CurrentUnitedHealthcarePolicy N/A

Durable Medical Equipment (DME), Prosthetics and Orthotics reimbursement

Defines UnitedHealthcare Community Plan Medicaid reimbursement rules for rental and purchase reporting, modifiers, monthly and daily rental billing, and applying to services billed on CMS-1500 or UB04 when specified; affects Same Specialty Physicians and Other Qualified Health Care Professionals and DME/P&O vendors.

Policy Summary

PayerUnitedHealthcare

PolicyDurable Medical Equipment (DME), Prosthetics and Orthotics reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionReport monthly rentals on CMS-1500 (or electronic equivalent) with the appropriate HCPCS and rental modifier using one unit per Calendar Month and From/To dates.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

monthlyrental reimbursed once per Calendar Month (one rate per month)

13 monthsmaximum rental months cap for rent-to-purchase comparison

dailycertain items reimbursed daily

A9900/A9901/L9900non-reimbursable supply codes

E0935

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example HCPCS reimbursed daily

Coverage and Rental/Purchase Criteria

DME/P&O rental and purchase criteria

Billing and reimbursement criteria for rental and purchase of DME, prosthetics and orthotics

Applies to UnitedHealthcare Community Plan Medicaid products and services billed on CMS-1500 (or electronic equivalent); applies to Same Specialty Physicians, Other Qualified Health Care Professionals and DME/P&O vendors.

Monthly rental items must be reported with an appropriate rental modifier (RR, KH, KI, KJ, KR, LL) and billed as one unit per Calendar Month using From and To dates; submissions that place multiple months on one claim line will be reimbursed as a single unit.

Purchase of an item must be identified using an applicable purchase modifier (KM, KN, NR, NU, UE) when billing for a purchased item.

When the same HCPCS code is provided for left and right sides, additional monthly rental rates are allowed when RT and LT modifiers are submitted on separate lines to represent each side.

Certain codes that include 'extension/flexion', 'supination/pronation' or 'each' in their description may allow up to two rental rates in the same Calendar Month (and when combined with RT/LT and multiple units, up to four rates as applicable).

A second ventilator (E0465, E0466, E0467) may be reimbursed as an additional monthly rental rate when the KX modifier is appended indicating medical policy requirements have been met.

ANY of the following

HCPCS E0935 is reimbursed on a daily rental basis consistent with CMS guidelines.

Coverage criteria

Coverage and reimbursement rules include rent-to-purchase limits, POS restrictions, non-reimbursable supply codes, and maintenance/service reimbursement rules.

Monthly rentals must be billed on a CMS-1500 (or electronic equivalent) using the appropriate HCPCS code and rental modifier (e.g., RR); report one unit per Calendar Month with From and To dates. A single claim line spanning multiple months will be reimbursed as one unit.

Daily rental is allowed for specified HCPCS codes (example: E0935) consistent with CMS guidelines; other devices follow CMS/PDAC or applicable state requirements.

Rental-to-purchase: rental fees from a single vendor are payable up to the lesser of the purchase price or the contract-specified maximum number of rental months (not to exceed 13 months for purchase-price comparison); when the rental cap is reached the item is considered purchased and vendors must stop billing rental.

Maintenance and service may be reimbursed once every six months when billed with the appropriate HCPCS code appended with modifier MS on a separate line; maintenance/service billing does not apply to orthotics or prosthetics for separate reimbursement.

State-specific DME coverage criteria

State-level rules and lists govern whether specific HCPCS codes must be billed as rental, purchase, or repair and which modifiers are required or disallowed.

Mississippi covers rental up to ten months or until the purchase price is reached; allows daily rental for E0202 when billed with RR or KR; HCPCS A4253 is only allowed with SC modifier.

Missouri is exempt from the monthly rental limit; Missouri requires NU/RR/RB modifiers for certain codes, allows TW (backup) with E0465 but not with E0466, and does not allow KX with E0465/E0466.

Missouri code lists: Missouri maintains extensive state-specific purchase/rental/repair code mappings and lists (see MO attachments for detailed HCPCS mapping).

New York covers rental up to ten months or until purchase price is reached and maintains state-specific purchase/rental code lists; NY also restricts POS to home and select POS codes and has state-specific guidance for maintenance reimbursement.

State exceptions and billing/reporting criteria

State-specific coverage and billing criteria for DME rental/purchase and modifiers.

