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REIMBURSEMENT POLICY

CMS-1500 Policy Number 2019R0109.LA

Proprietary information of United Healthcare Community Plan. Copyright 2019 UnitedHealthcare Services, Inc. 2019R0109.LA

Durable Medical Equipment, Orthotics and Prosthetics Policy, Professional for Louisiana

IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY

You are responsible for submission of accurate claims. This reimbursement policy is intended to ensure that you are reimbursed based on the code or codes that correctly describe the health care services provided. UnitedHealthcare Community Plan reimbursement policies uses Current Procedural Terminology (CPT

®*), Centers for Medicare and

Medicaid Services (CMS) or other coding guidelines. References to CPT or other sources are for definitional purposes only and do not imply any right to reimbursement. This reimbursement policy applies to all health care services billed on CMS 1500 forms and, when specified, to those billed on UB04 forms. Coding methodology, industry-standard reimbursement logic, regulatory requirements, benefits design and other factors are considered in developing reimbursement policy. This information is intended to serve only as a general reference resource regarding UnitedHealthcare Community Plan’s reimbursement policy for the services described and is not intended to address every aspect of a reimbursement situation. Accordingly, UnitedHealthcare Community Plan may use reasonable discretion in interpreting and applying this policy to health care services provided in a particular case. Further, the policy does not address all issues related to reimbursement for health care services provided to UnitedHealthcare Community Plan enrollees. Other factors affecting reimbursement supplement, modify or, in some cases, supersede this policy. These factors include, but are not limited to: federal &/or state regulatory requirements, the physician or other provider

contracts, the enrollee’s benefit coverage documents, and/or other reimbursement, medical or drug policies. Finally, this policy may not be implemented exactly the same way on the different electronic claims processing systems used by UnitedHealthcare Community Plan due to programming or other constraints; however, UnitedHealthcare Community Plan strives to minimize these variations. UnitedHealthcare Community Plan may modify this reimbursement policy at any time by publishing a new version of the policy on this Website. However, the information presented in this policy is accurate and current as of the date of publication. *CPT Copyright American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

Application

This reimbursement policy applies to UnitedHealthcare Community Plan Medicaid products. This reimbursement policy applies to services reported using the 1500 Health Insurance Claim Form (a/k/a CMS-1500) or its electronic equivalent or its successor form. This policy applies to all products and all network and non-network physicians and other qualified health care professionals, including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals.




Table of Contents

Policy

Overview

Reimbursement Guidelines

Rental or Purchase Modifiers

Monthly Rental

Daily Rental

Rental to Purchase

Maintenance and Service Fees

HCPCS Codes A9900, A9901 and L9900

Place of Service Initial Purchase and/or Rental State Exceptions

Definitions

Questions and Answers

Attachments

Resources

History

Policy

Overview

This policy describes how UnitedHealthcare Community Plan reimburses for the rental and/or purchase of certain items of Durable Medical Equipment (DME), Prosthetics and Orthotics. The provisions of this policy apply to the Same Specialty Physicians and Other Health Care Professionals, which includes DME, Prosthetic and Orthotic vendors, renting or selling DME, Prosthetics or Orthotics.

For purposes of this policy, Same Specialty Physician or Other Health Care Professional is defined as physicians and/or other health care professionals of the same group and same specialty reporting the same Federal Tax Identification number (TIN).

Refer to the UnitedHealthcare Community Plan "Maximum Frequency per Day" policy for additional information pertaining to reimbursement for physician claims submitted with multiple units for the same CPT or HCPCS code on the same date of service.

Reimbursement Guidelines

Rental or Purchase Modifiers

Some DME items are eligible for rental as well as for purchase. The codes representing these items are listed in Modifier Required Code List in the Attachments section below and must be reported with the appropriate rental or purchase modifier in order to be considered for reimbursement.

Rental guidelines are explained further in the sections titled Monthly Rental and Daily Rental.

Rental Modifiers (Medicaid)** The vendor must specify monthly rental of equipment using one or more of the following modifiers:

RR Rental




KH Initial Claim, purchase or first month rental KI Second or third monthly rental KJ Capped rental months four to fifteen KR Partial month LL Lease/rental (use the LL modifier when DME equipment rental is to be applied against the purchase price.

