Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)

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Program Overview

Health First Colorado (Colorado's Medicaid Program), covers Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) as described in this manual. Durable Medical Equipment (DME) is defined as equipment that can withstand repeated use and that generally would be of no value to the member in the absence of a disability, illness or injury. Prosthetics and Orthotics (P&O or O&P) are defined as replacement, corrective, or supportive devices that artificially replace a missing portion of the body, prevent or correct physical deformity or malfunction, or support a weak or deformed portion of the body. Disposable Medical Supplies (Supplies) are defined as supplies that are specifically related to the active treatment or therapy for an illness or physical condition; they are non-durable, disposable, consumable and/or expendable. This manual gives a summary of the covered DMEPOS benefits. It is periodically modified as new billing or policy information is implemented; therefore, the information in this manual is subject to change. The DMEPOS benefit may also be referred to as 'DME' or 'Supply'.

The list of open Supply Healthcare Common Procedure Coding System (HCPCS) Codes is provided in this manual, which the Health First Colorado updates and makes available to all enrolled DME providers at least annually. Providers should consult the current Supply HCPCS Codes included in this manual for updated benefit coverage, limitations, and prior authorization request (PAR) requirements. Providers may refer to the Code of Colorado Regulations, Program Rules (10 CCR 2505-10 Section 8.590), for specific regulations and guidance on providing the DMEPOS benefit.

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Eligible Providers

Providers must be enrolled as a Health First Colorado provider in order to:

  • Treat a Health First Colorado member
  • Submit claims for payment to the Health First Colorado

Note: For members with primary insurance refer to the PAR submission instructions below.

 

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Prescribing Providers

DMEPOS must be prescribed by a physician, physician assistant, or nurse practitioner. The prescription must be within the scope of the prescribing provider's license.

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Billing Providers

Billing Providers (the provider that bills/submits the claim) must acquire and retain Medicare DME accreditation and must be enrolled with the Department as a Supply Provider. At the time of enrollment, the Department requires proof of Medicare accreditation. The following exceptions apply:

  • Pharmacies with less than 5% of total revenue received from DMEPOS are not required to obtain Medicare accreditation.
  • Pharmacies and Prosthetic and Orthotic only providers are not required to provide proof of Medicare DME accreditation.

Mail order and out of state pharmacies do not qualify to provide DMEPOS though they may separately enroll as a Supply provider.

 

Out of state DMEPOS providers may only provide services for crossover Medicare/Health First Colorado members or have a specialized product that cannot be obtained through an in-state DMEPOS provider.

The Billing Provider must retain the member's prescription and related documentation for services for at least six (6) years and make it available for audit by the Department and its agents or representatives.

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Covered Benefits

DMEPOS must be medically necessary and prescribed by an authorized prescriptive authority for use by an eligible member. The following are categories of covered benefits and are further outlined in this section. Additional DMEPOS items are listed in the DMEPOS HCPCS table section of this manual.

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Durable Medical Equipment

DME refers to equipment and appliances that are primarily and customarily used to serve a medical purpose, generally are not useful to an individual in the absence of a disability, illness or injury, can withstand repeated use, and can be reusable or removable. DME may be rented or purchased.

Purchase: These items are purchased for a member.

Rental/Purchase: In general, these items are rented or purchased as follows:

  • The item is rented if the physician, physician assistant, or nurse practitioner documents that the anticipated need is six (6) months or less.
  • The item may be rented or purchased if the physician, physician assistant, or nurse practitioner documents that the anticipated need exceeds six (6) months.
  • Some items are required to be rented or purchased as indicated within this manual.

Once rental is initiated on an item, a subsequent request for prior approval of purchase of that item must be accompanied by additional supporting documentation validating the need for purchase. Rental reimbursements may not exceed the purchase price of the item. Once the purchase price of the item is reached, the rental will be considered purchased and no additional reimbursement will be made.

 

Example: If the monthly rental for an item is $30 and the new purchase price is $200, Health First Colorado will pay six (6) full months of rental, plus no more than $20 in the seventh month of rental. At that time, the item becomes the property of the member, and no more rental payments are made.

 

Continuous Rental: Most rented equipment will convert to purchase when the purchase price is met. The following are exceptions to this policy and may be rented indefinitely as they require frequent and/or substantial servicing:

  • Oxygen Equipment
  • Ventilators

 

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Transcutaneous or Neuromuscular Electrical Nerve Stimulators (TENS or NMES)

A prior authorization request (PAR) that includes a completed Questionnaire #9 is required for rental and purchase. A TENS or NMES unit must be trialed for at least a two (2) month rental period before a request for purchase will be considered.

  • All rental months must include the RR modifier on both PARs and claims.
  • In addition to the RR modifier, claims for the 1st month of rental must also include the KH modifier.
  • In addition to the RR modifier, claims for the 2nd month (and if applicable, the 3rd month) of rental must also include the KI modifier.
  • The purchase price is equivalent to 10 months of rental; requests for more than 10 months of rental will not be approved. The unit is considered owned by the member once the purchase price has been reached.
  • All supplies (i.e. lead wires, electrodes, batteries, etc.) are inclusive of the rental reimbursement and cannot be billed for separately while the unit is rented.

 

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Speech Generating Devices (SGDs)

SGDs allow a member with an expressive communication disorder (e.g., severe dysarthria, apraxia, aphasia, a laryngectomy and any other conditions that severely inhibit expressive communication) to express thoughts or ideas through an alternative means.

SGDs are classified as either Digitized or Synthesized (CCR 2505-10, §8.590.1.S):

Digitized - use words or phrases that have been pre-recorded by someone other than the member for playback, when commanded by the member.

Synthesized - utilize technology that allows input from the member in order to generate speech. These devices are not limited to pre-recorded messages and allow the member to create unique messages.

Tablet Computers are a benefit when they are primarily utilized as a Synthesized SGD.

 

Tablet Computer - A portable, integrated SGD, contained in a single panel, which utilizes touch screen technology. It is a device that has been manufactured by an entity that does not specialize in the production of SGDs or has not been re-branded specifically as an SGD.

Accessories for SGDs, such as speech generating software, mounting systems, safety and protection accessories (cases, screen protectors, etc.), and alternate access or input methods (buttons, switches, eye gaze, etc.), may be covered.

Communication Assessment
All PARs for SGDs and/or their accessories must include a communication assessment from the member's Speech Language Pathologist (SLP). (CCR 2505-10, §§8.590.3.E and 8.590.7.O).

The assessment must include documentation of:

  • The member's communication limitations and skills.
  • A history of communication-related therapies.
  • A description of the trials completed, including how each trial met or failed to meet the member's functional communication needs.
  • Evidence that alternative, natural communication methods have been ineffective.
  • The member's ability to operate the device or accessory, both cognitively and physically.
  • Expected improvement in the member's independence or personal safety, ability to communicate medical and basic needs, provide feedback on treatment or therapy programs, and prevent secondary impairments.

 

Repair
Repairs to an SGD or accessory do not require a communication assessment. If the frequency or cumulative cost of repairs is excessive (as determined by Health First Colorado's designated review entity), replacement will be considered. If the cumulative cost of repairs exceeds 60% of the cost of replacing the SGD and/or accessory (including labor), a quote for replacement must be included with the PAR.

Replacement (10 CCR 2505-10, §8.590.2.K)
The minimum replacement timeline for an SGD is five years, with the following exceptions:

  • There has been a significant change in the member's condition (as determined by Health First Colorado's designated review entity).
  • Stolen devices may be replaced within the five-year timeline; however, the member is limited to one-time replacement due to theft, and a police report must be provided for verification of the incident.

 

Accessories

  • Replacement accessories do not require an SLP assessment, provided that the replacement is an exact duplicate of the original.
    • In the event the original accessory has been discontinued or is otherwise no longer available, a manufacturer recommended alternative would not require an SLP assessment.

 

Limitations
Equipment, accessories and supplies that do not have a primary medical use will not be covered, which includes any items that are unnecessary for operation of the SGD, or are unrelated to the SGD (10 CCR 2505-10, §8.590.7.O.3.b.)

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Oxygen Contents and Oxygen Delivery Systems

Oxygen contents and delivery systems must be billed by the Supply provider.

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Continuous and Bilevel Positive Airway Pressure Devices (CPAP/BiPAP)

CPAPs and BiPAPs require a trial (rental) period of 30-90 days, in which the member must demonstrate compliance, before a purchase request will be approved. Home sleep studies are accepted and Questionnaire #8 is required for adults 21 years of age and over. Compliance is defined as usage that is ≥ 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the approved trial/rental period.

  • If the member does not reach compliance by the end of the trial period, a second trial period may be covered within a one year time frame at the discretion of the treating physician; a new prescription is required but not a new sleep study.
  • An extension of a trial period may be requested in the event of unforeseen circumstances (i.e. hospitalization, illness, etc.) and will be considered on a case-by-case basis.
  • Members 20 years of age and under may rent for up to six (6) months and provided that they demonstrate increasing compliance a purchase may be approved prior to reaching compliance.

Note: All related supplies are inclusive of the device's rental reimbursement and cannot be billed separately.

 

CPAP/BiPAP Replacement and Supplies

  • If a device is replaced within five (5) years because of loss, theft, or irreparable damage there is no requirement for a new sleep test or trial period.
  • If a device is replaced after five (5) years, there must be a face-to-face evaluation by the members treating physician (within six (6) months of the request) that documents that the beneficiary continues to use and benefit from the device. There is no requirement for a new sleep test or trial period.
  • When supplies are needed for a member-owned device, the PAR must include either a download from the device that demonstrates compliance or a face-to-face evaluation by the members treating physician (within six (6) months of the request) that documents that the beneficiary continues to use and benefit from the device.
  • If a member received a device prior to enrollment with Health First Colorado and is in need of a new device or supplies, then documentation that the beneficiary had a sleep test must be provided with the initial PAR. There is no requirement for a new sleep test unless the documentation from the prior test cannot be provided.