Texas (examples): A4253 limited to 2 units/month for insulin-dependent diabetics and 1 unit/month for noninsulin-dependent diabetics; combined A4253 + A9275 counts toward combined unit limits. E0956 billed for purchase only; E0471 is monthly rental with no purchase price and no rental month limit; KX modifier is not accepted with E0465/E0466 for a second ventilator under TX rules.

Virginia is exempt from the monthly rental unit limit and reimburses in daily units per state requirements.

Washington (WA): WA requires modifier U2 instead of KX for HCPCS E0465/E0466 when billing for a second ventilator; WA allows POS 99 for DME providers and certain codes (e.g., E0600) may be deemed purchased after 12 months of rental when billed with RR or TW.

Washington DC: Rental maximum is 6 months; E0936 is not covered.

HCPCS, Modifiers, and Code-Level Rules

DME items eligible for rental onlyHCPCSCovered

E0424

Various mappings to ventilator/related codes (see list)

Rental Modifiers (Medicaid)Modifier

KH	monthly rental modifier option
KI	monthly rental modifier option
KR	Partial month
LL	rental applied against purchase price
RR	rental modifier

Purchase Modifiers (Medicaid)Modifier

KM	purchase modifier
KN	purchase modifier
NR	rental-to-purchase
NU	purchase modifier
UE	purchase modifier

Second ventilator allowanceHCPCS|ModifierCovered

E0465	ventilator
E0466	ventilator
E0467	ventilator
KX	requirements specified in the medical policy have been met

Billing modifiers and non-reimbursable supply codesHCPCSCovered

RR	Rental modifier — identifies rental units per month; required to bill monthly rentals
MS	Maintenance and Service modifier — used to identify maintenance/service billed separately
A9900	Delivery/set-up/supplies — not separately reimbursable
A9901	Delivery/set-up/supplies — not separately reimbursable
L9900	Delivery/set-up/supplies — not separately reimbursable

Daily rental exampleHCPCSCovered

E0935

Device reimbursed on a daily rental basis consistent with CMS guidelines

Mississippi modifier rulesHCPCSCovered

A4253	Only allowed with SC modifier in Mississippi
E0202	Daily rental allowed when billed with RR or KR in Mississippi

Missouri modifier rulesHCPCSCovered

E0465	TW allowed (backup equipment) in Missouri; KX not allowed with E0465/E0466
E0466	TW not allowed in Missouri; KX not allowed with E0465/E0466

Texas DME rulesHCPCSCovered

A4253	2 units/month for insulin-dependent diabetics; 1 unit/month for noninsulin-dependent (Texas)
A9275	Counts toward combined unit limit with A4253 (Texas)
E0956	Billed for purchase only (Texas)
E0471	Monthly rental with no purchase price and no rental-month limit (Texas)

State-exception codesHCPCS

A4253	Insulin delivery supplies; state-specific monthly unit limits
A9275	Disposable supplies; combined monthly limits with A4253 in TX
E0956	DME purchase-only in Texas
E0471	Monthly rental with no purchase price (TX)
E0465	Ventilator; KX not accepted for second ventilator in TX; U2 required in WA
E0466	Ventilator; same as E0465
E0600	Deemed purchased after 12 months of rental (WA)
E0936	Not covered in Washington DC
L8614	Allowable in POS 22,23,24 in WI

inv-15: Monthly rental unit limit

Monthly reimbursement ruleUnitedHealthcare Community Plan reimburses one monthly rental rate per Calendar Month to the same provider for a given HCPCS code; multiple submissions or units in the same Calendar Month will result in only one monthly rate reimbursed.

Exceptions — laterality (RT/LT)Additional monthly rental rates allowed when the same HCPCS code is billed with RT and LT modifiers on separate lines to represent right and left sides.

Exceptions — codes with 'each' or extension/flexion descriptorsUp to two rental rates allowed in the same Calendar Month for codes with 'extension/flexion', 'supination/pronation' or 'each' in the description; combined with RT/LT and multiple units, up to four rates may be considered.

Second ventilator allowance

Billing, Reporting, and Vendor Responsibilities

Billing Rule

Claims submission responsibility

You are responsible for submission of accurate claims using CPT/CMS and other coding guidelines. Submit claims on CMS-1500 (or electronic equivalent) or UB04 when specified. Use the code(s) that correctly describe the services provided; follow CMS/NUCC/NUBC guidance. References to CPT/CMS are definitional and do not guarantee payment. UnitedHealthcare Community Plan may apply regulatory, contract, benefit design, or system-specific rules that affect reimbursement.

