CurrentUnitedHealthcarePolicy 2025R9012A

UnitedHealthcare Medicare Advantage reimbursement for DME, Prosthetics, Orthotics billed on CMS-1500

Governs UnitedHealthcare Medicare Advantage reimbursement rules for Durable Medical Equipment (DME), prosthetics, orthotics and related supplies billed on the CMS-1500 (1500) form, affecting network physicians, qualified health care professionals, and DME/PO suppliers.

Policy Summary

PayerUnitedHealthcare

PolicyCMS 1500 reimbursement for DME, Prosthetics, Orthotics

Policy CodePolicy 2025R9012A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionReport monthly rentals as a single claim line per Calendar Month with one unit and a single date span; use appropriate rental/purchase modifiers and indicate new or used for purchases.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1/monthMonthly rental frequency rule

6 monthsMaintenance/service frequency

E0935Daily rental example

KXSecond ventilator allowance

5 POSFacility POS not allowed

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DME/PO CMS-1500 Coverage Criteria

DME/PO CMS-1500 coverage criteria

Covered when ALL of the following apply:

Applies to all Medicare Advantage products and services reported on the CMS-1500 (1500) form or electronic equivalent, and to network physicians, other qualified health care professionals, and DME/PO vendors.

DME, prosthetics, orthotics and related supplies are assigned to CMS DMEPOS payment classes (e.g., inexpensive/routinely purchased; frequently serviced; customized; prosthetic/orthotic; capped rental; oxygen/equipment) and CMS determines the category for each HCPCS code.

Claims must specify rental versus purchase status; purchased items must indicate new or used. Appropriate rental or purchase modifiers must be reported for the claim to be considered for reimbursement.

Monthly capped rental items (reported with rental modifiers RR, KH, KI, KJ, KR or as otherwise identified) are reimbursed once per Calendar Month to the Same Specialty Physician or Other Qualified Health Care Professional; capped rental rules and cap-to-purchase transfer apply as described by CMS.

Daily rental exception: Certain items (example: HCPCS E0935) are reimbursed on a daily rental basis consistent with CMS guidelines.

A second ventilator may be allowed in the same Calendar Month when clinically necessary; one additional rental rate will be allowed when reported with modifier KX appended to HCPCS E0465 or E0466.

Maintenance and service are reimbursable only when billed with modifier MS on a separate claim line, limited to once every six months, and do not apply to orthotics or prosthetics.

Reimbursement is limited to items intended for use in a qualifying home Place of Service (POS) codes; devices dispensed for use in a POS other than the patient's home are not reimbursable.

Purchased DME, orthotics and prosthetics reported on a CMS-1500 by a physician or qualified health care professional in facility POS 19, 21, 22, 23 or 24 are not eligible for separate reimbursement when reported with no modifier or with purchase modifiers NU, UE, NR, KM, or KN.

DME/Orthotics/Prosthetics CMS-1500 billing criteria

Billing and coverage rules (UnitedHealthcare Medicare Advantage):

Purchased DME, orthotics, and prosthetics reported by a physician or other qualified health care professional on a CMS-1500 in facility POS 19, 21, 22, 23 or 24 will not be allowed separate reimbursement when reported with no modifier or with purchase modifiers NU, UE, NR, KM, or KN.

Monthly rental must be reported as a single claim line with one unit and a single Calendar Month date span; rental charges for multiple months must be billed on separate claim lines. If two claims show From dates in the same Calendar Month for the same item from the Same Specialty Physician or Other Qualified Health Care Professional, only one claim will be allowed.

UnitedHealthcare Medicare Advantage pays a single full Calendar Month rental rate and does not prorate for partial-month use (modifier KR does not trigger proration); exceptions are items designated for daily rental.

DME items not suitable for home use (for example certain implantable devices) are not reimbursed with a home POS and are not considered eligible for home-use DME reimbursement.

Coding, Modifiers, and Pricing Sources

Rental and purchase modifiersModifier

RR	Rental modifier
KH	Rental modifier
KI	Rental modifier
KJ	Rental modifier
KR	Rental modifier
NU	Purchased, new
UE	Purchased, used
NR	Purchased modifier
KM	Purchased modifier
KN	Purchased modifier

Repair/replacement/maintenance modifiersModifier

MS	Maintenance/service fee modifier
RB	Replacement part for repair (beneficiary owned DME)
RA	Replacement due to loss, irreparable damage, or theft

Example HCPCS referencedHCPCS

KX	Requirement met modifier (used here to allow second ventilator)
E0465	Ventilator HCPCS example
E0466	Ventilator HCPCS example
E0935	Item reimbursed on a daily rental basis

Pricing and code sourcemixed

DMEPOS Fee Schedule

Use DMEPOS Fee Schedule for pricing and coding guidance

Purchase modifiers not allowed for separate reimbursement in facility POSModifierNot Covered

NU	New equipment purchase modifier
UE	Used durable medical equipment
NR	Not rented modifier
KM	Clinical trial modifier (listed as purchase modifier in policy)
KN	Unassigned/other purchase modifier (listed in policy)

Monthly Reimbursement Limit

Monthly reimbursement limitOne monthly rate reimbursed once per Calendar Month per code/vendor; exceptions for RT/LT modifiers (allowing additional rate for separate sides) and authorized second ventilator with KX for E0465/E0466.