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Mobility Equipment (Manual Wheelchairs, Power Wheelchairs and Scooters)

All mobility equipment purchases require a PAR and must be accompanied by a signed letter of medical necessity from a physician, physician assistant or nurse practitioner. Customized items must be identified separately and included in the letter of medical necessity.

Members who meet medical criteria guidelines may receive one (1) primary device and, when deemed necessary, one (1) secondary device within a five (5)-year time period. Replacement of stolen equipment requires a police report that conforms to criteria outlined in the Colorado Revised Statutes. Primary and secondary equipment cannot be duplicates.

Billing

  • Providers must retain record of the serial number for each approved item. ALL claims for wheelchairs must be submitted with the serial number of the equipment that was approved on the PAR.
  • Primary, secondary, and back-up equipment are identified by their modifier(s) and serial number and should be indicated on all wheelchair claims to avoid duplicate claim denials.
  • Beginning July 1, 2017 all PARs and claims for:
    • New primary and new secondary mobility equipment and all associated components must include the NU modifier.
    • New equipment that is replacing existing equipment, the RA modifier should be included.
    • Parts (or systems) that are being replaced as part of a modification should include the NU and RA modifier.
    • Parts that are being replaced as part of a repair should include the RB modifier and should not include the NU modifier.

Note: Any time used equipment or parts are provided rather than new equipment or parts, the UE modifier should be used or used in place of the NU modifier. Please reference the Used and Refurbished DME and P&O section for additional information.

 

Repair
Primary and Secondary mobility equipment repairs are a Health First Colorado benefit when the member owns the equipment and the repair cost does not exceed the equipment's replacement cost. Repairs to back-up equipment or the short-term rental of back-up equipment may be covered. PARs for wheelchair repair no longer require a prescription or signature from the physician.

Prior Authorization for Repairs and Modifications
PARs submitted with multiple pieces of equipment on the same request will be denied; each wheelchair or scooter that requires PAR must be submitted on separate requests. The following information must be included in the request; requests lacking any of the following information will result in a denial or will be returned to the provider for the missing information:

  • Equipment type indication: manual, power; or scooter and
  • Manufacturer, make, and model; and
  •  
  • Serial number: PARs for repair and modification must identify the serial number of the base equipment in field 16 (paper) or field 12 (electronic) on the PAR form; and
  • If available, the original wheelchair purchase date or PAR number; and
  • Beginning July 1, 2017, the PAR must contain the RA or RB modifier depending on the request.

Note: Repairs for members residing in a nursing facility may be covered if the wheelchair was owned by the member prior to entering the facility. In this instance, the PAR must indicate that the member is residing in the nursing facility by checking "yes" in the appropriate field on the PA request. The PAR will not be processed without this disclosure.

 

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Complex Rehabilitation Technology (CRT)

Program Overview
Complex Rehabilitation Technology (CRT) includes individually configured manual wheelchair systems, power wheelchair systems, adaptive seating systems, alternative positioning systems, standing frames, gait trainers, and specifically designed options and accessories classified as DME. Only qualified CRT suppliers may bill CRT procedure codes. The CRT procedure codes are listed beginning on page 170.

Eligible Providers
Prescribing Providers

Complex Rehabilitation Technology must be prescribed by a physician, physician assistant or a nurse practitioner. The prescription must be within the scope of the prescribing provider's license.

Billing Providers

Only providers enrolled as a CRT supplier may bill for CRT codes. In order to qualify as a CRT supplier, providers must:
  • Be accredited by a recognized accrediting organization as a supplier of CRT.
  • Meet the supplier and quality standards established for DME suppliers under the Medicare or Health First Colorado program.
  • Employ at least one (1) qualified CRT professional (ATP) for each location.
  • Have CRT professionals present during member evaluation to:
    • Assist in selecting the appropriate CRT items for such needs and capacities
    • Provide the member technology- related training in the proper use and maintenance of the selected CRT items
    • Directly involve with the assessment, and determination of the appropriate individually configured complex rehabilitation technology for the member, with such involvement to include seeing the member visually either in person or by any other real-time means within a reasonable time frame during the determination process
  • Maintain a reasonable supply of parts, adequate physical facilities, and qualified services or repair technicians to provide members with prompt service and repair of all CRT it sells or supplies.
  • Provide the member written information at the time of sale as to how to access service and repair.

Existing Health First Colorado DME providers that want to enroll as a CRT Supplier, need to request a letter of intent to enroll as a CRT supplier. Suppliers with multiple Health First Colorado provider ID numbers need to submit a letter of intent for each provider ID number that will bill CRT for Health First Colorado.

 

Billing for Repairs
Providers must retain record of the serial number for each approved repair item. The serial number must also be included on the CMS 1500 claim form in field 30 for all paper claims.

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Prosthetics and Orthotics (P&O)

The benefit includes, but is not limited to, items such as breast prostheses, braces, artificial limbs, implants, and

orthopedic shoes for diabetic members. Some services require prior authorization.

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Supplies

Disposable Supplies

Disposable supplies are a benefit of the Health First Colorado for use by the member in his/her home. With the exception of gloves, the Home Health agency is responsible for providing all supplies necessary to meet the universal precaution requirement during a visit.

Beginning August 1, 2015, nasal atomizers (A4210) are a benefit when used in conjunction with the rescue medications Naloxone or Midazolam. For coverage information on Naloxone and Midazolam, refer to Appendix P found under the Appendices drop-down section on the Billing Manuals web page.

Effective September 1, 2020, coverage of the Peristeen System product is being amended to allow for medically necessary daily use in addition to every-other day use. The below table details the benefit for this product. Both HCPCS require prior authorization.

HCPCS

Item Description

Daily Use

Every-other Day Use

A4459

Manual pump-operated enema system, includes balloon, catheter and all accessories, reusable, any type.

 

1 unit of service = 1 pump of 90 uses and 15 catheters.

4 units per year

2 units per year

A9270

Peristeen Supplies, includes catheters and 1 bag.

 

1 unit of service  = 1 pack of 15 catheters.

21 units per year

11 units per year

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Enteral Nutrition Products

Enteral nutrition (EN) refers to medical formula/solutions when ordered by a physician, physician assistant, or nurse practitioner and provided according to standards of practice. The allowance for all items includes delivery to a member's residence. Equipment, supplies, and nutrients for enteral feeding or food supplements are a benefit when prior authorized.

Durable Medical Equipment providers should request that members participate in the Women, Infants & Children (WIC) program as a primary resource for medically necessary enteral nutrition products. Enteral nutrition products prescribed over the WIC limit are a covered benefit. Providers have the option of requesting a three (3) month PAR for members in the process of applying for WIC. After WIC determination is completed, provider may then submit a new PAR for one (1) year less one (1) day.

PARs and claims must identify the calculated number of units as specified in the current Supply HCPCS Codes section of this billing manual. Nutritional supplements are not for replacement of conventional foods or for use as a convenience item.

Home Intravenous (IV) Equipment

Home Intravenous (IV) equipment is a benefit for administration of Total Parenteral Nutrition (TPN), administration of antibiotics, maintenance of electrolyte balances, hydration, or other medications. The home IV therapy solutions and medications in this manual that are indicated as a home mix are a pharmacy benefit. The following HCPCS codes must be provided by a pharmacy per pharmacy billing requirements using a rebatable National Drug Code (NDC) number: B4164, B4168, B4172, B4176, B4178, B4180, B4189, B4193, B4197, B4199, B4216, B5000, B5100, and B5200. These codes are only reimbursed as a supply benefit for crossover claims when provided as an inpatient therapy for full benefit Medicare-Health First Colorado members.

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Diabetic Supplies

Most diabetic supplies, such as glucose testing meters, test strips and other related supplies are a benefit with a prescription from a physician, physician assistant or nurse practitioner. Diabetic supplies are available for insulin, and non-insulin dependent members. Diabetic supplies MUST be billed as DMEPOS. Pharmacies billing supplies must follow Supply billing procedures and will not be reimbursed if billed as a pharmacy claim using NDC codes.

Incontinence Products or Briefs

The prescribing practitioner's prescription must include incontinence as a condition of a primary or secondary diagnosis in order for the member to qualify for reimbursement by the Health First Colorado. Diapers or briefs for children under four (4) years old are an expected childhood expense and are not a Health First Colorado benefit.
COMBINATION LIMIT: Products are limited to 240 per calendar month in any combination of diapers, liners, and undergarments. Medically necessary usage above that amount requires prior authorization. Incontinence wipes are not a benefit.

A4520 Incontinence garment, any type, (e.g. brief, diaper) each
The code A4520 is not an open code. If the PDAC has assigned an incontinence product the code A4520, the claim (and PAR if required) should use the most appropriate T-code listed in the HCPCS code table within this manual.

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Special Considerations

Rental

There may be a financial cap on rental items. If the total cost for rental of an item reaches the cost of purchase, the item will be converted to a purchase unless otherwise specified. Rental amounts in excess of purchase amounts are subject to recovery.

Modifier RR (rental) or KR (partial month rental) should be on all PARs (if required) and claims. One unit of a code with the RR modifier is the equivalent of a one-month rental. One unit of a code with the KR modifier is the equivalent of a one-day rental.

  • In some cases, as indicated in the HCPCS table, RR billed with multiple units and a date span is used to represent a daily rental. The number of days in the date span should equal the number of units for that line item.

Accessories, supplies, maintenance, and repairs are inclusive in the reimbursement of rented equipment, unless otherwise specified.

