CMS 1500 Reimbursement Policy — DME, Prosthetics and Orthotics (rental and purchase billing rules)
Governance of UnitedHealthcare reimbursement rules for durable medical equipment (DME), prosthetics, and orthotics billed on the CMS-1500 (or electronic equivalent) affecting UnitedHealthcare Commercial and Individual Exchange providers and suppliers.
Policy Summary
PayerUnitedHealthcare
PolicyCMS 1500 Reimbursement Policy — DME, Prosthetics and Orthotics
Policy CodePolicy 2025R01O9G
Change TypeTemplate updates, attachments and code list revisions
Effective Date
Next Review Date
Key ActionReport monthly rentals on a single CMS-1500 claim line with one unit and a Calendar Month date span; use separate lines for additional months.
Policy Embedded List 'Codes with Flexion, Extension, Pronation or Supination in Description' updated.
Attachments Section: Items Eligible for Rental or Purchase list was updated.
Policy: Overview Section updated and application clarified to both Commercial and Individual Exchange benefit plans.
1/monthdefault monthly rental reimbursement rule
up to 2allowed for certain bilateral or multi-device codes
6 monthsmaintenance/service frequency
A9901/L9900
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delivery/set-up/supplies exclusion
home POShome POS limitation for certain DME
1rental reporting unit per claim line
Coverage and Billing Criteria
DME rental/purchase and billing criteria
Billing and reimbursement criteria for DME, prosthetics, and orthotics
Items eligible for rental or purchase must be reported with the appropriate rental (e.g., RR, KH, KI, KJ, KR) or purchase (e.g., NU, UE, NR, KM, KN) modifier to be considered for reimbursement. Total reimbursement for a single code from a single vendor is limited to either the purchase price or the maximum number of rental months, whichever is less (does not apply to oxygen equipment or ventilators).
UnitedHealthcare reimburses only one monthly rental rate per Calendar Month to the Same Specialty Physician or Other Qualified Health Care Professional for a given code when submitted with rental modifier(s) (RR and/or KH, KI, KJ, KR), except where specific exceptions apply.
Exceptions (allow additional rental rates)
Second ventilator: one additional rental rate will be allowed in the same Calendar Month for a second ventilator reported with a rental modifier plus modifier KX appended to HCPCS code E0465, E0466, or E0467.
Certain multi-device or side-specific codes: up to two rental rates will be allowed in the same Calendar Month for codes with 'extension/flexion', 'supination/pronation' or 'each' in the description; when reported with RT and LT and multiple units, UnitedHealthcare will consider up to one unit per side (total up to two rental rates).
Report monthly rental on the CMS-1500 (or electronic equivalent) using the appropriate HCPCS code and rental modifier. Submit one unit for each Calendar Month time span with the rental initiation date in the 'From' field and the end date in the 'To' field. Aggregating multiple months on one claim line (e.g., reporting three months as 3 units with one From/To span) will result in reimbursement of only one unit.
Monthly rental must be reported on a single claim line with one unit and a single Calendar Month date span; multiple months require separate claim lines, and only one rental claim will be allowed per month from the Same Specialty Physician or Other Qualified Health Care Professional. Modifier KR does not cause proration; UnitedHealthcare pays a single monthly rate regardless of days used in the Calendar Month (except for items listed under 'Rental: Daily').
Maintenance and service fees (reported with modifier MS) are reimbursable once every six months to the Same Specialty Physician or Other Qualified Health Care Professional when billed on a separate line; maintenance and service does not apply to orthotics or prosthetics.
Delivery, set-up and supplies are included in the payment rates for DME, orthotics, and prosthetics; codes A9901 and L9900 will not be reimbursed separately.
DME suppliers must report the Place of Service (POS) code where the device is intended to be used. Reimbursement for certain DME items is limited to POS codes that qualify as the patient's home; items dispensed for use in a POS other than the patient's home are not reimbursable.
DME coverage and billing rules
Coverage and billing criteria for DME:
Reimbursement for certain DME items is limited to Place of Service (POS) codes that qualify as the patient's home (01, 04, 09, 12, 13, 14, 16, 31, 32, 33, 54, 55, 56, 65). DME dispensed for use in a POS other than the patient's home are not reimbursable.