Submit accurate claims using correct CPT, HCPCS, and modifier coding.
Bill on CMS-1500 (or electronic equivalent) or UB04 as directed by NUCC/NUBC guidelines.
Follow payer, state, and contract-specific billing requirements.

Billing Rule

Monthly rental reporting

Monthly rental of DME, orthotics, or prosthetics must be reported with the appropriate HCPCS and a rental modifier (e.g., RR or state/vendor-specific modifiers KH, KI, KJ, KR, LL). Report one unit per Calendar Month using From and To dates; the From date determines the Calendar Month span. If submitted with multiple units or repeated lines in the same Calendar Month, only one monthly rate will be reimbursed to the Same Specialty Physician or Other Qualified Health Care Professional unless a state exception applies.

Terms and Definitions

inv-33: Calendar Month definition

Definition — Calendar MonthA Calendar Month is the period from a day of one month to the corresponding day of the next month and is determined by the 'From' date reported on the claim.

Billing implicationMonthly rental must be reported with a From (initiation) date and To (end) date that span a single Calendar Month; multiple months must be billed on separate lines with From dates in different months.

Proration policyUnitedHealthcare Community Plan pays a single monthly rental rate once per Calendar Month and does not prorate for partial‑month use (modifier KR does not reduce the monthly rate).

inv-34: List of codes that must be reported with rental or purchase modifiers

Modifier-required code listThe policy's 'Attachments' section contains the list of codes that must be reported with the appropriate rental or purchase modifier; those codes must be reported with the modifier to be considered for reimbursement.

Policy Summary

PayerUnitedHealthcare

PolicyDurable Medical Equipment (DME), Prosthetics and Orthotics reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionReport monthly rentals on CMS-1500 (or electronic equivalent) with the appropriate HCPCS and rental modifier using one unit per Calendar Month and From/To dates.

SourceLink

On This Page

Delivery, set-up and supplies are included in the payment rates for the item and are not separately reimbursable; codes A9900, A9901 and L9900 will not be reimbursed separately.

Reimbursement for certain DME items is limited to places of service that qualify as the patient’s home; suppliers must report the POS where the device is intended to be used and devices provided for use outside those POS are not reimbursable.

ANY of the following

Follow state modifier lists and state-specific rental/purchase rules (examples include Arizona, Mississippi, Missouri, New York, Tennessee, Texas, Washington DC, Wisconsin).

Certain supplies are included in the initial purchase or rental payment and may not be billed separately (for example, components such as walker brakes included with base code E0141).

TennCare requires coverage and reimbursement for repairs and at least one preventive maintenance visit annually; TennCare requires reporting of the base wheelchair code with MS modifier for informational purposes only.

Texas maintains state-specific rules (examples: A4253/A9275 monthly unit limits by diabetic status; E0956 billed for purchase only; E0471 monthly rental with no purchase price and no rental month limit; KX not accepted for E0465/E0466 to indicate a second ventilator).

Washington DC limits rental to a maximum of 6 months and does not cover E0936.

General: Some states are exempt from monthly rental limits or reimburse in daily units; several states maintain modifier-required code lists and state attachments that specify required billing modifiers and whether codes are rental, purchase or repair.

Wisconsin does not apply monthly rental unit limits and allows daily unit limits; L8614 is allowable in POS 22, 23, 24; modifier 50 is not allowed with certain listed procedure codes and LT/RT must be used to identify laterality when applicable.

Reporting and repair: Monthly rental must be reported using a Calendar Month date span on separate claim lines for each month; UnitedHealthcare pays one monthly rental rate per vendor per Calendar Month and does not prorate for partial months (KR) except for items specifically listed as Daily Rental. Repair codes (e.g., K0462, K0739, K0740) are not reimbursed separately during the rental period because repair is included in the rental payment; repairs may be allowed for purchased items.

State attachments: Attachments to the policy include state-specific modifier-required code lists and repair/purchase code lists (examples: Arizona, Missouri, Nebraska, Ohio, Tennessee) that must be followed for billing in those states.