 

For equipment that is considered a continuous rental, accessories and supplies may be billed separately. Continuous rental items (i.e. ventilators) do not require the KH (1st month rental) modifier. Additionally, if a member qualifies to have a back-up ventilator, two (2) units may be billed per month, otherwise, only one (1) unit is allowable.

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Related Medical Supplies

Supplies accompanying DME that has been prescribed and is owned by and currently being used by the member are covered.

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Used and Refurbished DME and P&O

Supply providers have the option to request used and/or refurbished DME and P&O. Equipment may be donated, passed down from a sibling, or purchased from a DMEPOS provider post refurbishment. Used equipment also includes equipment that has not been previously rented or sold (e.g., equipment used for trial periods or as a demonstrator). All used and refurbished equipment requires a PAR.

The DMEPOS provider must guarantee that the equipment provided to the member is in "like new" condition, and that any modifications are made prior to the delivery of the equipment. The cost of repairs or modifications must not exceed the cost of replacement equipment. The provider will maintain a one (1) year limited warranty that covers all necessary parts or repairs. Comparison pricing for new equipment must be included in the PAR documentation. PAR documentation must include the make, model, and serial number of equipment. The Used Equipment (UE) modifier must be included on all used and refurbished equipment PARs and claims.

Examples of allowable used or refurbished equipment include but are not limited to:

  • Manual Wheelchairs
  • Power Operated Vehicles (Scooters)
  • Power Wheelchairs
  • Hospital Beds (Frame only, new mattress must be purchased)
  • Lifts
  • Speech Generating Devices

If new equipment is rented to and subsequently purchased by the same member, it would not be considered used. Supplies (disposable items) may not be provided as used.

 

Unless a part of the Upper Payment Limit(UPL), the maximum allowable for used/refurbished equipment is 60% of the equipment's maximum allowable for purchase.

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Dates of Service after the Death of a Health First Colorado Member

Health First Colorado will reimburse supply providers for durable medical rental equipment, oxygen, and bulk supplies that are drop-shipped to the member's home for services rendered during the month of the member's death. Health First Colorado will make recoveries for other services following the date of the member's death, or for rental and bulk supplies billed after the month of the member's death.

Shipped Supplies

Suppliers may not automatically dispense a quantity of supplies on a predetermined regular basis. Members must be contacted prior to shipping to ensure that member information is correct, there have been no changes to the prescription, and supplies/additional supplies are needed. Member contact consists of either a request from the member/caregiver that supplies are needed or a member/caregiver's response to an inquiry by the DMEPOS Provider that supplies are needed. Members may not be charged for costs associated with shipping and handling.

Providers must use the date the supply was delivered to the member as the “From Date” on claim submissions for shipped supplies.

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Face-To-Face (F2F) Requirements

A face-to-face (F2F) encounter is a federally required visit in which members must meet with a physician, or other allowed practitioner, within six months prior to the start of service for certain DME items.

The F2F encounter documentation must demonstrate that the prescriber met F2F with the member specifically related to the member's primary clinical need for the prescribed DME item.

Allowed Practitioners
The F2F must be conducted and documented by the following allowed practitioners:

  1. Physician,
  2. Physician Assistant,
  3. Nurse Practitioner, or
  4. Clinical Nurse Specialist.

Non-physicians (listed above) that perform a F2F, must communicate their clinical findings of that F2F encounter to the physician responsible for prescribing the related DME. These, and all F2F clinical findings, must be incorporated into a written or electronic document included and maintained in the member's medical record.

 

Medicare Coding
The F2F requirement does not apply to all DME but is required for those codes that Medicare has published as requiring a F2F encounter.

To date, Medicare has chosen to not enforce their F2F requirements. As a result, the F2F code list has not been updated since 2016.

Six Month Requirement – Start of Services
The F2F encounter must happen within 6 months prior to the start of services and must be performed by the prescribing physician or other allowed practitioner.

Start of Services: The date the member receives the DME item.

A F2F is only required for the initiation of the DME. The provision of the prescribed DME item does not require multiple F2F encounters for each related item; only documentation that the F2F occurred and is related to the main reason the DME item is needed.

 

Repair and replacement do not require the F2F.

Documentation
The F2F encounter must be documented to include the following:

  1. the primary reason the member requires the prescribed DME; and
  2. the F2F encounter was related to the primary reason the member requires the prescribed DME; and
  3. the signature allowed practitioner who performed the F2F encounter;
  4. the date of the F2F encounter;
  5. that the F2F encounter occurred within six months.

The member's medical need for the DME item should be clearly communicated in the F2F documentation. This will aid manufacturers in supplying the DME item without sending the member back multiple times for unnecessary F2F encounters.

 

Note: The prescriber's responsibility, concerning a F2F encounter, is to meet with the member and document the member's medical need for an item of DME, NOT to detail every DME item the member might need.

Telehealth

F2F encounters may be performed via telehealth if available.

Pricing

There are three (3) ways to determine the maximum allowable for DMEPOS: the fee schedule, the Manufacturer's Suggested Retail Price (MSRP), and By Invoice.

Percentages noted below can be found in 10 CCR 2505-10, Section 8.590.7 of the Health First Colorado rules.

Usual and Customary Charge (U&C): What a provider would charge the general public for the product/service.

The Submitted Charge on a claim, regardless of how the maximum allowable is determined, should always be a provider's U&C.

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Fee Schedule

For fee schedule items, reimbursement is the lower of the U&C or the fee schedule rate. No additional handling, shipping, or tax charges may be billed.

For the majority of the DMEPOS codes, the fee schedule can be found on the Health First Colorado Fee Schedule.

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Federal Upper Payment Limit (UPL) requirement

As of January 1, 2018, Health First Colorado is required to comply with the Consolidated Appropriations Act of 2016 (Section 503) which means Health First Colorado cannot pay more than what Medicare would have paid in the aggregate for certain DME services. The original effective date was January 1, 2019 but the Cures Act (Section 5002) changed the effective date to January 1, 2018.

  1. Compliance is measured by Health First Colorado's aggregate expenditure on a per calendar year basis.
  2. If the code was NOT billed/paid by both Medicare and Health First Colorado during the prior calendar year, it is NOT included.
  3. Only DME codes beginning with A, E, and K are included.
  4. Orthotics, prosthetics, and disposable supply codes are NOT included.
  5. Medicare's competitive bid codes that are in line with points two and three are included.
  6. Oxygen and oxygen systems are included.

Codes that fall within the scope of the UPL are indicated on the HCPCS Table in the Comments column with the following notation:

*Code is subject to the 2019 DME UPL

The fee schedule for the DME UPL codes can be found on the Rates and Fee Schedules web page under Durable Medical Equipment, Upper Payment Limit.

 

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Manufacturer Suggested Retail Price (MSRP)

If the fee schedule states "Code is Manually Priced", reimbursement is the lower of (MSRP less 17.51%) or the provider's U&C.

  • The provider must keep a copy of the item's invoice and documented MSRP.
  • The documented MSRP must include the name of the provider's employee that received and documented the MSRP, and the date the MSRP was received.
  • Providers may not submit for reimbursement for either state sales tax collection or shipping costs.
  • Providers must add the 'SC' modifier when using the MSRP for pricing.
  • Providers must attach a copy of the MSRP on all claims.
    • Providers may manually indicate on the MSRP documentation the actual quantity supplied to the member if it differs from claim total.
  • Providers may not use MSRP pricing for procedure code A9901.

 

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By Invoice

If the fee schedule states "Code is Manually Priced" and the product has no MSRP, reimbursement is the lower of the Actual Acquisition Cost plus 20.70% or the provider's U&C.

Actual Acquisition Costs are defined as the manufacturer's list price for the item less any standard trade discount applied to lower the actual cost to the provider but excluding any time sensitive or otherwise conditional discounts available to the provider. The provider must keep a copy of the item's invoice.
Misrepresentation of Actual Acquisition Costs could result in State or Federal, civil or criminal sanctions.

In order to receive the maximum allowable reimbursement for By Invoice items, one (1) unit of procedure code A9901 with the 'UB' modifier must be included on the claim. The Submitted Charge for A9901 should reflect the provider's U&C minus the Actual Acquisition Cost.

Reimbursement for A9901 will be the lower of (U&C minus Actual Acquisition Cost) or 19.50% of the Actual Acquisition Cost.

Providers must attach a copy of the invoice on all claims.

Line items that are reimbursed by invoice must:

  • Include the 'UB' modifier; and
  • The Submitted Charge must match the amount on the invoice (excluding A9901).

 

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Maximum allowable for A9901
= (total of all other line items on the claim with the 'UB' modifier) x (19.50%)

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Hypothetical Example
B9998: Actual Acquisition Cost = $100

  • U&C minus Actual Acquisition Cost: $125 - $100 = $25
  • 19.50% of Actual Acquisition Cost: $100 x 19.50% = $19.50
1 B9998 UB Submitted Charge = $100 ➙ Reimbursement = $100
2 A9901 UB Submitted Charge = $25 ➙ Reimbursement = $19.50

Effective 7/1/2018, A9901 will no longer be used for Manual Pricing by invoice. The percentage above the invoice cost will be calculated in line with the base code, similar to how MSRP works.

1 E1399 UB $1000 (actual invoice cost)
2 A9901 UB $195.00 (19.50% of the invoice cost)

Effective July 1, 2018, maximum allowable is:

1 E1399 UB $1207.00 (actual invoice cost + 20.70%)

The Submitted Charge should reflect the provider's U&C.

The math for calculating the maximum allowable must be shown. It may be added to the invoice or a separate attachment. Using the above example:

  • $1000 x 1.207 = $1207.00, or
  • $1000 x .207 = $207.00 + $1000 = $1207.00
  • If the full quantity on the invoice was not provided to the member (i.e. a bulk order) a breakdown of the cost per unit multiplied by the quantity provided must be shown. In the instance where a manufacturer puts the cost per unit on their invoice, the per unit price calculation does not need to be shown. However, the unit price does need to be multiplied by the quantity provided.

