Durable Medical Equipment
Original Author: Dr. Veronica F. McGowan
A note from the author of this resource about free resources: When using free resources, the
responsible coder will triangulate a finding with other sources to verify accuracy. Insurance plans
frequently produce free coding cheat sheets which may serve convenience purposes; the
responsible coder seeks vetted resources with effective dates and stated policy impacts from
official resources. One issue with educational materials associated with medical and clinical
coding is that since code sets are updated often, free or low-cost reference guides are not readily
available; even if available, the likelihood the resource has undergone rigorous review is low.
Such limitations also apply to this free resource, in that the rating system made available at the
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versions to insure accuracy nor is in a position to demand that updated materials be stored at the
OER Commons site. Because of the potential legal consequences of filing inaccurate claims, and
the potential loss to research data pools and data quality improvement initiatives, responsible
coders should consider professional resources as the gold standard in their practice.
Introduction
Based on Healthcare Common Procedure Coding System (HCPCS) Level II codes and
Medicare’s policies, durable medical equipment (DME) codes are defined for equipment which:
“(a) can withstand repeated use; (b) is primarily and customarily used to serve a medical
purpose; (c) generally is not useful to a person in the absence of an illness or injury; and (d) is
appropriate for use in the home. For items to be considered DME, all requirements of the
definition must be met.” (Center for Medicaid and Medicare Services, 2015). In general, DMEs
provide a therapeutic benefit to users and require a prescription to be eligible for coverage. Since
some conditions are of a short term nature, such as the need for a wheelchair to provide
assistance in the case of broken leg(s), billing for DMEs supports capped rentals with related
costs including shipping and handling, setup and labor, patient training, maintenance and repairs,
and accessory purchases. Coverage begins on the day of use by the patient, that is, after it has
been delivered, setup, and the patient has been trained in its usage. Manufacturer’s warranty
supersedes repair or replacement claims.
DME codes start with a letter and are followed by numbers; the HCPCS code range is E0100E8002. For example, E1390 describes an oxygen concentrator, single delivery port, capable of
delivering 85 percent or greater oxygen concentration at the prescribed flow rate. The purpose
of DME codes encompasses larger issues; as an example, 2016 rules implement statutory
requirements for bid surety bonds and state licensure for the Durable Medical Equipment,
Prosthetics, Orthotics, and Supplies (DMEPOS) and its Competitive Bidding Program (CBP).
The 2016 rule expands the breach of contract appeal rights of suppliers, finalizes changes to fee
schedule adjustments, establishes bid limits, handles equipment requests for dually eligible
beneficiaries, and establishes single payment amounts for certain groupings of similar items with
different features to address price inversions. Some of the 2016 rules are already having an
impact with Newman, Barrette, and McGraves-Lloyd (2017) citing the Medicare competitive
bidding program as responsible for realizing significant price savings and Montebello (2018)
describing the efforts of some states to insure a smoother transition for dually eligible
beneficiaries to obtain durable medical equipment with provisional prior authorization from
Medicaid for such items.
The 2008 National Coverage Determination by the US Centers for Medicare and Medicaid
Services (CMS) describes conditions that must be met in order for reimbursement to continue
beyond 90 days. One complication in coding Medicare coverage of DME codes is the rigid
threshold for acceptable degree of adherence, and requirements of face-to-face evaluation and
documented clinical response in a specific timeframe (Brown, 2010). In addition, field
discussion suggests that recent price increases for durable medical equipment (Hartman, et al.,
2017) may impact coverage expansion and contraction trends.
An excellent free resource is the American Academy of Professional Coders (AAPC) coder
search engine (https://www.aapc.com/medical-coding/ ). As an example, a search on replacement
socket and HCPCS code L8000 reveals this is a code for a healthcare claim for: Breast
prosthesis, mastectomy bra, without integrated breast prosthesis form, any size, any type.
Confirming this is updated guidance from Blue Cross\Blue Shield (2018) says that L8000 is the
code for: L8000–L8039 General prosthesis; breast (code range).
The Centers for Medicare and Medicaid Services contracts with a Pricing, Data Analysis and
Coding (PDAC) contractor to maintain a Durable Medical Equipment Prosthetic and Orthotic
Supplies (DMEPOS) Guide for items that have been coded by the PDAC. As of 2019, the current
site is: https://www.dmepdac.com/ and maintained by Pametto GBA. Users of the DMECS
Guide are expected to be coding professionals, however, since the document is public, members
of the public may use the guide to become informed participants in processes related to their
healthcare.
References
Brown, L. K. (2010). Use it or lose it: Medicare's new paradigm for durable medical equipment
coverage?. Chest, 138(4), 785-789.
Center for Medicaid and Medicare Services. (2015). 42 CFR, 414.202. Retrieved from
https://www.cms.gov/Center/Provider-Type/Durable-Medical-Equipment-DMECenter.html
Centers for Medicare & Medicaid Services. (2016, November). Medicare program; end-stage
renal disease prospective payment system, coverage and payment for renal dialysis
services furnished to individuals with acute kidney injury, end-stage renal disease quality
incentive program, durable medical equipment, prosthetics, orthotics and supplies
competitive bidding program bid surety bonds, state licensure and appeals process for
breach of contract actions, durable medical equipment, prosthetics, orthotics and supplies
competitive bidding program and fee schedule adjustments, access to care issues for
durable medical equipment; and the comprehensive end-stage renal disease care model.
Final rule. Federal Register, 4, 81(214):77834-969.
Excellus Blue Cross\Blue Shield. (2018, February 22). External prosthetic devices policy
number: 1.01.18. Retrieved from
https://www.excellusbcbs.com/wps/wcm/connect/acecc3d8-69e6-4e19-a80edc878b6fcb43/ext_prosth+mpc3+18.pdf?MOD=AJPERES&CACHEID=acecc3d8-69e64e19-a80e-dc878b6fcb43
Hartman, M., Martin, A. B., Espinosa, N., Catlin, A., & National Health Expenditure Accounts
Team. (2017). National health care spending in 2016: Spending and enrollment growth
slow after initial coverage expansions. Health Affairs, 37(1), 150-160.
Montebello, P. (2018). Facilitating access to Medicaid Durable Medical Equipment for dually
eligible beneficiaries in the fee-for-service system: Three state approaches (No.
19628eb6163541da9bceccb3ca075d88). Mathematica Policy Research. Retrieved from
https://www.integratedcareresourcecenter.com/PDFs/ICRC_Access_to_DME_in_FFS_0
6-2018.pdf
Newman, D., Barrette, E., & McGraves-Lloyd, K. (2017). Medicare competitive bidding
program realized price savings for durable medical equipment purchases. Health
Affairs, 36(8), 1367-1375.