One additional monthly rental rate may be allowed for a second ventilator when KX modifier is appended to indicate medical policy requirements are met.

inv-16: rent-to-purchase maximum months

Rent‑to‑purchase cap (general)Rental fees from a single vendor are payable up to the lesser of the purchase price or a maximum number of rental months; the maximum varies by vendor contract.

Contract-specific determinationThe maximum number of rental months for comparison to purchase price is determined by the vendor's contract with UnitedHealthcare Community Plan.

Policy ceiling for comparisonFor price-comparison purposes the policy notes the maximum number of rental months will not exceed 13 months unless specified by the vendor contract.

inv-17: A4253/A9275 monthly units (Texas)

A4253 — insulin-dependentTexas Medicaid: A4253 limited to 2 units per month for insulin-dependent diabetics.

A4253/A9275 combinedIn Texas the combined total of A4253 and A9275 is 2 units per month for insulin-dependent diabetics and 1 unit per month for non‑insulin‑dependent diabetics.

A4253 — noninsulin-dependentTexas Medicaid: A4253 limited to 1 unit per month for noninsulin-dependent diabetics (counts toward combined limit with A9275).

inv-18: Washington DC rental maximum

DC rental maximumWashington DC Medicaid: rental maximum is 6 months.

Code exclusion exampleWashington DC: HCPCS E0936 is not covered.

Append rental modifier RR and/or permitted state/vendor modifiers (KH, KI, KJ, KR, LL) as applicable.
Report Units = 1 for each Calendar Month span.
Enter rental initiation date in the From field and the end date in the To field for each monthly line.
Example: E1130-RR submitted as three separate monthly lines (each Units=1 with appropriate From/To) for a 3-month rental; a single line with Units=3 and From/To spanning 3 months will be paid as one unit.

Billing Rule

Daily rental reporting

Daily rental is allowed for specified HCPCS (for example, E0935) and for other devices as permitted by CMS, PDAC, or state requirements. When daily rental is allowed, follow the applicable state or CMS guidance for unit reporting and modifiers.

HCPCS E0935 reimbursed on a daily basis consistent with CMS guidelines.
Other devices: follow CMS/PDAC/state-specific rules for daily rental eligibility and billing.

Billing Rule

Rental-to-Purchase Billing

Vendors must stop billing rental when the vendor contract's rent-to-purchase maximum (rental cap) is reached. Rental fees are payable up to the lesser of the vendor contract's maximum rental months (not to exceed 13 months) or the purchase price. Daily rental items may have vendor-specific limits; oxygen and ventilators are exempt from some rental limits. Indicate rental vs purchase using the appropriate modifier.

Rental payable up to the lesser of purchase price or contract-specified maximum rental months (maximum not to exceed 13 months).
Vendors must cease rental billing once contract Rent-to-Purchase maximum is reached; item considered purchased and not reimbursable thereafter.
Use the applicable rental/purchase modifier to document whether equipment was rented or purchased.

Denial Risk

Prior approval restriction after rental initiation

Once rental has been initiated, subsequent requests to convert that same item to a purchase via prior approval will be denied — the rental-to-purchase rules and vendor contract terms control transition to purchase.

Prior approval for purchase after rental initiation is not allowed once rental has begun for that item.

Note

Tennessee wheelchair MS modifier use (informational)

TennCare requires use of the base wheelchair code with the MS modifier for informational tracking of maintenance and repairs; this use is informational only and does not result in separate payment under TennCare rules.

Report base wheelchair code + modifier MS for TennCare data tracking (no payment).
UPRV will apply base wheelchair code + MS modifier to CRT visit types for tracking (preventative maintenance, repair, combined).

Billing Rule

State-specific billing/modifier rules (TX, WA, DC)

State-specific billing notes — Texas: follow Texas Medicaid rules for monthly limits, purchases, and modifier acceptance. Washington: follow WA Medicaid modifier and POS rules for certain ventilator codes and allow POS 99 for DME providers. Washington DC: observe rental maximums and non-covered codes.

Texas: A4253 — 2 units/month for insulin-dependent diabetics (1 unit/month for non-insulin dependent); A4253 and A9275 combined limits apply. E0956 billed purchase only. E0471 monthly rental with no purchase price and no rental month limit. E0465/E0466: KX modifier is not accepted to reflect a second ventilator in Texas.
Washington: Use modifier U2 (not KX) on E0465/E0466 to indicate a second ventilator; WA allows POS 99 for DME providers.
Washington DC: Rental maximum is 6 months; HCPCS E0936 is not covered in DC.