After verifying the calculation, claims processors will price the claim at the lower of U&C or the actual invoice cost plus the percentage.

 

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Maximum Allowable for Rental

Fee schedule: With the exception of oxygen and items noted as continuous rental, rental reimbursement caps at the item's purchase price.

MSRP or By Invoice Pricing: Fee schedule items that require manual pricing for rental, excluding oxygen, are reimbursed using the MSRP or Invoice methodology, divided by 13, for one month of rental. If for a partial month rental, divide again by 30 for the daily maximum allowable. Total rental reimbursement cannot exceed the maximum allowable purchase price.

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Rebates

If a rebate is available, the provider must reflect U&C minus the rebate received or anticipated from the manufacturer.

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Prior Authorization Requests (PARs)

Some supply items and most DME items require prior authorization. A member may be required to receive an occupational therapy evaluation to determine appropriateness of prescribed equipment such as motorized chairs. This manual contains a detailed list of prior authorization requirements as well as the correct form and mailing address for each PAR.

Prior Authorization Requests must be submitted and approved before services are rendered. The service must be rendered by the identified supplier on the approved PAR. Services rendered must match the approved services exactly.

Approval of a PAR does not guarantee Health First Colorado payment and does not serve as a timely filing waiver. Prior authorization only assures that the approved service is a medical necessity and is considered a benefit of Health First Colorado. All claims, including those for prior authorized services, must meet eligibility and claim submission requirements (e.g., timely filing, detailed provider information, detailed description of medical necessity, all required attachments included, etc.) before payment can be made.

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PAR Submission

All PARs must be submitted by the supply provider that intends to submit the claim for the service and have an attached prescription from the prescribing authority and any other required documentation. Each PAR must include the name and phone number of the member's Primary Care Physician (if applicable). PAR requests for members with a non-Health First Colorado primary care physician must include the primary care provider's National Provider Identifier (NPI), contact information and note in the "comment" section stating that the referring provider is not a Health First Colorado provider and prescriptive authority has been verified. Providers shall not charge a member for items covered as a Health First Colorado benefit. This includes but is not limited to blood pressure monitors, blood glucose monitors, walkers, canes, nutritional supplements, and incontinence products.

Prior Authorization Request dates typically have a date span for one (1) year less one (1) day. Exceptions for decreased span dates less than one (1) year are allowed in certain circumstances such as short-term rental or WIC application period. Dates must not exceed one (1) year and must match the dates on individual line items or the PAR will be denied.

All PARs and revisions processed by the ColoradoPAR Program must be submitted through www.ColoradoPAR.com. Prior Authorization Requests submitted via fax or mail will not be processed by the ColoradoPAR Program and subsequently not reviewed for medical necessity. These PARs will be returned to providers via mail.

This requirement only impacts PARs submitted to the ColoradoPAR Program.

The electronic PAR format will be required unless an exception is granted by the ColoradoPAR Program. Exceptions may be granted for providers who submit five (5) or less PARs per month. To request an exception, more information on electronic submission, or any other questions regarding PARs submitted to the ColoradoPAR Program, please contact the ColoradoPAR Program at 888-801-9355 or refer to the Department's Colorado PAR Program webpage.

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PAR Review and Notification

The actual number of units approved for any item may be reduced or increased by the reviewer evaluating the PAR.

Once review is complete, the status of a PAR (approved, partially approved or denied) is available through the Health First Colorado Secure Web Portal (Web Portal). In addition, both the provider and the member receive a letter indicating whether or not the services were authorized. The letter will include a PAR number that must be included on the claim.

Submitting Claims after PAR Approval

Providers must receive an approval for all items/services that require a prior authorization before submitting a claim.

Once prior authorization is received, claims should only include the approved PAR number and, if applicable, the serial number of the approved equipment. In most cases, it is not necessary to submit a copy of the approved PAR. Providers will be notified if a copy of the approved PAR is needed.

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Questionnaires

All questionnaires are located in the Provider Services Forms web page of the Department's website, under DMEPOS Questionnaires.

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Complex Rehabilitation Technology (CRT)

There are two (2) levels of documentation requirements associated with PARs for CRT:

  1. Basic Documentation
    • This level of documentation does not require a specialty evaluation. Basic documentation requirements apply to all CRT wheelchairs and wheelchair-related items that require a PAR. The basic documentation should include at a minimum the following information:
    • Member's name, date of birth, residence address, height and weight, and all relevant medical diagnoses.
    • A summary of the member's current medical condition, prognosis, previous and current treatments that are pertinent to the requested item.
    • Length of anticipated need for the requested item.
    • A brief description of the member's impairment in functional mobility that establishes that they have a mobility limitation and the item is needed for a medical purpose.
    • If the recommended item is not the least costly option available to meet the member's medical need, documentation must contain a brief description of the impairments in body functions or structures that rule out use of the less costly item to justify the need for the recommended item.
    • A description of how the member will operate the device (e.g. self-propel, tiller, joystick, etc.). Include a statement summarizing the member's mental and physical abilities/limitations as they pertain to member's ability to operate the recommended equipment appropriately for the duration of recommended use and in the environments in which it will routinely be used.
    • If applicable, a brief description of the member's seating and positioning needs, and how these will be adequately met by the recommended device.
    • If applicable, a brief description of where the equipment is to be used (example home, school, place of work, neighborhood, rural, city, train, etc...), including the accessibility of member's residence or non-institutional setting. Include if the equipment will be transported in a vehicle and how, as well as the capability of the member or caregiver to properly operate the equipment in these environments.
    • A brief description of any anticipated changes in the member's physical size, medical or functional status which may require modifications to the equipment, and how the equipment will accommodate the member's needs over time. The recommended equipment should be capable of modification to meet the needs for anticipated improvement or deterioration of functional mobility when possible.
    • Detailed description of all manually priced items that are requested including manufacturer's retail pricing or invoice information with itemized pricing, including the description of the specific base, any attached seating system components, and any attached accessories.
    • All basic documentation paperwork (except for repair and replacement) requires the signature of the ordering physician, indicating that he or she agrees with the recommendation, and has evaluated the member within the past 12 months of signing and dating the required paperwork.
  2. Specialty Evaluation Documentation

    This level of documentation provides further details in order to establish medical necessity. A specialty evaluation is an assessment performed by a licensed/certified medical professional (such as a Physical Therapist, Occupational Therapist, or physician) who has no financial relationship with the DME supplier and who has specific training and experience in complex rehab technology wheelchair evaluations. The evaluation includes the physical and functional evaluation, treatment plan, goal setting, preliminary device feature determination, trials/simulations, fittings, function related training, determination of outcomes, and related follow-up. This evaluation is performed in conjunction with an equipment supplier who is a Rehabilitation Engineering and Assistive Technology Society of North America (RESNA)-certified Assistive Technology Professional (ATP), and who assists with the home environment accessibility survey, system configuration, fitting, adjustments, programming, and product related follow up.

    Specialty evaluation is required for:

    • A new CRT wheelchair or a replacement CRT wheelchair after the 5th year mark for adults and 3rd year mark for children.
    • A new custom contoured seating system or modification.
    • An addition of power seating or alternative drive control to a wheelchair.

     

    Items that require a specialty evaluation must include both the basic and specialty evaluation documentation. Documentation for specialty evaluation should include the following information in addition to the basic documentation requirements previously listed:

    • Date(s) of specialty evaluation
    • The name and signature of licensed/certified medical professional completing the evaluation and assessment
    • A statement attesting that the person performing the assessment has no financial relationship with the DME provider should be included.
    • A brief description of the specialty evaluation process that was completed, which includes a summary of the pertinent assessment findings/outcomes in the following assessment areas that apply:
      • Functional mobility, including transfers
      • Sitting balance/postural alignment
      • Existence and severity of postural asymmetries
      • Sensory function, if impaired
      • Neuromusculoskeletal function (movement, muscle tone, coordination)
      • Mat exam (joint range of motion, deformities, orthopedic impairment), addressing the existence and severity of orthopedic deformities
      • Equipment trials/simulations
    • A description of the member's current mobility and/or seating equipment, how long the member has been using the current equipment and why it no longer meets the member's needs.
    • Information on any recent changes in the member's physical or functional status, and any expected or potential surgeries that will improve or further limit mobility.
    • If applicable, information regarding the member's seating and positioning needs and the specific seating equipment and accessories required to meet those needs.
    • A summary of the type of mobility equipment that will best meet the member's medical and functional needs and an explanation of the basic and/or instrumental ADLs that will be possible with this equipment that would not be possible with a lower level or lower cost item.
    • If applicable, documentation that supports why a tilt seat function is necessary to meet the member's medical and/or functional needs.
    • If a member has a progressive disability, the documentation must indicate how the item will accommodate the member's needs over time. If a member is expected to grow, the wheelchair must have a growth potential.
    • All specialty evaluation paperwork requires the signature of the ordering physician, indicating that he or she agrees with the recommendation and has evaluated the member within the past 12 months of signing and dating the required paperwork.

     

NOTE: Specialty evaluation is not required for CRT repair and replacement.

 

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Record Keeping

Supply providers must maintain the records described below for all items provided to member. Supply providers must keep the information for six (6) years, and provide a copy of any documentation to the Department and member or his/her representative upon request.