Purchase Modifiers (Medicaid)** The following modifiers indicate that an item has been purchased:

NU New Equipment (use the NR modifier when DME which was new at the time of rental is subsequently purchased)

UE Used Equipment NR New when rented KM Replacement of facial prosthesis including new impression/moulage KN Replacement of facial prosthesis using previous master model

Other Allowable DME Modifiers MS Six month maintenance and servicing fee for reasonable and necessary parts and labor which are not

covered under any manufacturer or supplier warranty

** AZ has a State-specific list that is different from above. See “Attachments” section at end of policy for list.

Monthly Rental

Monthly Rental Monthly rental of DME, orthotics, or prosthetics identified by the applicable code with a rental modifier RR and/or modifiers KH, KI, KJ, KR, LL appended will be reimbursed once per Calendar Month to the Same Specialty Physician or Other Health Care Professional. A Calendar Month is the period of duration from a day of one month to the corresponding day of the next month (please see Definitions) and is determined based on the “From” date reported on the claim.

If a code is submitted with modifier RR and/or modifiers KH, KI, KJ, KR, LL with units greater than 1, or multiple times during the same Calendar Month, UnitedHealthcare Community Plan will only reimburse one monthly rate per Calendar Month to the Same Specialty Physician or Other Health Care Professional except where noted below.

Modifiers RT and LT An additional rental rate will be allowed in the same Calendar Month for codes with a rental modifier when both

modifiers RT and LT are submitted for the same HCPCS code on separate lines. Modifiers RT and LT may be used to report an item for the right or left side of the body and convey that multiples of that item are being utilized.

Second Ventilator It may be necessary for a patient to rent two ventilators in the same month. Examples of situations where a second ventilator may be necessary include:

A patient requires one type of ventilator (e.g., a negative pressure ventilator with a chest shell) for part of the day and needs a different type of ventilator (e.g., a positive pressure ventilator with a nasal mask) during the rest of the day.

A patient who is confined to a wheelchair requires a ventilator mounted on the wheelchair for use during the day and needs another ventilator of the same type for use while in bed. Without both pieces of equipment the patient may be prone to certain medical complications, may not be able to achieve certain appropriate medical outcomes, or may not be able to use the medical equipment effectively.

One additional rental rate will be allowed in the same Calendar Month for a second ventilator reported with a rental modifier plus modifier KX (Requirements specified in the medical policy have been met), appended to HCPCS codes E0465 or E0466. Codes with Extension/Flexion, Supination/Pronation, or Each in the Description

Up to two rental rates will be allowed in the same Calendar Month for codes with "extension/flexion," "supination/pronation" or "each" in the description. These codes describe services where multiple devices may




be reported. If these codes are reported with modifiers RT and LT and multiple units, UnitedHealthcare Community Plan will consider for separate reimbursement up to two units for each side for a total of up to four rental rates in the same Calendar Month.

For additional information, refer to the Questions and Answers section, Q&A #4, and the Attachments section.

Reporting Monthly Rental

Monthly rental of DME, Orthotics, or Prosthetics should be reported on a 1500 Health Insurance Claim Form (a/k/a CMS-1500) or its electronic equivalent or its successor form according to the National Uniform Billing Committee (NUBC) and the National Uniform Claim Committee (NUCC) guidelines. The appropriate HCPCS code and rental modifier are submitted with one unit for each Calendar Month time span. The rental initiation date is entered in the "From" field, and the end date in the "To" field.

In the following example, the rental for HCPCS code E1130 (Standard wheelchair, fixed full-length arms, fixed or swing-away detachable footrests), is initiated on 1/10/2013, and the item is rented for 3 months. The claim should be submitted as follows:

Code Modifier Units From Date To Date

E1130 RR 1 1/10 2/9

E1130 RR 1 2/10 3/9

E1130 RR 1 3/10 4/9

E1130-RR reported with 3 units, a From Date of 1/10 and a To Date of 4/9 on one line will result in reimbursement of only 1 unit.

Daily Rental

UnitedHealthcare Community Plan will allow a daily rental for the following items to the Same Specialty Physician or Other Health Care Professional.