ScopeApplies to the Same Specialty Physician or Other Qualified Health Care Professional — one monthly rental reimbursement to the same provider per Calendar Month.

Rental modifier requirementItem must be reported with a rental modifier (e.g., RR, KH, KI, KJ, KR) to be considered for monthly rental reimbursement.

Aggregate vendor limitTotal reimbursement from a single vendor for a single code limited to either purchase price or maximum rental months, whichever is less (rental limits exclude oxygen and ventilators).

Billing and Provider Action Requirements

Billing Rule

Report rental/purchase and item condition — claims must specify rental vs purchase and indicate new or used for purchased equipment; use appropriate rental/purchase modifiers

Some DME items are eligible for rental as well as for purchase. Claims must specify whether equipment is rented or purchased. For purchased equipment, the itemized bill or claim must also indicate whether equipment is new or used. The codes must be reported with the appropriate rental or purchase modifier in order to be considered for reimbursement. Some DME items are eligible for rental only; those codes must be reported with the appropriate rental modifier.

Report rental vs purchase on claims.
For purchased equipment indicate new (NU/UE) or used (used modifier) on itemized bill or claim.
Use appropriate rental (e.g., RR, KH, KI, KJ, KR) or purchase (e.g., NU, UE, NR, KM, KN) modifiers.

Billing Rule

Monthly rental limits and modifier use — only one monthly rental reimbursement per calendar month per code/vendor, except RT/LT exceptions and second ventilator allowance

Definitions and Payment Classes

DMEPOS Payment Classes

Payment classes overviewDMEPOS are categorized into payment classes: Inexpensive/routinely purchased; Frequently serviced; Customized items; Prosthetic/Orthotic devices; Capped rental items; Oxygen and oxygen equipment.

CMS roleCMS determines the payment class that applies to each HCPCS code and issues instructions for changes.

Class codes examplesExamples of class codes in policy: IN (Inexpensive), FS (Frequently Serviced), CR (Capped Rental), OX (Oxygen), PO (Prosthetics/Orthotics), SU (Supplies), TE (TENS).

Rental vs Purchase Reporting

Reporting requirementItems must be reported with an appropriate rental or purchase modifier to be considered for reimbursement.

Purchased equipment conditionFor purchased equipment, claims must indicate whether the equipment is new or used on the itemized bill or claim.

Policy Summary

PayerUnitedHealthcare

PolicyCMS 1500 reimbursement for DME, Prosthetics, Orthotics

Policy CodePolicy 2025R9012A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionReport monthly rentals as a single claim line per Calendar Month with one unit and a single date span; use appropriate rental/purchase modifiers and indicate new or used for purchases.

SourceLink

On This Page

For coding and pricing guidance, refer to the DMEPOS Fee Schedule and applicable CMS/CGS manuals.

Maintenance/Service Frequency

Maintenance frequencyMaintenance and service reimbursed once every six months to the Same Specialty Physician or Other Qualified Health Care Professional.

Modifier requiredReport maintenance with HCPCS code appended with modifier MS to identify maintenance/service fees.

Separate line requirementMS modifier must be reported on a separate claim line to be considered for separate reimbursement from rental or purchase.

ExclusionsMaintenance and service reimbursement does not apply to Orthotics or Prosthetics.

Monthly Rental Claim Frequency

Monthly rental claim frequencyOne claim allowed per Calendar Month per Same Specialty Physician or Other Qualified Health Care Professional for the same item; duplicate From dates in the same month will result in only one allowed claim.

Single-line reportingReport monthly rental as a single claim line with one unit and a single Calendar Month date span (From and To fields for that month).

Multiple monthsRental charges for multiple months must be billed on separate claim lines, each with a different month span.

Monthly capped rental of DME, Orthotics, or Prosthetics identified by the applicable code with a rental modifier (RR and/or KH, KI, KJ, KR) will be reimbursed once per Calendar Month to the Same Specialty Physician or Other Qualified Health Care Professional. An additional monthly rental reimbursement may be allowed in the same Calendar Month only when RT and LT modifiers are submitted on separate lines for the same HCPCS code. If units >1 or multiple lines for the same code are submitted in the same Calendar Month, UnitedHealthcare Medicare Advantage will reimburse only one monthly rate per Calendar Month to the Same Specialty Physician or Other Qualified Health Care Professional.

Only one monthly rental reimbursement per Calendar Month per code/vendor/provider, except when RT and LT are submitted on separate lines for the same HCPCS code.
Report monthly rentals on a single claim line with one unit and a single Calendar Month date span; multiple months must be billed on separate lines with different From dates.