  • Prescribing practitioner's prescription(s);
  • Approved prior authorization requests;
  • Additional documentation received from physicians or other licensed practitioners;
  • Documentation that the member or caregiver has been provided with the following:
    • Manufacturer's instructions;
    • Warranty information;
    • Registration documents;
    • Service manual; and
    • Operating guides.
  • Documentation on all reimbursed equipment, which shall include:
    • Manufacturer's name and address;
    • Date acquired;
    • Acquisition cost;
    • Model number;
    • Serial number; and
    • Accessories, attachments or special features included in the item.
  • Verification that equipment requiring repairs belongs to the presenting member.

 

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Billing Information

Refer to the General Provider Information manual for general billing information.

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Using Modifiers

Modifiers are used with HCPCS codes to describe circumstances that may change or alter payment, or provide additional information. Refer to the approved modifiers for use with DME procedure codes in field locator 19c in the Paper Claim Reference Table section.

The following modifiers are approved for use with DME procedure codes and must be used when applicable:

BO Orally administered nutrition, not by feeding tube
KH DMEPOS item, initial claim, purchase or first month rental KI DMEPOS item, second or third month rental.
KR Rental item, billing for partial month
MS Six (6) month maintenance and servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warranty
RR Rental (use the RR modifier when DME is to be rented)
SC Medically Necessary Service or Supply - To be used with MSRP priced codes only
TT Individualized service provided to more than one (1) member in same setting TW Secondary or back-up equipment
UB Invoice cost – To be used with "By Invoice" priced codes only
NU New Equipment
UE Used Equipment
Effective July 1, 2017
RA Replacement of a DME, orthotic or prosthetic item
RB Replacement of part of a DME, orthotic or prosthetic item furnished as part of a repair
Effective June 1, 2018:
KF Item designated by the FDA as a Class III device

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Procedure/HCPCS Codes Overview

The Colorado Department of Health Care Policy and Financing develops procedure codes that are approved by the Centers for Medicare & Medicaid Services (CMS). The codes are used for submitting claims for services provided to Health First Colorado members and represent services that may be provided by enrolled certified Health First Colorado providers.

The Healthcare Common Procedural Coding System (HCPCS) is divided into two (2) principal subsystems, referred to as level I and level II of the HCPCS. Level I of the HCPCS is comprised of CPT (Current Procedural Terminology), a numeric coding system maintained by the American Medical Association (AMA).

The CPT is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other health care professionals. Level II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT codes, such as ambulance services, durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office. Level II codes are also referred to as alphanumeric codes because they consist of a single alphabetical letter followed by four (4) numeric digits, while CPT codes are identified using five (5) numeric digits.

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Paper PAR Instructional Reference

Field Label Completion Format Instructions
The upper margin of the PAR form must be left blank. This area is for authorizing agency use only.
Invoice/Pat Account Number Text Optional

Enter up to 12 characters (numbers, letters, hyphens) that help the provider identify the claim or member.
1. Member Name Text Required

Enter the member's last name, first name, and middle initial exactly as it appears on the eligibility verification.

Example: Adams, Mary A.
2. Member Identification Number 7 characters Required

This number consists of a letter prefix followed by six (6) numbers.

Example: A123456
3. Sex Check box
M   F
Required

Enter an "X" in the appropriate box.
4. Date of Birth 6 digits Required

Enter the member's birth date using a MMDDYY format.

Example: January 1, 2015 = 010115
5. Member Address Characters:
numbers and letters
Required

Enter the member's full address: Street, city, state, and zip code.
6. Member Telephone Number Text Optional

Enter the member's telephone number.
7. Prior Authorization Number None Leave Blank

This field is automatically system assigned
8. Dates Covered by This Request 6 digits for From date and 6 digits for Through date Optional

Enter the date(s) within which service(s) will be provided. If left blank, dates are entered by the authorizing agent. Authorized services must be provided within these dates. Use the MMDDYY format.

Example: January 1, 2016 – January 31, 2016 = From 010116 Through 013116
9. Does Member Reside in a Nursing Facility? Check Box
Yes   No
Required

Check the appropriate box.
10.Group Home Name if Member Resides in a Group Home Text Conditional

Complete if member resides in a group home.

Enter the name of the group home or residence.
11.Diagnosis Text Required

Enter the diagnosis code and sufficient relevant diagnostic information to justify the request. Include the prognosis. Provide relevant clinical information, other drugs or alternative therapies tried in treating the condition, results of tests, etc., to justify a Health First Colorado determination of medical necessity. Approval of the PAR is based on documented medical necessity. Attach documents as required.
12.Requesting Authorization for Repairs Text Conditional

Complete if requesting repairs for equipment owned by the member.

Enter the serial number of the equipment.
13.Indicate Length of Necessity Text Conditional

Complete if renting equipment. Provide best estimate of how long equipment will be needed.
14.Estimated Cost of Equipment Digits Conditional

Complete if purchasing, replacing, or repairing equipment. Provide best estimate of cost for labor and replacement part(s) for repair or cost for purchases.
15.Services To Be Authorized None Preprinted

Do not alter preprinted lines. No more than five (5) items can be requested on one (1) form.
16.Describe Procedure, Supply, or Drug to be Provided Text Required

Enter the description of the service/procedure to be provided. Include model number for DME purchase or serial number for repair.
17.Procedure, Supply or Drug Code 5 digits Required

Enter the appropriate HCPCS code for each item that will be billed on the claim form. The authorizing agent may change any code.

The approved code(s) on the PAR form must be used on the claim form.
18.Number of Services Digits Required

Enter the number of units for supplies, services or equipment requested. If this field is blank, the authorizing agent will complete with one (1) unit.
19.Authorized No. of Services None Leave Blank

The authorizing agent indicates the number of services authorized which may or may not equal the number requested in Field 18 (Number Of Services).
20.A=Approved
D=Denied
None Leave Blank

Providers should check the PAR on-line or refer to the PAR letter.
21.Primary Care Physician (PCP) Name Text Conditional

Complete if member has a PCP. Enter the PCP's name as it appears on the current eligibility verification.
Telephone Number Text Optional

Enter the PCP's telephone number.
22.Primary Care Physician Address Text Conditional

Complete if member has a PCP. Enter the PCP's complete address.
23.PCP Provider Number 8 Digits Conditional

Complete if member has a PCP. Enter the PCP's eight-digit Colorado Medical Assistance provider number. This number must be obtained by contacting the PCP for the necessary authorization.
24.Name and Address of Provider Requesting Prior Authorization Text Required

Enter the complete name and address of the physician requesting prior authorization (the physician ordering/writing the prescription).
25.Name of Provider Who will Render Service Text Required

Enter the name and telephone number of the supplier who will render the service.
26.Signature Text Required

The prescribing authority must sign the PAR or the prescription must be attached. If prescription is attached notate "see attached." Do not send the original prescription; send a photocopy on an 8½ x 11 sheet. The written diagnosis must be entered in Field 11 (Diagnosis), even if a prescription form is attached.

A rubber stamp facsimile signature is not acceptable on the PAR.
Telephone Number Text Required

Enter the telephone number of the requesting provider.
27. Date Signed 6 Digits Required

Enter the date the PAR form is signed by the requesting provider.
28. Requesting Provider Number 8 Digits Required

Enter the eight-digit Health First Colorado provider number of the requesting provider.
Telephone Number Text Required

Enter the telephone number of the requesting provider.
29. Billing Provider Number 8 Digits Required

Enter the eight (8)-digit Health First Colorado provider number of the billing provider. The billing provider must be enrolled in the Health First Colorado.
30. Comments or Reasons For Denial of Benefits None Leave Blank

Refer to the PAR response for comments submitted by the authorizing agency.
31. PA Number Being Revised Text Leave Blank

This field is completed by the authorizing agency.

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Prior Authorization Request (PAR) Form

Prior Authorization Request (PAR) Form

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Paper Claim Reference Table

Supply and DME claims are submitted on the CMS 1500 claim form or as an 837P transaction. The following paper claim form reference table shows required fields and detailed field completion instructions.

Instructions for completing and submitting electronic claims are available through the X12N Technical Report 3 (TR3) for the 837P (wpc-edi.com), 837P Companion Guide (in the EDI Support section of the Department's Web site), and in the Web Portal User Guide (via within the portal).

CMS Field Number & Label Field is? Instructions
1. Insurance Type Required Place an "X" in the box marked as Medicaid.
1a. Insured's ID Number Required Enter the member's Health First Colorado seven-digit Medicaid ID number as it appears on the Medicaid Identification card. Example: A123456.
2. Patient's Name Required Enter the member's last name, first name, and middle initial.
3. Patient's Date of Birth/Sex Required Enter the member's birth date using two digits for the month, two digits for the date, and two digits for the year. Example: 070114 for July 1, 2014.

Place an "X" in the appropriate box to indicate the sex of the member.
4. Insured's Name Conditional Complete if the member is covered by a Medicare health insurance policy.

Enter the insured's full last name, first name, and middle initial. If the insured used a last name suffix (e.g., Jr, Sr), enter it after the last name and before the first name.
5. Patient's Address Not Required  
6. Client Relationship to Insured Conditional Complete if the member is covered by a commercial health care insurance policy.
7. Insured's Address Not Required  
8. Reserved for NUCC Use    
9. Other Insured's Name Conditional If field 11d is marked "yes", enter the insured's last name, first name, and middle initial.
9a. Other Insured's Policy or Group Number Conditional If field 11d is marked "yes", enter the policy or group number.
9b. Reserved for NUCC Use    
9c. Reserved for NUCC Use    
9d. Insurance Plan or Program Name Conditional If field 11d is marked "yes", enter the insurance plan or program name.
10a-c. Is patient's condition related to? Conditional When appropriate, place an "X" in the correct box to indicate whether one or more of the services described in field 24 are for a condition or injury that occurred on the job, as a result of an auto accident or other.
10d. Reserved for Local Use    
11. Insured's Policy, Group or FECA Number Conditional Complete if the member is covered by aMedicare health insurance policy.