HCPCS codes E0935 (Continuous passive motion exercise device for use on knee only), and E0936 (Continuous passive motion exercise device for use other than knee) are reimbursed on a daily basis consistent with CMS guidelines.

The following HCPCS codes are also reimbursed on a daily basis: E0193, Powered air flotation bed (low air loss therapy) E0194, Air fluidized bed E0277, Powered pressure-reducing air mattress E0304, Hospital bed, extra heavy-duty, extra wide, with weight capacity greater than 600 pounds, with any type

side rails, with mattress E0371, Nonpowered advanced pressure reducing overlay for mattress, standard mattress length and width E0372, Powered air overlay for mattress, standard mattress length and width E0373, Nonpowered advanced pressure reducing mattress E1639, Scale, each E2402, Negative pressure wound therapy electrical pump, stationary or portable

Rental to Purchase

Rental fees from a single vendor are payable up to either the purchase price of an item or a maximum number of rental months, whichever is less. The maximum number of rental months for comparison to the purchase price varies according to the vendor’s contract. Once the Rent-to-Purchase maximum (or Rental Cap) specified in the contract is reached, the item is considered purchased and is not reimbursable. Daily rental items may also be subject to rental limits, depending on the vendor’s contract. These rental limits do not apply to oxygen equipment or to ventilators.

The vendor is responsible for complying with all the terms of their contract with UnitedHealthcare Community Plan, including the provision that requires the vendor to stop billing for rental of items when the maximum rental amount for




those items specified in their contract has been reached.

Identification of whether the equipment was rented or purchased must be documented by the use of the applicable modifier referenced in the Rental or Purchase Modifiers section above.

Maintenance and Service Fees

The UnitedHealthcare Community Plan allows for reimbursement of maintenance and service once every six months to the Same Specialty Physician or Other Health Care Professional. The appropriate HCPCS code appended with modifier MS (maintenance/service fee) is required to identify such services. The Maintenance and Service modifier (MS) must be reported on a separate line in order to be considered for separate reimbursement from the rental or purchase of the equipment.

Maintenance and Service includes the following:

regular routine maintenance and performance checks as required to maintain the warranty or performance standards

re-education compliance with alerts and recalls necessary supplies in accordance with the applicable agreement back-up equipment emergency availability and replacement equipment when out-of-service for repair.

For the purposes of this policy, maintenance and servicing does not apply to Orthotics or Prosthetics.

HCPCS Codes A9900, A9901 and L9900

Delivery, set-up and supplies are included in the payment rates associated with a DME, Orthotic, or Prosthetic item. They are not reimbursable services when submitted alone or with another service.

Therefore, UnitedHealthcare Community Plan will not separately reimburse the following codes: A9900 (Miscellaneous DME supply, accessory, and/or service component of another HCPCS code) A9901 (DME delivery, set up, and/or dispensing service component of another HCPCS code) L9900 (Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS L code)

Place of Service

DME Suppliers Consistent with CMS guidelines, reimbursement of certain DME items is limited to a place of service (POS) that qualifies as the patient’s home. The following POS codes would qualify as the patient’s home: 01, 04, 09, 12, 13, 14, 16, 31, 32, 33, 54, 55, 56, and 65. DME suppliers should report the POS code where the device is intended to be used. DME dispensed for use in a POS other than the patient’s home are not reimbursable. Refer to the UnitedHealthcare “Supply” policy for additional information pertaining to place of service 31 or 32. Devices not intended for home use There are specific DME items or implantable devices that are not suitable for dispensing or using in the home setting and are therefore not reimbursed with a home POS.

Initial Purchase and/or Rental

CMS guidelines indicate when DME items are purchased or rented; there are certain supplies that are included in the initial purchase or during the rental period. For example, upon initial issue of a walker (E0141), if brakes are being provided at the same time, the charges for these are included in the reimbursement for the walker and may not be billed separately.




State Exceptions

Arizona Arizona has separately designated code and modifier lists.

Arizona Medicaid is exempt from monthly rental limit due to State requirements.

California Code E0781 needs to be reimbursed at a daily rate when billed with modifier RR.

Codes A4604, A7045, E0484, and E1355 can only be billed with modifier NU. Modifiers RB and RR are not allowed.