Initial purchase: certain supplies provided at initial issuance (for example, walker brakes with E0141) are included in the initial purchase reimbursement and may not be billed separately.
Monthly rental reporting: monthly rental must be reported on a single claim line with one unit and a single Calendar Month date span; multiple months require separate lines. If two claims for the same item show From dates in the same Calendar Month from the Same Specialty Physician or Other Qualified Health Care Professional, only one claim will be allowed for that month.
Rental proration: UnitedHealthcare pays a single monthly rental rate regardless of the number of days used within the Calendar Month when modifier KR is used; the item is not prorated. Exceptions exist for items designated under 'Rental: Daily'.
Coding, Modifiers, and Code Lists
Modifiers and excluded HCPCSHCPCS
RR
Rental modifier
KH
Rental modifier
KI
Rental modifier
KJ
Rental modifier
KR
Rental modifier
NU
Purchase modifier
UE
Purchase modifier
NR
Purchase modifier
KM
Purchase modifier
KN
Purchase modifier
1–10 of 13
1/2
Items eligible for rental only and code mappingsHCPCS
E0424
Mapped to rental-only or related codes (examples: E0424,1 = E0431; E0424,2 = E0433; E0424,3 = E0434; E0424,4 = E0439; E0424,5 = E1392; E0424,6 = K0738)
Coding guidance for bilateral devices and repair codes during rentalHCPCS
E1800
Report bilaterally as separate RT and LT lines with one unit each when device provided for both sides of the body
K0739
Repair code — repair included in rental payment and not separately reimbursed during rental period
K0740
Repair code — repair included in rental payment and not separately reimbursed during rental period
K0462
Repair code — repair included in rental payment and not separately reimbursed during rental period
inv-06: Monthly rental units per calendar month — One monthly rate reimbursed per calendar month per vendor/Same Specialty provider (unless exceptions apply)
RuleOne monthly rate reimbursed per Calendar Month to the Same Specialty Physician or Other Qualified Health Care Professional when a code is billed with rental modifiers (e.g., RR, KH, KI, KJ, KR).
ExceptionExceptions allow additional monthly rates only where specifically noted in policy (e.g., certain bilateral or multi-device scenarios).
Unit HandlingIf a code with RR (or KH/KI/KJ/KR) is submitted multiple times or with units >1 in the same Calendar Month, only one monthly rate will be reimbursed.
inv-07: Maintenance/service frequency — Once every six months
Frequency LimitMaintenance and service reimbursable once every six months to the Same Specialty Physician or Other Qualified Health Care Professional when billed with modifier MS.
Provider Billing Actions and Requirements
Billing Rule
Claims submission responsibility and applicability
Providers are responsible for accurate claim submission on the CMS-1500 (or electronic equivalent). This policy applies to services reported on the CMS-1500 or its electronic successor. Ensure claims accurately reflect the services provided and follow applicable coding guidelines and payer-specific instructions.
Submit claims using the CMS-1500 form or electronic equivalent.
Ensure codes and modifiers accurately describe services rendered.
Billing Rule
Place of Service reporting and reimbursement limitation
Report the Place of Service (POS) code that reflects where the device will be used. Reimbursement for certain DME items is limited to POS codes that qualify as the patient’s home. Items dispensed for use in a POS that does not qualify as the patient’s home will not be reimbursed.
Definitions and Terms
inv-12: Same Specialty Physician or Other Qualified Health Care Professional — definition entry
DefinitionPhysicians and/or Other Qualified Health Care Professionals of the same group and same specialty reporting the same Federal Tax Identification Number (TIN).
IncludesDME, Prosthetic and Orthotic vendors when renting or selling items covered by this policy and reporting under the same TIN.
RelevanceUsed to determine the single monthly rental reimbursement entitlement when multiple claims are submitted for the same item within a Calendar Month.
DefinitionCalendar Month (rental) — The period from the 'From' date reported on the claim to the corresponding day of the next month; used to determine monthly rental reimbursement.