Enter the insured's policy number as it appears on the ID card. Only complete if field 4 is completed.
11a. Insured's Date of Birth, Sex Conditional Complete if the member is covered by aMedicare health insurance policy.

Enter the insured's birth date using two (2) digits for the month, two (2) digits for the date and two (2) digits for the year.
Example: 070115 for July 1, 2015.

Place an "X" in the appropriate box to indicate the sex of the insured.
11b. Other Claim ID Not Required  
11c. Insurance Plan Name or Program Name Not Required  
11d. Is there another Health Benefit Plan? Conditional When appropriate, place an "X" in the correct box. If marked YES, complete 9, 9a and 9d
12. Patient's or Authorized Person's signature Required Enter "Signature on File", "SOF", or legal signature. If there is no signature on file, leave blank or enter "No Signature on File".

Enter the date the claim form was signed.
13. Insured's or Authorized Person's Signature Not Required  
14. Date of Current Illness Injury or Pregnancy Conditional Complete if information is known. Enter the date of illness, injury or pregnancy, (date of the last menstrual period) using two (2) digits for the month, two (2) digits for the date and two (2) digits for the year.Example: 070116 for July 1, 2016.

Enter the applicable qualifier to identify which date is being reported
431 Onset of Current Symptoms or Illness
484 Last Menstrual Period
15. Other Date Not Not Required  
16. Date Patient Unable to Work in Current Occupation Not Required  
17. Name of Referring Physician Required  
18. Hospitalization Dates Related to Current Service Conditional Complete for services provided in an inpatient hospital setting. Enter the date of hospital admission and the date of discharge using two (2) digits for the month, two (2) digits for the date and two (2) digits for the year. Example: 070116 for July 1, 2016. If the member is still hospitalized, the discharge date may be omitted. This information is not edited.
19. Additional Claim Information Conditional Durable Medical Equipment

Complete for DME purchases, repairs, and labor.

Enter the make, model and serial number of the equipment.
20. Outside Lab?
$ Charges
Not Required  
21. Diagnosis or Nature of Illness or Injury Required Enter at least one but no more than twelve diagnosis codes based on the member's diagnosis/condition.

Enter applicable ICD-10 indicator.
22. Medicaid Resubmission Code Conditional List the original reference number for resubmitted claims.

When resubmitting a claim, enter the appropriate bill frequency code in the left- hand side of the field.
7 - Replacement of prior claim
8 - Void/Cancel of prior claim
This field is not intended for use for original claim submissions.
23. Prior Authorization Conditional Complete for medical equipment and supplies that require prior authorization. If the procedure code requires prior authorization, enter the prior authorization from the approved Prior Authorization Request (PAR). Do not combine services from more than one (1) approved PAR on a single claim form. Do not attach a copy of the approved PAR unless advised to do so by the authorizing agency or the fiscal agent.
24. Claim Line Detail Information The paper claim form allows entry of up to six detailed billing lines. Fields 24A through 24J apply to each billed line.

Do not enter more than six lines of information on the paper claim. If more than six lines of information are entered, the additional lines will not be entered for processing.

Each claim form must be fully completed (totaled).

Do not file continuation claims (e.g., Page 1 of 2).
24A. Dates of Service Required The field accommodates the entry of two dates: a "From" date of services and a "To" date of service. Enter the date of service using two digits for the month, two digits for the date and two digits for the year. Example: 010116 for January 1, 2016.
From To
01 01 19               
or
From To
01 01 19 01 01 19
Span dates of service
From To
01 01 19 01 31 19
Practitioner claims must be consecutive days.
Single Date of Service: Enter the six digit date of service in the "From" field. Completion of the "To" field is not required. Do not spread the date entry across the two fields.

Span billing: permissible if the same service (same procedure code) is provided on consecutive dates.

Durable Medical Equipment Rental
The "To" date of service must represent the last date of the rental period.
24B. Place of Service Required Enter the Place of Service (POS) code that describes the location where services were rendered. The Health First Colorado accepts the CMS place of service codes.
04 Homeless Shelter
11 Office
12 Home
15 Mobile Unit
20 Urgent Care Facility
21 Inpatient Hospital
22 Outpatient Hospital
23 Emergency Room Hospital
25 Birthing Center
26 Military Treatment Center
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
41 Transportation - Land
52 Psychiatric Facility Partial Hospitalization
53 Community Mental Health Center
54 Intermediate Care Facility - MR
60 Mass Immunization Center
61 Comprehensive IP Rehab Facility
62 Comprehensive OP Rehab Facility
65 End Stage Renal Dialysis Treatment Facility
71 State - Local Public Health Clinic
99 Other Unlisted
24C. EMG Not Required  
24D. Procedures, Services, or Supplies Required Enter the HCPCS procedure code that specifically describes the service for which payment is requested.

All procedures must be identified with codes in the current edition of Physicians Current Procedural Terminology (CPT). CPT is updated annually.

HCPCS Level II Codes
The current Medicare coding publication (for Medicare crossover claims only).

Only approved codes from the current CPT or HCPCS publications will be accepted.
24D. Modifier Conditional Enter the appropriate procedure-related modifier that applies to the billed service. Up to four modifiers may be entered when using the paper claim form.
BO Orally administered nutrition, not by feeding tube
KH DMEPOS item, initial claim, purchase or first month rental KI DMEPOS item, second or third month rental.
KR Rental item, billing for partial month
MS Six (6) month maintenance and servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warranty
RR Rental (use the RR modifier when DME is to be rented)
SC Medically Necessary Service or Supply - To be used with MSRP priced codes only
TT Individualized service provided to more than one (1) member in same setting TW Secondary or back-up equipment
UB Invoice cost – To be used with "By Invoice" priced codes only
NU New Equipment
UE Used Equipment
Effective July 1, 2017
RA Replacement of a DME, orthotic or prosthetic item
RB Replacement of part of a DME, orthotic or prosthetic item furnished as part of a repair
Effective June 1, 2018:
KF Item designated by the FDA as a Class III device
24E. Diagnosis Pointer Required Enter the diagnosis code reference letter (A-L) that relates the date of service and the procedures performed to the primary diagnosis.

At least one diagnosis code reference letter must be entered.

When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow.

This field allows for the entry of 4 characters in the unshaded area.
24F. $ Charges Required Enter the usual and customary charge for the service represented by the procedure code on the detail line. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.

Some CPT procedure codes are grouped with other related CPT procedure codes. When more than one procedure from the same group is billed, special multiple pricing rules apply.

The base procedure is the procedure with the highest allowable amount. The base code is used to determine the allowable amounts for additional CPT surgical procedures when more than one procedure from the same grouping is performed.

Submitted charges cannot be more than charges made to non-Health First Colorado covered individuals for the same service.

Do not deduct Health First Colorado co- payment or commercial insurance payments from the usual and customary charges.
24G. Days or Units Required Enter the number of services provided for each procedure code.

Enter whole numbers only- do not enter fractions or decimals.
24H. EPSDT/Family Plan Conditional EPSDT (shaded area)
For Early & Periodic Screening, Diagnosis, and Treatment related services, enter the response in the shaded portion of the field as follows:
AV Available- Not Used
S2 Under Treatment
ST New Service Requested NU Not Used
Family Planning (unshaded area)
Not Required
24I. ID Qualifier Not Required  
24J. Rendering Provider ID # Required In the shaded portion of the field, enter the NPI of the Health First Colorado provider number assigned to the ,strong>individual who actually performed or rendered the billed service. This number cannot be assigned to a group or clinic.
25. Federal Tax ID Number Not Required  
26. Patient's Account Number Optional Enter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA).
27. Accept Assignment? Required The accept assignment indicates that the provider agrees to accept assignment under the terms of the payer's program.
28. Total Charge Required Enter the sum of all charges listed in field 24F. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
29. Amount Paid Conditional Enter the total amount paid by Medicare or any other commercial health insurance that has made payment on the billed services.

Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
30. Rsvd for NUCC Use    
31. Signature of Physician or Supplier Including Degrees or Credentials Required Each claim must bear the signature of the enrolled provider or the signature of a registered authorized agent.

Each claim must have the date the enrolled provider or registered authorized agent signed the claim form. Enter the date the claim was signed using two digits for the month, two digits for the date and two digits for the year. Example: 070116 for July 1, 2016.
32. 32- Service Facility Location Information
32a- NPI Number
32b- Other ID #
Required Enter the name, address and ZIP code of the individual or business where the member was seen or service was performed in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.
33. Billing Provider
Info & Ph #
Required Enter the name of the individual or organization that will receive payment for the billed services in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
33a- NPI Number Required  
33b- Other ID #   If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.

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Timely Filing

For more information on timely filing policy, including the resubmission rules for denied claims, please see the General Provider Information manual.

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Column Instructions for HCPCS Code Table

Code Column

HCPCS codes consist of a letter followed by four (4) numbers. Read the entire entry to determine the benefit status of the item. Providers are instructed to submit the HCPCS code most closely describing the item being requested on the PAR form. The Health First Colorado reserves the right to amend the coding for any approved item.

Description Column

A description of the item as provided by Centers for Medicare and Medicaid Services (CMS) is listed. When possible and appropriate, the description of the item includes a notation of the billing unit. For disposable supplies, one (1) billing unit represents one (1) item unless otherwise noted.

PAR Column

This column is used to identify if prior authorization is required for the item identified and to identify which reviewing agency to send the PAR to for review.

Yes PARs for these items are reviewed by the Colorado PAR Program.
No The identified item does not require prior authorization when provided to an eligible member. If there is a unit limit and the member needs to exceed that limit, a PAR may be submitted.
Con (Conditional) The item requires prior authorization under certain circumstances. See the comments section next to the item or the subheading description for an explanation of the circumstances.