Code E1392 is a rental only code and must be billed with modifier RR.

Codes E1230, K0010, K0011, K0012 are restricted to repair only and must be billed with modifier RB. If modifier NU or RR is billed, the claim is to be denied.

Codes E2312, E2321, E2322, E2327, and E2373 must be billed with modifiers RB/NU/KC for patient owned power wheelchairs or with modifiers RR/KC for a power wheelchair rental. The modifiers must be entered on the claim in that specific order.

Code E2378 must be billed with modifiers NU/RBNU. E2378 can be billed with NU or NU and RB.

Code A9900 is separately reimbursable

Florida Florida Medicaid rent-to-purchase equipment total reimbursement may not exceed a total of ten (10) monthly claims.

Code A9900 is separately reimbursable

Iowa Per Iowa Medicaid, LTC, and waiver program requirements:

RB modifier must be used for the maintenance of purchased equipment and NOT the MS modifier

Daily Rental is reimbursed when billed with RR modifier for: o E0202 for specific Medicaid products o E0779 and E0780

Effective 9/1/2018 - E1390 is a monthly rental and will no longer be reimbursed as a daily rental when billed with an RR modifier

Monthly rentals that are rented for less than a full month – Append a KR modifier in addition to RR modifier. The number of units should be the number of days the item was rented.

Kansas The State of Kansas allows an RR modifier for 1 month rental (when appropriate) on the following hearing aid codes: V5030, V5040, V5050, V5060, V5120, V5130, V5140, V5160, V5210, V5220, V5242, V5243, V5244, V5245, V5246, V5246, V5247, V5248, V5249, V5250, V5251, V5252, V5253, V5254, V5255, V5256, V5257, V5258, V5259, V5260, V5261, V5264, V5266.

The State of Kansas allows code E0202 to be billed as daily rental.

The State of Kansas allows ventilators to be reimbursed at a daily rate.

The State of Kansas allows a monthly limit of 6 boxes of test strips (HCPC A4253) for insulin dependent diabetics and 2 box of test strips for non-insulin dependent diabetics.

Kansas uses a customized, state identified DME Modifier Required list

Mississippi The Division of Medicaid (MS CAN) covers rental of equipment up to ten (10) months, or up to the purchase price, whichever is less.

Per state regulation MSCAN allows daily rental for code E0202 when billed with modifier RR or KR.

Missouri Per Missouri state regulations

Missouri Medicaid allows modifier TW (back-up equipment) with HCPCS code E0465.

Missouri Medicaid does not allow modifier TW (back-up equipment) with HCPCS code E0466.

Missouri Medicaid does not allow modifier KX (requirements specified in the medical policy have been met) with HCPCS codes E0465 and E0466.

Missouri Medicaid does not allow modifier MS.

Missouri Medicaid does not allow modifier RB with any rental modifier as repair is covered if the equipment is not being rented. Missouri uses a customized DME Repair Code list which can




be found in the Attachment Section

Missouri Medicaid uses a customized list of DME codes that require a purchase (NU), rental (RR), or repair (RB) modifier for reimbursement.

Nebraska Nebraska allows multiple units to be reimbursed as a daily rental when the KR modifier is billed with a specific list of codes. The codes that are included can be found on the Nebraska KR List in the Attachment Section.

NE allows A9900 to be billed as a supply kit with Breast Pumps and Apnea Monitors.

The state of NE does not cover a purchase of HCPCS code E0604. There is a 12 month rental cap for this code. Purchase is not allowed; therefore, claim should not deny for purchase price.

Ohio Ohio does not require modifiers on all codes in the policy. The codes that are excluded can be found on the Ohio DME Modifier Bypass List in the Attachment Section.

Texas Texas Medicaid allows:

A4253 - 2 units per month for insulin dependent diabetics and 1 unit per month for noninsulin dependent diabetics.

A4253 and A9275 – A combined total of 2 units per month for insulin dependent diabetics and a combined total of 1 unit per month for noninsulin dependent diabetics.

E0695 - Billed for purchase only. Texas Medicaid does NOT allow:

E0465 and E0466 – KX modifier is not accepted to reflect a second ventilator.