Determination
Policy Summary
PayerUnitedHealthcare
PolicyCMS 1500 Reimbursement Policy — DME, Prosthetics and Orthotics
Policy CodePolicy 2025R01O9G
Change TypeTemplate updates, attachments and code list revisions
Effective Date
Next Review Date
Key ActionReport monthly rentals on a single CMS-1500 claim line with one unit and a Calendar Month date span; use separate lines for additional months.
Repair during rental: repair charges (e.g., K0739, K0740, K0462) are included in the rental payment and are not separately reimbursed during the rental period. Repairs may be allowed for DME items that are purchased (patient-owned).
Modifier RequirementThe HCPCS code must be appended with modifier MS and reported on a separate claim line to be considered for separate reimbursement.
ScopeMaintenance and service includes routine maintenance, re-education, compliance with recalls, back-up equipment, necessary supplies per agreement, emergency availability and replacement during repair.
ExclusionMaintenance and servicing reimbursement does not apply to Orthotics or Prosthetics under this policy.
inv-08: rental_reporting_unit — one unit per Calendar Month per claim line
Reporting UnitOne unit per Calendar Month per claim line: submit the HCPCS code and rental modifier with one unit for each Calendar Month time span.
Date SpanEnter the rental initiation date in the 'From' field and the month's end date in the 'To' field for that Calendar Month on the claim line.
Multiple MonthsRental charges for multiple months must be reported on separate claim lines for each Calendar Month; reporting multiple months on one line will result in reimbursement of only one unit.
Report the POS where the device is intended to be used.
Qualifying home POS codes: 01, 04, 09, 12, 13, 14, 16, 31, 32, 33, 54, 55, 56, 65.
DME dispensed for use in a non-home POS is not reimbursable.
Billing Rule
Monthly rental reporting and reimbursement
Monthly rental for DME should be reported on a single claim line with one unit and a single Calendar Month date span (enter the rental initiation date in the From field and the end date of that month in the To field). Do not report multiple months on the same claim line. If multiple claims for the same item from the same provider show From dates in the same month, only one will be allowed.
Report one unit per monthly rental line with From/To spanning that Calendar Month.
Do not combine multiple months' rentals on one claim line — submit separate lines for each calendar month.
Only one claim per provider per item is allowed for a given calendar month; duplicate same-month From dates will result in denial of the second claim.
The Calendar Month is determined based on the 'From' date reported on the claim; each month of rental must have a From date in a different month to be reimbursed as separate months.
RationaleUnitedHealthcare reimburses by Calendar Month rather than a fixed 30‑day period because billing cycles commonly use corresponding monthly dates (e.g., 1/9 to 2/9).
inv-14: Durable Medical Equipment (DME) — definition entry
DefinitionDurable Medical Equipment (DME) — Medical equipment that can withstand repeated use, is not disposable, serves a medical purpose, and is generally not useful in the absence of sickness or injury.
ScopeIncludes items reimbursed under rental or purchase provisions of this policy when reported on the CMS-1500 with appropriate modifiers.
Relation to PolicyDME reimbursement rules in this policy cover rental vs. purchase, place-of-service limitations, maintenance/service, and excluded delivery/set-up codes.
inv-15: Orthotic — definition entry
DefinitionOrthotic — An external appliance such as a brace or splint that prevents or assists movement of the spine or limbs, used to support or restrict motion of a diseased or injured body part.
Service ExclusionMaintenance and servicing reimbursement does not apply to Orthotics or Prosthetics under this policy.
ClaimingOrthotics are subject to the policy's rules regarding rental vs. purchase and reporting on the CMS-1500 when applicable.
DefinitionCalendar Month — The period from a day of one month to the corresponding day of the next month; used to define the monthly rental time span on claims.
Claim ReportingFor each Calendar Month of rental, enter the From date and the corresponding To date on the claim line; multiple months require separate lines to be reimbursed separately.
ImplicationIf two claims for the same item show From dates in the same month from the Same Specialty Physician or Other Qualified Health Care Professional, only one will be allowed for that month.