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Unit Limit Column

Unit limits are displayed with the maximum unit allowable and the minimum time between requests. Some items may have special provisions for unit limits with more detail in the Comment Column.

  • Y = Year
  • M = Month
  • W = Week
  • D = Day

**This column is being updated on a continual basis; further updates will be made to complete this column. No changes are being made to unit limits; they are only being identified in an easily accessible column. Unit limits may be identified in the comment column until changes are made.**

 

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Comment Column

The comment section outlines specific or special instructions as well as more detailed information on unit limits where applicable.

Comments expand on the description and identify any required special PAR or billing instructions. The notation "DELETED" means that the code is invalid effective the day following the date shown in the "COMMENTS" column. Newly added codes become effective on the date shown. For example, procedure codes deleted effective 12/31/17 can be used only for non-prior authorized services provided prior to 1/1/18 or on PARs approved prior to 1/1/18.

Questionnaires: Some codes require a questionnaire to be filled out to be sent in with the PAR. The questionnaires can be found on the Department’s website on the ,a href="https://www.colorado.gov/hcpf/provider-forms">Forms web page under Durable Medical Equipment, Prosthetics, Orthotics & Supplies (DMEPOS) Forms. In the code table, a questionnaire is indicated by ‘Q’ and the number associated with the questionnaire (I.e. Q1, Q2, Q15, etc.).

F2F: (Face-to-face) Codes that fall under the face-to-face regulation are indicated by the notation ‘F2F’. Please refer to the Face-To-Face section of this manual for details of the regulation.

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HCPCS Code Table

This opens a new web page; there are links back to this section of this manual.

CRT HCPCS Code Table

The following codes are pure CRT codes. Only qualified CRT suppliers may bill for these codes.

For the purpose of the table below only, please note the following definitions.

New
  • Purchase of equipment not previously owned.
  • Replacement equipment after the 5th year mark for adults and 3rd year mark for children.
Mod (Modification)
A change or alteration to a member owned piece of equipment. I.E. A different seating system to be placed on an existing base.
Con (Conditional)
Specialty eval is only required when the member is switching from or adding to a standard drive control (Joystick, any type) and/or attendant control.

CRT HCPCS Code Table

*The Specialty Eval column represents when the eval is required and is not intended to limit or restrict access to Specialty Evals.

Code Description PAR Unit Limits Comments Specialty Eval
New Mod
E0637 Combination sit to stand/table system, any size including pediatric, with seat lift feature, with or without wheels Yes     Yes Yes
E0638 Standing frame/table system, one (1) position (e.g. upright, supine or prone stander), any size including pediatric, with or without wheels Yes     Yes Yes
E0641 Standing frame/table system, multi-position (e.g. three-way stander), any size including pediatric, with or without wheels Yes     Yes Yes
E0642 Standing frame/table system, mobile (dynamic stander), any size including pediatric Yes     Yes Yes
E0986 Manual wheelchair accessory, push activated power assist, each Yes   Required: F2F No No
E1002 Wheelchair accessory, power seating system, tilt only Yes   Required: Q15 Yes Yes
E1003 Wheelchair accessory, power seating system, recline only, without shear reduction Yes   Required: Q15 Yes Yes
E1004 Wheelchair accessory, power seating system, recline only, with mechanical shear reduction Yes   Required: Q15 Yes Yes
E1005 Wheelchair accessory, power seating system, recline only, with power shear reduction Yes   Required: Q15 Yes Yes
E1006 Wheelchair accessory, power seating system, combination tilt and recline, without shear reduction Yes   Required: Q15 Yes Yes
E1007 Wheelchair accessory, power seating system, combination tilt and recline, with mechanical shear reduction Yes   Required: Q15 Yes Yes
E1008 Wheelchair accessory, power seating system, combination tilt and recline, with power shear reduction Yes   Required: Q15 Yes Yes
E1009 Wheelchair accessory, addition to power seating system, mechanically linked leg elevation system, including pushrod and leg rest, each Yes     Yes Yes
E1010 Wheelchair accessory, addition to power seating system, power leg elevation system, including pushrod and leg rest, each Yes     Yes Yes
E1011 Modification to pediatric size wheelchair width adjustment package (not to be dispensed with initial chair) Yes   For modification of existing wheelchair only No No
E1012 Wheelchair accessory, addition to power seating system, center mount power elevating leg rest/platform, complete system, any type, each Yes     Yes Yes
E1014 Reclining back, addition to pediatric size wheelchair Yes   Required: F2F, Q15 No No
E1037 Transport chair, pediatric size Yes   Required: F2F
*Code is subject to the 2019 DME UPL
No No
E1161 Manual adult size wheelchair, includes tilt- in-space Yes   Required: F2F
*Code is subject to the 2019 DME UPL
No No
E1220 Wheelchair, specially sized or constructed (indicate brand name, model number, if any, and justification) Yes     Yes No
E1228 Special back height for wheelchair Yes   Required: F2F No No
E1229 Wheelchair, pediatric size, not otherwise specified Yes     Yes No
E1231 Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, with seating system Yes     No No
E1232 Wheelchair, pediatric size, tilt-in-space, folding, adjustable, with seating system Yes   Required: F2F
*Code is subject to the 2019 DME UPL
No No
E1233 Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, without seating system Yes   Required: F2F
*Code is subject to the 2019 DME UPL
No No
E1234 Wheelchair, pediatric size, tilt-in-space, folding, adjustable, without seating system Yes   Required: F2F
*Code is subject to the 2019 DME UPL
No No
E1235 Wheelchair, pediatric size, rigid, adjustable, with seating system Yes   Required: F2F
*Code is subject to the 2019 DME UPL
No No
E1236 Wheelchair, pediatric size, folding, adjustable, with seating system Yes   Required: F2F
*Code is subject to the 2019 DME UPL
No No
E1237 Wheelchair, pediatric size, rigid, adjustable, without seating system Yes   Required: F2F
*Code is subject to the 2019 DME UPL
No No
E1238 Wheelchair, pediatric size, folding, adjustable, without seating system Yes   Required: F2F
*Code is subject to the 2019 DME UPL
No No
E1239 Power wheelchair, pediatric size, not otherwise specified Yes     Yes No
E2209 Accessory, arm trough, with or without hand support, each Yes   1 unit = 1 arm trough No No
E2291 Back, planar, for pediatric size wheelchair including fixed attaching hardware Yes     No No
E2292 Seat, planar, for pediatric size wheelchair including fixed attached hardware Yes     No No
E2293 Back, contoured, for pediatric size wheelchair including fixed attaching hardware Yes     No No
E2294 Seat, contoured, for pediatric size wheelchair including fixed attaching hardware Yes     No No
E2295 Manual wheelchair accessory, for pediatric size wheelchair, dynamic seating frame, allows coordinated movement of multiple positioning features Yes     Yes No
E2300 Wheelchair accessory, power seat elevation, system, any type Yes     Yes Yes
E2301 Wheelchair accessory, power standing system, any type Yes     Yes Yes
E2310 Power wheelchair accessory, electronic connection between wheelchair controller and two (2) or more power seating system motor, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware Yes     Yes No
E2311 Power wheelchair accessory, electronic connection between wheelchair controller and one (1) power seating system motor, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware Yes     Yes No
E2312 Power wheelchair accessory, hand or chin control interface, mini-proportional remote joystick, proportional, including fixed mounting hardware Yes     Yes No
E2313 Power wheelchair accessory, harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware, each Yes     Yes No
E2321 Power wheelchair accessory, hand control interface, remote joysticks, non- proportional, including all related electronics, mechanical stop switch, and fixed mounting hardware Yes     Yes No
E2322 Power wheelchair accessory, hand control interface, multiple mechanical switches, non-proportional, including all related electronics, mechanical stop switch, and fixed mounting hardware Yes     Yes No
E2323 Power wheelchair accessory, specialty joystick handle for hand control interface, prefabricated Yes     Yes No
E2324 Power wheelchair accessory, chin cup for chin control interface Yes     No No
E2325 Power wheelchair accessory, sip and puff interface, non-proportional, including all related electronics, mechanical stop switch, and manual swing away mounting hardware Yes     Yes Yes
E2326 Power wheelchair accessory, breath tube kit for sip and puff interface Yes     No No
E2327 Power wheelchair accessory, head control interface, mechanical, proportional, including all related electronics, mechanical direction change switch, and Yes     Yes Con
E2328 Power wheelchair accessory, head control or extremity control interface, electronic, proportional, including all related electronics and fixed mounting hardware Yes     Yes Con
E2329 Power wheelchair accessory, head control interface, contact switch mechanism, non- proportional, including all related electronics, mechanical stop switch, mechanical direction change switch, head array, and fixed mounting hardware Yes     Yes Con
E2330 Power wheelchair accessory, head control interface, proximity switch mechanism, non-proportional, including all related electronics, mechanical stop switch, mechanical direction change switch, head array, and fixed mounting hardware Yes     Yes Con
E2331 Power wheelchair accessory, attendant control, proportional, including all related electronics and fixed mounting hardware Yes     Yes Yes
E2351 Power wheelchair accessory, electronic interface to operate speech generating device using power wheelchair control interface Yes     No No
E2373 Power wheelchair accessory, hand or chin control interface, compact remote joystick, proportional, including fixed mounting hardware Yes     Yes No
E2374 Power wheelchair accessory, hand or chin control interface, standard remote joystick (not including controller), proportional, including all related electronics and fixed mounting hardware, replacement only Con 1 per 3 Y PAR required for more than 1 per 3 Y No No
E2376 Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, replacement only Con 1 per Y Over 1 unit requires PAR No No
E2377 Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue Yes     No No
E2609 Custom fabricated wheelchair seat cushion, any size Yes   Identify specific brand/name of cushion requested on prior authorization request Yes Yes
E2610 Wheelchair seat cushion, powered Yes   Identify specific brand/name of cushion requested on prior authorization request Yes Yes
E2617 Custom fabricated wheelchair back cushion, any size, including any type mounting hardware Yes   Identify specific brand/name of cushion requested on prior authorization request Yes Yes
E8000 Gait trainer, pediatric size, posterior support, includes all accessories and components Yes   Use for adults also Yes Yes
E8001 Gait trainer, pediatric size, upright support, includes all accessories and components Yes   Use for adults also Yes Yes
E8002 Gait trainer, pediatric size, anterior support, includes all accessories and components Yes   Use for adults also Yes Yes
K0005 Ultra-lightweight wheelchair Yes   Required: F2F
*Code is subject to the 2019 DME UPL
Yes No
K0008 Custom manual wheelchair base Yes     Yes No
K0009 Other manual wheelchair/base Yes   Do not use for titanium manual wheelchairs; see K0005 or K0008.
*Code is subject to the 2019 DME UPL
Yes No
K0669 Wheelchair accessory wheelchair seat or back cushion does not meet specific code criteria or no written coding verification from DME PDAC Yes     Yes Yes
K0835 Power wheelchair, group 2 standard, single power option, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds Yes   *Code is subject to the 2019 DME UPL Yes No
K0836 Power wheelchair, group 2 standard, single power option, captain’s chair. Member weight capacity up to and including 300 pounds Yes   *Code is subject to the 2019 DME UPL Yes No
K0837 Power wheelchair, group 2 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds Yes   *Code is subject to the 2019 DME UPL Yes No
K0838 Power wheelchair, group 2 heavy duty, single power option, captain’s chair, patient weight capacity 301 to 450 pounds Yes   *Code is subject to the 2019 DME UPL Yes No
K0839 Power wheelchair, group 2 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds Yes   *Code is subject to the 2019 DME UPL Yes No
K0840 Power wheelchair, group 2 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 601 pounds or more Yes   *Code is subject to the 2019 DME UPL Yes No
K0841 Power wheelchair, group 2 standard, multiple power option, sling/solid seat/back, patient weight capacity up to including 300 pounds Yes   *Code is subject to the 2019 DME UPL Yes No
K0842 Power wheelchair, group 2 standard, multiple power option, captain’s chair, patient weight capacity up to and including 300 pounds Yes   *Code is subject to the 2019 DME UPL Yes No
K0843 Power wheelchair, group 2 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds Yes   *Code is subject to the 2019 DME UPL Yes No
K0848 Power wheelchair, group 3 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds Yes   *Code is subject to the 2019 DME UPL Yes No
K0849 Power wheelchair, group 3 standard, captain’s chair, patient weight capacity up to and including 300 pounds Yes   *Code is subject to the 2019 DME UPL Yes No
K0850 Power wheelchair, group 3 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds Yes   *Code is subject to the 2019 DME UPL Yes No
K0851 Power wheelchair, group 3 heavy duty, captain’s chair, patient weight capacity 301 to 450 pounds Yes   *Code is subject to the 2019 DME UPL Yes No
K0852 Power wheelchair, group 3 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds Yes   *Code is subject to the 2019 DME UPL Yes No
K0853 Power wheelchair, group 3 very heavy duty, captain’s chair, patient weight capacity, 451 to 600 pounds Yes   *Code is subject to the 2019 DME UPL Yes No
K0854 Power wheelchair, group 3 extra heavy duty, sling/solid seat/back, patient weight capacity 601 pounds or more Yes     Yes No
K0855 Power wheelchair, group 3 extra heavy duty, captain’s chair, patient weight capacity 601 pounds or more Yes     Yes No
K0856 Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds Yes   *Code is subject to the 2019 DME UPL Yes No
K0857 Power wheelchair, group 3 standard, single power option, captain’s chair, patient weight capacity up to and including 300 pounds Yes   *Code is subject to the 2019 DME UPL Yes No
K0858 Power wheelchair, group 3 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds Yes   *Code is subject to the 2019 DME UPL Yes No
K0859 Power wheelchair, group 3 heavy duty, single power option, captain’s chair, patient weight capacity 301 to 450 pounds Yes   *Code is subject to the 2019 DME UPL Yes No
K0860 Power wheelchair, group 3 very heavy duty, single power option, sling/solid seat/back. Member weight capacity 451 to 600 pounds Yes   *Code is subject to the 2019 DME UPL Yes No
K0861 Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to including 300 pounds Yes   *Code is subject to the 2019 DME UPL Yes No
K0862 Power wheelchair, group 3 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds Yes   *Code is subject to the 2019 DME UPL Yes No
K0863 Power wheelchair, group 3 very heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds Yes   *Code is subject to the 2019 DME UPL Yes No
K0864 Power wheelchair, group 3 extra heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 601 pounds or more Yes     Yes No
K0868 Power wheelchair, group 4 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds Yes     Yes No
K0869 Power wheelchair, group 4 standard, captain’s chair, patient weight capacity up to and including 300 pounds Yes     Yes No
K0870 Power wheelchair, group 4 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds Yes     Yes No
K0871 Power wheelchair, group 4 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds Yes     Yes No
K0877 Power wheelchair, group 4 standard, single power option, sling/solid seat/back, patient weight capacity up to including 300 pounds Yes     Yes No
K0878 Power wheelchair, group 4 standard, single power option, captain’s chair, patient weight capacity up to and including 300 pounds Yes     Yes No
K0879 Power wheelchair, group 4 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds Yes     Yes No
K0880 Power wheelchair, group 4 very heavy duty, single power option, sling/solid seat/back, patient weight 451 to 600 pounds Yes     Yes No
K0884 Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds Yes     Yes No
K0885 Power wheelchair, group 4 standard, multiple power option, captain’s chair weight capacity up to and including 300 pounds Yes     Yes No
K0886 Power wheelchair, group 4 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds Yes     Yes No
K0890 Power wheelchair, group 5 pediatric, single power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds Yes     Yes No
K0891 Power wheelchair, group 5 pediatric, multiple power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds Yes     Yes No
K0898 Power wheelchair, not otherwise classified Yes     Yes No