Virginia Virginia is exempt from the monthly rental unit limit due to State requirements. Virginia reimburses in daily rather than monthly units.

Washington Washington (WA) Medicaid requires modifier U2 instead of KX to be billed on HCPC codes E0465 or E0466 for a second ventilator. WA Medicaid allows POS 99 to be billed by DME Providers for Durable Medical Equipment & Non-Medical Equipment services.

Wisconsin Per Wisconsin Medicaid state regulations:

Monthly rental unit limits do not apply. Daily unit limits are allowed rather than monthly units.

HCPCS code L8614 is allowable in the following POS 22, 23, 24

Definitions

Calendar Month The period from a day of one month to the corresponding day of the next month.

Durable Medical Equipment Medical equipment which: *Can withstand repeated use *Is not disposable *Is used to serve a medical purpose *Is generally not useful to a person in the absence of sickness or injury *Is appropriate for use in the home

Orthotic An external appliance such as a brace or splint that prevents or assists movement of the spine or limbs. A brace is used for the purpose of supporting a weak or deformed body part of a Customer or restricting or eliminating motion in a diseased or injured part of the body.

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

Same Specialty Physician or Other Health Care Professional

Physicians and/or other health care professionals of the same group and same specialty reporting the same Federal Tax Identification number.




Questions and Answers

1

Q: Why is a rental month defined as a Calendar Month when months vary as to their number of days?

A: The rationale for reimbursing rental once per Calendar Month rather than once per 30 day period is due to the fact that some months are less or greater than 30 days. Vendor billing trends indicate that rentals are reported on a cycle billing method; i.e., item dispensed on 1/9/13, and rented for 3 continuous months. Resulting bills will be submitted with 1/9/13 and 2/9/13 and 3/9/13 dates of service.

2

Q: How should monthly rental of DME items be reported?

A: According to the National Uniform Billing Committee (NUBC) and the National Uniform Claim Committee (NUCC), monthly rental of an item should be reported on a single claim line with one unit and a single calendar month date span—that is, for one month, enter the rental initiation date in the From field and the end date of that month’s rental in the To field. Rental charges for multiple months should not be reported on the same line. If two claims are submitted that show From dates in the same month for the same item from the Same Specialty Physician or Other Health Care Professional, only one claim will be allowed and the second claim for the same month will not be covered. See the policy section titled Reporting Monthly Rental for an example of how to report more than one month’s rental for the same item. Note that each line in the example has a From date in a different month.

3

Q: Why does UnitedHealthcare Community Plan pay a full Calendar Month rental rate when modifier KR is used, which indicates the item is only rented for a partial Calendar Month?

A: Regardless of whether the item is used for a full Calendar Month or only a few days within a Calendar Month, UnitedHealthcare's Community Plan contracted rental rates will be allowed once per Calendar Month to the same vendor. For example, E0202 (Phototherapy (bilirubin) light with photometer) is reported with modifier KR and 7 units to indicate the number of days it was used in a Calendar Month. Regardless of the number of days it is used within that Calendar Month, UnitedHealthcare Community Plan pays a single monthly rate to the same vendor and does not prorate the services to allow a daily rate. This is consistent with the terms of our participating agreements.

The exceptions to the above are the items listed in the section titled Daily Rental.

4

Q: How should a vendor report a device that has been provided for extension and flexion on both sides of the body, e.g., code E1800 (Dynamic adjustable elbow extension/flexion device, includes soft interface material)?

A: Because two devices were used on both sides of the body, it is appropriate to report this as E1800-RR-RT with two units for the right side, and E1800-RR-LT with two units for the left side.

5

Q: Are repair codes K0739 (Repair or nonroutine service for durable medical equipment other than oxygen equipment), K0740 (Repair or nonroutine service for oxygen, per 15 minutes) or K0462 (Temporary replacement for patient-owned equipment being repaired) reimbursed during the rental period for Durable Medical Equipment?

A: Repair of DME items is included in the rental payment and not separately reimbursed. Repair may be allowed for DME items that are purchased (patient-owned).