Rental-only codesSome DME items are rental‑only and must be reported with an appropriate rental modifier as indicated in the Attachments.

inv-35: Monthly rental of DME

Monthly rental — definitionMonthly rental of DME, Orthotics, or Prosthetics is reporting the applicable HCPCS with a rental modifier (RR and/or KH, KI, KJ, KR, LL) and one unit per Calendar Month using From and To dates.

Claim formReport monthly rental on CMS-1500 (or electronic equivalent) with the appropriate HCPCS and rental modifier; submitting multiple months on one line will result in reimbursement of only one unit.

Who may receive rental reimbursementUnitedHealthcare Community Plan reimburses the Same Specialty Physician or Other Qualified Health Care Professional for monthly rentals.

inv-36: Daily rental of DME

Daily rental — definitionDaily rental is reimbursement of specified HCPCS items on a per‑day basis rather than per Calendar Month (example: HCPCS E0935 is reimbursed daily consistent with CMS guidelines).

Other devicesOther devices may be reimbursed as daily rentals in accordance with CMS/PDAC or state requirements; daily rental items are listed in the policy where applicable.

inv-37: Maintenance and Service (MS)

MS modifier frequencyMaintenance and service (HCPCS + modifier MS) is reimbursable once every six months when billed on a separate line.

Separate line requiredThe MS modifier must be appended to the appropriate HCPCS code and reported on a separate claim line to be considered for separate reimbursement from rental or purchase.

ApplicabilityMaintenance and service reimbursement applies to DME; the policy notes it does not apply to orthotics or prosthetics where specified (see policy criteria).

inv-38: Place of Service (home)

Home POS listReimbursement of certain DME items is limited to places of service that qualify as the patient's home: 01, 04, 09, 12, 13, 14, 16, 31, 32, 33, 54, 55, 56, and 65.

Supplier reporting requirementDME suppliers should report the POS where the device is intended to be used; items dispensed for use outside the home POS are not reimbursable.

inv-39: NU/RR/RB modifiers

NU = purchase/newUse NU modifier to indicate an item was purchased (state lists may require NU for reimbursement).

RR = rentalUse RR modifier to indicate monthly rental; other rental modifiers include KH, KI, KJ, KR, LL as appropriate.

RB = repairRB modifier indicates repair (some states use customized repair code lists and disallow RB with rental modifiers).

inv-40: TW modifier

TW modifier — backup equipment (MO)Missouri Medicaid allows modifier TW (back-up equipment) with HCPCS code E0465 but does not allow TW with E0466.

TW not allowed for E0466Per Missouri state regulations, TW is not allowed with code E0466.

inv-41: Calendar Month (duplicate/reference)

Calendar Month referenceSee definition: Calendar Month is the period from a day of one month to the corresponding day of the next month and is determined by the 'From' date on the claim.

Billing example referenceRefer to the Reporting Monthly Rental section and Q&A examples for billing multiple months (each line must have a From date in a different month).

inv-42: Durable Medical Equipment

DME definition — durability and purposeDurable Medical Equipment: medical equipment which can withstand repeated use, is not disposable, serves a medical purpose, is generally not useful absent sickness or injury, and is appropriate for home use.

inv-43: Orthotic / Prosthetic

Orthotic — definitionOrthotic: an external appliance such as a brace or splint that prevents or assists movement of the spine or limbs and supports or restricts motion of a diseased or injured body part.

Prosthetic — definitionProsthetic: a device that replaces all or part of an external body organ or replaces all or part of the function of a permanently inoperative or malfunctioning external body organ.

inv-44: Monthly rental reimbursement practice

Single monthly payment practiceUnitedHealthcare Community Plan pays a single monthly rental rate once per Calendar Month to the same vendor and does not prorate for partial‑month use (modifier KR does not reduce payment).

No proration exampleEven when KR is used to indicate partial‑month days, the contracted monthly rental rate will be allowed once per Calendar Month to the same vendor.

Daily rental exceptionItems listed in the 'Daily Rental' section are exceptions to the single monthly rate practice and are reimbursed per day where specified.

inv-45: Repair reimbursement during rental

Repair included during rentalRepair of DME items is included in the rental payment and repair charges are not separately reimbursed during the rental period.

Repair for purchased itemsRepair may be reimbursed for DME items that are purchased (patient‑owned) and are no longer under rental coverage.