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Supply (Wound Care) CMS 1500 Claim Example

Supply (Wound Care) CMS 1500 Claim Example

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DME (Wheelchair) CMS 1500 Claim Example

DME (Wheelchair) CMS 1500 Claim Example

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DMEPOS Revisions Log

Revision Date Section/Action Made by
12/1/2016 Manual revised for interChange implementation. For manual revisions prior to 12/01/2016, please refer to Archive. HPE (now DXC)
12/27/2016 Updates based on Colorado iC Stage II Provider Billing Manual Comment Log v0_2.xlsx HPE (now DXC)
1/10/2017 Updates based on Colorado iC Stage Provider Billing Manual Comment Log v0_3.xlsx HPE (now DXC)
1/19/2017 Updates based on Colorado iC Stage Provider Billing Manual Comment Log v0_4.xlsx HPE (now DXC)
1/26/2017 Updates based on Department 1/20/2017 approval email HPE (now DXC)
5/22/2017 Updates based on Fiscal Agent name change from HPE to DXC DXC
2/22/2018 Minor style/formatting edits BU
3/26/2018 TENS/NMES: removed duplicated rows from HCPCS Table and moved the policy guidance to the Covered Benefits section.
C/BiPAP: Updated rental minimum from 60 to 30 days
Added clarification on the usage of the RA, RB, NU, and UE modifiers under Billing for Wheelchairs.
Added RA modifier to last bullet under (wheelchair) repairs and mods.
Re-titled AACDs to SGDs, removed language regarding incorporation by reference in the CCR, and added language from the 2013 AACD BCS that was not put into Rule.
Pricing: Updated Rule reference from 8.590.7.I to 8.590.7, updated section to reflect 1.402% rate increase from Long Bill (SB17-254), added clarity/re-worded By Invoice section. Added information regarding upcoming process change (no A9901).
A4649/T5999
E2378: corrected units from 1 to 3 per year (1 per feature)
HCPF
6/25/2018 Updated general billing and timely to point to general manual HCPF
2/11/2019 Updated Manufacturer Suggested Retail Price (MSRP) section with new percentage calculation examples. DXC
3/9/2019 Updated the codes subject to the Upper Payment Limit as identified by the PDAC codes both Medicare and Medicaid paid for in 2019.
Added Prosthetic and Orthotic codes with current prior authorization requirements and associated unit limits.
Removed NCCI MUE unit limits and redirected providers to see the NCCI MUE list to reflect most current limits published by CMS.
Manufacturers Suggested Retail Price (MSRP) reimbursement updated to reflect July 1, 2018 rates.
HCPF
7/10/2019 Updated Appendices’ links and verbiage DXC
7/18/2019 Added new rates for lesser-of HCPF
2/26/2020 Converted to web page HCPF
9/10/2020 Added Line to Box 32 under the CMS 1500 Paper Claim Reference Table HCPF
10/21/2020
  • E0600: noted that continuous rental is allowed.
  • A4459 A9270: incorporated October 2020 Provider Bulletin for Peristeen System
  • E8000, E8001, E8002, E0637, E0638, E0641, E0642: incorporated September/October Provider Bulletin for CRT Eval requirements to “yes”, effective October 1 2020.
  • E1028: removed the unit limit of “4”. Unit limit defaults to the NCCI MUE value.
  • E0607: updated unit limit to “2 per year”, from “1 per year”, to align with interChange limit.
  • Clarified shipped supply dates for claims, in Shipped Supplies section. 
HCPF