Attachments

UnitedHealthcare Community Plan Codes with Each in Description

A list of codes indicating that more than one device or service may be reported.

of 1

E0111 E0956 E1016 E2217 E2361 E2390 K0039 K0069E0113 E0957 E1017 E2218 E2363 E2391 K0040 K0070E0116 E0959 E1018 E2219 E2365 E2392 K0041 K0071E0117 E0961 E2205 E2220 E2371 E2394 K0042 K0072E0153 E0967 E2206 E2221 E2381 E2395 K0043 K0073E0154 E0971 E2207 E2222 E2382 E2396 K0044 K0077E0157 E0973 E2209 E2224 E2383 E2619 K0045 K0733E0159 E0974 E2211 E2225 E2384 K0015 K0046E0175 E0990 E2212 E2226 E2385 K0017 K0047E0951 E0994 E2213 E2227 E2386 K0018 K0051E0952 E0995 E2214 E2228 E2387 K0019 K0052E0953 E1009 E2215 E2358 E2388 K0037 K0053E0954 E1015 E2216 E2359 E2389 K0038 K0065

2019A UnitedHealthcare Community Plan Codes with Each in Description

Codes w Each in Descrip

bjack36File AttachmentWorksheet in U Policy Managers State information State information LA 8.1.19 LA Versions Completed by RPMU DME, Orthotics and Prosthetics Policy, Professional for Louisiana.pdf




Attachments

UnitedHealthcare Community Plan Codes with Flexion, Extension, Pronation or Supination in Description

A list of codes indicating that more than one device or service may be reported.

UnitedHealthcare Community Plan Medicaid DME Policy Modifier Required Code List

List of codes requiring a Rental or Purchase modifier for Medicaid

DME Items Eligible for Rental Only

A list of codes representing items that may be eligible for rental only and that must be reported with an appropriate rental modifier.

UnitedHealthcare Community Plan DME Policy Arizona Modifier Required Code List

Arizona Specific list of codes requiring a Rental or Purchase modifier

UnitedHealthcare Community Plan DME Policy Arizona Modifier List

Arizona Specific list of acceptable modifiers indicating whether the item was rented or purchased

UnitedHealthcare Community Plan CA New Purchase Codes List

California Medicaid list of codes that are allowed as new/purchase only and require a purchase (NU) modifier for reimbursement.

UnitedHealthcare Community Plan CA New Purchase and Rental Codes List

California Medicaid list of codes that are allowed as new/purchase or rental only and require a purchase (NU) or rental (RR) modifier for reimbursement.

UnitedHealthcare Community Plan CA Rental Codes List

California Medicaid list of codes that are allowed as rental only and require a rental (RR) modifier for reimbursement.

UnitedHealthcare Community Plan CA Repair Codes List

California Medicaid list of codes that are not allowed if both modifier RB and any rental modifier in any position are appended to a code on the California Medicaid DME Repair Code list.

UnitedHealthcare Community Plan Policy MO Medicaid DME Repair Code list

Missouri Medicaid list of codes that are not allowed if both modifier RB and any rental modifier in any position are appended to a code on the Missouri Medicaid DME Repair Code list.