Billing Rule

Maintenance/service billing — report maintenance/service with MS modifier on a separate line; limited to once every six months

UnitedHealthcare Medicare Advantage allows for reimbursement of maintenance and service once every six months to the Same Specialty Physician or Other Qualified Health Care Professional. The appropriate HCPCS code appended with modifier MS is required and must be reported on a separate line to be considered for separate reimbursement from the rental or purchase of the equipment.

Maintenance/service billed with modifier MS on a separate line.
Maintenance/service reimbursable only once every six months.
Maintenance and Service includes routine maintenance, re-education, compliance with recalls/alerts, necessary supplies per agreement, back-up equipment, and emergency availability/replacement. (Does not apply to Orthotics or Prosthetics.)

Billing Rule

Place of Service billing restrictions — do not bill purchased DME/PO on CMS-1500 in certain facility POS codes for separate reimbursement; DME intended for use at home has POS restrictions

DME suppliers must report the Place of Service (POS) where the device is intended to be used. DME intended for use in a location other than the member's home (non-home POS) is not reimbursable. The following POS codes qualify as the member's home: 01, 04, 09, 12, 13, 14, 16, 33, 54, 55, 56, and 65.

Report the POS where the device is intended to be used.
DME dispensed for use in a POS other than the patient's home are not reimbursable.

Billing Rule

Facility POS purchase billing restriction — do not bill separate reimbursement for purchased DME/orthotics/prosthetics on CMS-1500 when provided in facility POS 19,21,22,23,24

Consistent with CMS guidelines and the facility prospective payment methodologies, UnitedHealthcare Medicare Advantage will not allow separate reimbursement for the purchase of certain DME, Orthotics, and Prosthetics when reported by a physician or health care professional on a CMS-1500 claim form in Facility POS 19, 21, 22, 23, or 24. This applies when services are reported with no modifier or with one of the specified purchase modifiers.

Do not bill separate reimbursement for purchased DME/Orthotics/Prosthetics on CMS-1500 when provided in Facility POS 19, 21, 22, 23, or 24.
Purchase modifiers that trigger this restriction include: NU, UE, NR, KM, KN.

Modifiers referencedPolicy references purchase modifiers such as NU and UE (and others listed elsewhere) and rental modifiers (e.g., RR).

Home Place of Service (POS) Codes

Home POS codesPlace of service codes that qualify as the member's home: 01, 04, 09, 12, 13, 14, 16, 33, 54, 55, 56, 65.

Reporting instructionDME suppliers should report the POS code where the device is intended to be used.

Non-home restrictionDME dispensed for use in a POS other than the patient’s home are not reimbursable.

Durable Medical Equipment (DME) - Definition

Definition (summary)Durable Medical Equipment (DME): Medical equipment that can withstand repeated use, is not disposable, serves a medical purpose, is generally not useful in the absence of sickness or injury, and is appropriate for use in the home.

Key characteristicsDME must be reusable, medically necessary, and suitable for home use.

Policy contextDME classification and payment rules follow CMS guidance and HCPCS code categorization.

Orthotic - Definition

Definition (summary)Orthotic: An external appliance such as a brace or splint that prevents or assists movement of the spine or limbs; used to support a weak or deformed body part or to restrict/eliminate motion in a diseased or injured part.

Use casesDesigned to support, restrict, or assist movement of body parts and used in the home setting when appropriate.

Maintenance exclusionMaintenance and service reimbursement does not apply to orthotics under this policy.

Prosthetic - Definition

Definition (summary)Prosthetic: A device that replaces all or part of an internal body organ or replaces function of a permanently inoperative or malfunctioning internal body organ.

ScopeIncludes devices that replace body parts or functions and are subject to CMS coding and reimbursement rules.

Home useProsthetics are considered under DMEPOS categories and reimbursable when appropriate for home use per policy.

Rental Month Definition and Billing

Rental month definitionA rental month is defined as a Calendar Month; rentals are reimbursed once per Calendar Month rather than per 30-day period.

Proration policyUnitedHealthcare Medicare Advantage pays a full Calendar Month rental rate regardless of partial-month use (modifier KR does not invoke proration), except for items designated as daily rental.

Billing guidanceMonthly rental should be reported as a single claim line with one unit and a single Calendar Month date span; multiple months billed on separate lines.

Same Specialty Physician or Other Qualified Health Care Professional

Definition (summary)Same Specialty Physician or Other Qualified Health Care Professional: Physicians and/or other health care professionals of the same group and same specialty reporting the same Federal Tax Identification number.

RelevanceRental and maintenance frequency rules and claim allowance apply to services billed to the Same Specialty Physician or Other Qualified Health Care Professional.

ImplicationDuplicate claims from providers sharing the same Federal Tax Identification number for the same item and month may result in only one allowed claim.