two)
E2358	Non-sealed battery (will be denied)

Wheelchair seating coding notesHCPCSNot Covered

E2610	Powered seat cushion (denied/not proven effective)
E1028	Manual swing-away mounting hardware (coding guidance)

WalkersHCPCSNot Covered

E0144	Enclosed frame walker (not medically necessary — denied)
E0159	Brake attachment for wheeled walker (replacement only)

Hearing aid batteries and limitsCPTCovered

L8622	Alkaline battery — 150 per 6 months per device
L8621	Zinc air battery — 150 per 6 months per device
L8623	Lithium ion battery — 2 per year per device
L8624	Lithium ion battery variant — 2 per year per device
V5266	Disposable battery — 72 per day up to 144 per year per aid

Commode and toilet-seat related HCPCSHCPCS

E0170	Commodes with seat lift mechanism (free standing)
E0171	Commodes with seat lift mechanism (free standing)
E0172	Toilet seat lift mechanism (attached to toilet)
E0244	Raised toilet seat
A9270	Bidets or bidet-incorporated toilet seats
E0168	Extra wide/heavy-duty commode chairs (>=23 inches, >=300 lbs)

HCPCS modifiers required/usedModifier

KX	Indicates policy criteria met for wheelchair and hospital bed DME items
GA	Waiver of liability statement on file
GY	Item statutorily non-covered
GZ	Item expected to be denied as not reasonable/necessary

inv-09: Battery - Alkaline (L8622) — 150 per 6 months per device.

CodeL8622

Limit150 per 6 months (per device)

NotesApplies to hearing aid/cochlear implant supplies; anatomical modifiers required where applicable.

inv-10: Battery - Zinc Air (L8621) — 150 per 6 months per device.

CodeL8621

Limit150 per 6 months (per device)

NotesApplies to hearing aid/cochlear implant supplies; anatomical modifiers required where applicable.

inv-11: Battery - Lithium Ion (L8623/L8624) — 2 per year per device.

CodesL8623, L8624

Limit2 per year (per device)

NotesApplies to hearing aid/cochlear implant supplies; anatomical modifiers required where applicable.

inv-12: Disposable Battery (V5266) — 72 per day up to 144 per year per aid.

CodeV5266

Limit72 per day (per aid), up to 144 per year (per aid)

NotesDisposable battery limits apply to hearing aids; counts are per aid per day/year.

inv-13: Rental and billing span — capped rental devices billed with a date span covering the calendar month; overlapping dates of service will be denied.

PolicyCapped rental devices must be billed with a 'from' and 'to' date span that encompasses the month being billed.

Denial RiskClaims with overlapping dates of service will be denied.

Bilateral ItemsTo receive separate reimbursement for bilateral items, use appropriate laterality modifiers (RT, LT) on separate lines; up to one unit per side with maximum two rental rates within the same calendar month.

What providers must do

Documentation Required

Documentation requirement — submit CMS-standard documentation

We align with the Centers for Medicare & Medicaid Services (CMS) standard documentation requirements for supplies and DME. Submit documentation meeting CMS standard documentation requirements for DME claims (see CMS Article A55426).

Billing Rule

Hearing device limits and possible authorization

Below are specified limits that Priority Health will apply to supplies, parts and replacement parts for hearing aids and cochlear implants. Authorization rules may apply. Anatomical modifiers to describe specific side of the body will be required.

Battery - Alkaline (CPT L8622): Maximum limit = 150 per 6 months (per device).
Battery - Zinc Air (CPT L8621): Maximum limit = 150 per 6 months (per device).
Battery - Lithium Ion (CPT L8623/L8624): Maximum limit = 2 per year (per device).
Battery Charger (CPT L8625): Maximum limit = 1 per 2 years (per device).
External Controller (CPT L8628): Maximum limit = 1 per 4 years (per device).
Sound/Speech Processor (CPT L8627): Maximum limit = 1 per 4 years (per device).
Speech Processor and Controller- Integrated (CPT L8619): Maximum limit = 1 per 4 years (per device).
Microphone (CPT L8616): Maximum limit = 1 per year (per device).
Headpiece/Headset (CPT L8615): Maximum limit = 1 per 3 years (per device).
Transmitter Cable (CPT L8618): Maximum limit = 1 per year (per device).
Transmitter Coil (CPT L8617): Maximum limit = 1 per 3 years (per device).
Transmitting Coil and Cable - Integrated (CPT L8629): Maximum limit = 1 per 3 years (per device).
Disposable Battery (CPT V5266): Maximum limit = 72 per day (per aid) up to 144 per year (per aid).
Auditory osseointegrated device, external sound processor, excludes transducer/actuator, replacement only, each (L8691): 1 per 4 years.
Auditory osseointegrated device, external sound processor, used without osseointegration, body worn, includes headband or other means of external attachment (L8692): 1 per 4 years.

Note

Place of service reference — review DME POS billing policy

Review specific information regarding DME place of service billing requirements in Priority Health's Durable Medical Equipment (DME) place of service (POS) billing policy before submitting claims.

Definitions and item notes

inv-17: Documentation requirements — standard documentation requirements for DME claims follow CMS Article A55426 and DME MAC guidance.

StandardDocumentation must meet CMS standard documentation requirements for DME MACs (CMS Article A55426).

ClaimsSubmit documentation supporting medical necessity, item furnished, and dates of service with DME claims.

GuidanceFollow DME MAC guidance and provider manual instructions for required supporting records.

inv-18: Miscellaneous DME policy — payment and documentation rules for various durable medical equipment items.

ScopePolicy identifies payment and documentation requirements for various durable medical equipment items.

Column II RuleColumn II codes are included in the allowance for the corresponding Column I code when provided at the same time.

Frequency LimitsUsual maximum quantities and frequencies are specified per HCPCS/K code; see listed code-specific limits (examples provided).

inv-19: Commodes (E0170, E0171) — commodes with a seat lift mechanism.

CodesE0170, E0171

DescriptionCommodes with a seat lift mechanism: free-standing commode pan with integrated seat that can be raised, may include forward tilt.

NotesColumn II codes may be included in allowance when provided at same time (see policy examples).

inv-20: Toilet seat lift (E0172) — toilet seat lift mechanism attached to the toilet.

CodeE0172

DescriptionToilet seat lift mechanism attached to the toilet; seat can be raised with or without forward tilt and may be manual or electric.

Coverage NoteToilet-top seat lifts (E0172) may be non-covered in some eligibility scenarios; review seat lift eligibility criteria in policy.

inv-21: Raised toilet seat (E0244) — raised toilet seat that increases toilet seat height, fixed or adjustable.

CodeE0244

DescriptionRaised toilet seat that increases toilet seat height; fixed or adjustable, can be attached or rest on the bowl.

UseProvides added height only; distinct from seat lift mechanisms which raise and may tilt.

inv-22: Bidet (A9270) — bidets or bidet-incorporated toilet seats and similar cleansing devices.

CodeA9270

DescriptionBidets or bidet-incorporated toilet seats and similar cleansing devices.

NotesCoded as A9270 for bidet-type cleansing devices; consider Column II inclusion rules when provided with related commode items.

OpenPayer

Miscellaneous Durable Medical Equipment (DME) billing and payment rules

Coverage rules and limits

HCPCS / modifier / code-specific guidance

What providers must do

Definitions and item notes