HCPCS - DME, Drugs, and Services


CMS says Less Paperwork for DME Suppliers after Jan 2023! 2022-08-18


 Reimbursement for most Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) is established by fee schedules. Payment is limited to the lower of the actual charge or the fee schedule amount.

The fee schedule classifies most DMEPOS into one of six categories explained below:

  1. Inexpensive or other routinely purchased DME
  2. Items requiring frequent and substantial servicing
  3. Customized items
  4. Other prosthetic and orthotic devices
  5. Capped rental items
  6. Oxygen and oxygen equipment

For some basic information to get you started including modifiers and how CMS views DMEPOS, CLICK HERE


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CMS Announces Changes to DME Program

by  Wyn Staheli, Director of Content - innoviHealth

CMS recently announced that there have been some changes made to the DMEPOS program. The Medicare Learning Network (MLN) “DMEPOS Quality Standards” lists several changes to the program. Read more about understanding these changes.

Compliance Billing: Power Mobility Devices

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

In May of 2022, the OIG conducted a nationwide audit of Power Mobility Device (PMD) repairs for Medicare beneficiaries. The findings were not favorable; the audit revealed CMS paid 20% of durable medical suppliers incorrectly during the audit period of October 01, 2018- September 30, 2019. This was a total of $8 million in device repairs out of $40 million paid by CMS. We gathered information in this article to assist providers and suppliers in keeping the payments received, protecting beneficiaries, and assisting you in ensuring compliance.

CMS says Less Paperwork for DME Suppliers after Jan 2023!

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

This is important news for durable medical suppliers! Effective January 1, 2023, CMS is discontinuing the use of Certificates of Medical Necessity (CMNs) and DME information forms (DIFs). We knew this was coming as the MLN sent out an article on May 23, 2022, but it is time to make sure your staff knows about these changes.

2022-05-26-MLNC - Biosimilars: Interchangeable Products May Increase Patient Access

by  CMS - MLNConnects

News - COVID-19: New Administration Code for Pfizer Pediatric Vaccine Booster Dose - - Biosimilars: Interchangeable Products May Increase Patient Access - - Critical Care Evaluation & Management Services: Comparative Billing Report in May - -...

Continuous Glucose Monitors (CGMs) -- New Codes

by  Wyn Staheli, Director of Content - innoviHealth

New codes for continuous glucose monitors (CGMs) became effective on April 1, 2022. The following information is excerpted from MLN Matters MM12564 regarding CGMs. Be sure to review this information and implement policies to ensure accurate reporting/billing. On December 28, 2021, we published the Medicare DMEPOS final rule in the Federal Register. This addressed the ...

Opportunities to Identify Risk Adjustable Chronic Conditions Expands in 2022

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Medicare made changes to the rules governing concurrently reporting transitional care management services and chronic care management services during the same calendar month. How might this help providers identify chronic conditions that risk adjust?

58% of Improper Payments due to Medical Necessity for Ventilators

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

Proper documentation not only protects the provider, the payer, and the patient, it protects the integrity of the entire healthcare system. When it comes to coverage and documentation for durable medical, the DMEPOS supplier and staff must be familiar with the National and Local Coverage Determinations (NCDs and LCDs) as these are ...

HCPCS Codes Were NOT all Created for the Same Purpose

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

Have you ever wondered why you were unable to find a particular product/code with our DMEPOS search? When looking for HCPCS Level II codes, there are several kinds of codes and not all HCPCS codes were created for the same purpose. If you are searching for a certain HCPCS product ...

Healthcare Common Procedure Coding System (HCPCS)

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

There are three main code sets and Healthcare Common Procedure Coding System (HCPCS), is the third most common code set used. They are often called Level II codes and are used to report non-physician products supplies and procedures not found in CPT, such as ambulance services, DME, drugs, orthotics, supplies, ...

When Can You Bill Orthosis Components Separately?

by  Wyn Staheli, Director of Content - innoviHealth

Othoses often have extra components. When can you bill those components separately? For example, can you bill for a suspension sleeve (L2397) with a knee orthosis (e.g., L1810)?

Home Oxygen Therapy

by  Raquel Shumway

Home Oxygen Therapy Guidelines

Capped Rental Items

by  Kristy Ritchie

CMS Gives guidance on Capped Rental Items: Items in this category are paid on a monthly rental basis not to exceed a period of continuous use of 13 months. Based on Supplier Standard 5, suppliers are required to advise beneficiaries of the rent/purchase option for capped rentals and inexpensive or routinely purchased items. ...

Home Oxygen Therapy -- CMN for Oxygen

by  Raquel Shumway

The Certificate of Medical Necessity (CMN) for Oxygen is a required form that helps to document the medical necessity for oxygen therapy. It also documents other coverage criteria for the oxygen use. For payment on a home oxygen claim, the information in the supplier’s records or the patient’s medical record must be substantiated with the information in the CMN.

Preventive Medicine: Breastfeeding Supplies

by  Find-A-Code™

Preventive Medicine Topics Page Breastfeeding Supplies Procedure Codes A4286: Locking ring for breast pump, replacement E0602: Breast pump, manual, any type E0603: Breast pump, electric (ac and/or dc), any type E0604: Breast pump, hospital grade, electric (ac and / or dc), any type S9443: Lactation classes, non-physician provider, per session ICD-10-CM ...

Coverage Criteria for Nonwearable Automatic Defibrillators

by  Find-A-Code™

According to Noridian and CGS Administrators LCD L33690, a nonwearable automatic defibrillator (E0617) is covered for beneficiaries in two circumstances. They meet either (1) both criteria A and B or (2) criteria C, described below: The beneficiary has one of the following conditions (1-8):A documented episode of cardiac arrest due to ventricular fibrillation, not due to a ...

Home Oxygen Therapy -- A Face-to-Face Encounter

by  Raquel Shumway

What is required for a Home Oxygen Therapy, Face-to-Face Encounter.

DME Documentation Requirements

by  Wyn Staheli, Director of Content - innoviHealth

Properly documenting DME orders is crucial for reimbursement. It should be noted that without meeting the payer requirements, the claim will be denied. For Medicare, the beneficiary will not be responsible for paying for the item if the provider and/or supplier do not meet requirements. Commercial payers have similar policies so carefully ...

Modifier NU


Is it necessary to use the modifier NU for all supplies? or is NU part of the code itself? Where should the NU be noted on the 1500 form?

Licensure to Dispense Drugs for Indian Health Services (Rev. 1040, 09-11-06)

by  Jared Staheli, MPP

In order to bill drugs to the DME MACs, the supplier must be a pharmacy. States may not regulate the qualifications of Federal employees who are carrying out their authorized Federal activities within the scope of their employment. However, IHS employees are not subject to state licensure laws and IHS ...

NSC Supplier Number for Indian Health Services (Rev. 1040, 09-11-06)

by  Jared Staheli, MPP

To enable direct billing of DMEPOS, an IHS supplier must enroll with the NSC as a “DME Supplier”, secure a Medicare supplier billing number and comply with the supplier standards specified in 42 CFR §424.57, and submit all DME claims to the appropriate DME MAC based on current DME jurisdiction ...

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Proper Coding and Billing for Drugs, Biologicals and Injections 

by  Find-A-Code™

Proper Coding and Billing for Drugs, Biologicals and Injections

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