E1800 E1811 E1825 L1843 L2425 L3912 L5859 L6645

E1801 E1812 E1830 L1844 L2622 L3925 L5961 L6646

E1802 E1815 E1831 L1845 L2624 L3927 L5973

E1805 E1816 E1840 L1846 L3730 L5845 L6620

E1806 E1818 L0635 L1851 L3900 L5848 L6621

E1810 E1820 L0636 L1852 L3901 L5850 L6624

2019A UnitedHealthcare Community Plan Codes with Flexion, Extension,

Pronation or Supination in Description

Page 1 of 1


A4604 E0235 E0572 E0855 E1083 E1830 E2388 K0098

A4611 E0236 E0574 E0856 E1084 E1840 E2389 K0105

A4612 E0239 E0575 E0860 E1085 E1841 E2390 K0195

A4613 E0247 E0580 E0870 E1086 E2000 E2391 K0455

A4618 E0249 E0585 E0880 E1087 E2100 E2392 K0606

A4635 E0250 E0600 E0890 E1088 E2101 E2394 K0607

A4636 E0251 E0601 E0900 E1089 E2120 E2395 K0608

A4637 E0255 E0602 E0910 E1090 E2201 E2396 K0730

A4640 E0256 E0603 E0911 E1092 E2202 E2397 K0733

A7017 E0260 E0604 E0912 E1093 E2203 E2402 K0738

A7045 E0261 E0605 E0920 E1100 E2204 E2500 K0800

A8000 E0265 E0606 E0930 E1110 E2205 E2502 K0801

A8001 E0266 E0607 E0935 E1130 E2206 E2504 K0802

B9000 E0271 E0610 E0940 E1140 E2207 E2506 K0806

B9002 E0272 E0615 E0941 E1150 E2208 E2508 K0807

B9004 E0273 E0617 E0942 E1160 E2209 E2510 K0808

B9006 E0274 E0618 E0944 E1161 E2210 E2601 K0813

E0100 E0275 E0619 E0945 E1170 E2211 E2602 K0814

E0105 E0276 E0620 E0946 E1171 E2212 E2603 K0815

E0110 E0277 E0621 E0947 E1172 E2213 E2604 K0816

E0111 E0280 E0627 E0948 E1180 E2214 E2605 K0820

E0112 E0290 E0628 E0950 E1190 E2215 E2606 K0821

E0113 E0291 E0629 E0951 E1195 E2219 E2607 K0822

E0114 E0292 E0630 E0952 E1200 E2220 E2608 K0823

E0116 E0293 E0635 E0955 E1221 E2221 E2611 K0824

E0117 E0294 E0636 E0956 E1222 E2222 E2612 K0825

E0130 E0295 E0637 E0957 E1223 E2224 E2613 K0826

E0135 E0296 E0638 E0958 E1224 E2225 E2614 K0827

E0140 E0297 E0650 E0959 E1225 E2226 E2615 K0828

E0141 E0300 E0651 E0960 E1226 E2227 E2616 K0829

E0143 E0301 E0652 E0961 E1227 E2228 E2619 K0830

E0144 E0302 E0655 E0966 E1228 E2231 E2620 K0831

E0147 E0303 E0656 E0967 E1230 E2310 E2621 K0835

E0148 E0304 E0657 E0968 E1232 E2311 E2622 K0836

E0149 E0305 E0660 E0969 E1233 E2312 E2623 K0837

E0153 E0310 E0665 E0970 E1234 E2313 E2624 K0838

E0154 E0316 E0666 E0971 E1235 E2321 E2625 K0839

E0155 E0325 E0667 E0973 E1236 E2322 K0001 K0840

E0156 E0326 E0668 E0974 E1237 E2323 K0002 K0841

E0157 E0371 E0669 E0978 E1238 E2324 K0003 K0842

E0158 E0372 E0671 E0980 E1240 E2325 K0004 K0843

E0159 E0373 E0672 E0981 E1250 E2326 K0005 K0848

E0160 E0424 E0673 E0982 E1260 E2327 K0006 K0849

E0161 E0425 E0675 E0983 E1270 E2328 K0007 K0850

E0162 E0430 E0691 E0984 E1280 E2329 K0010 K0851

E0163 E0431 E0692 E0985 E1285 E2330 K0011 K0852

E0165 E0433 E0693 E0986 E1290 E2340 K0012 K0853

E0167 E0434 E0694 E0990 E1295 E2341 K0015 K0854

E0168 E0435 E0705 E0992 E1296 E2342 K0017 K0855

E0170 E0439 E0720 E0994 E1297 E2343 K0018 K0856

E0175 E0440 E0730 E0995 E1298 E2351 K0019 K0857

2019A UnitedHealthcare Community Plan Medicaid DME Policy Modifier

Required Code List

2019A UnitedHealthcare Community Plan Medicaid DME Policy Modifier

Required Code List

E0181 E0450 E0731 E1002 E1310 E2360 K0020 K0858

E0182 E0457 E0740 E1003 E1353 E2361 K0037 K0859

E0184 E0459 E0744 E1004 E1355 E2362 K0038 K0860

E0185 E0460 E0745 E1005 E1372 E2363 K0039 K0861

E0186 E0461 E0747 E1006 E1390 E2364 K0040 K0862

E0187 E0462 E0748 E1007 E1391 E2365 K0041 K0863

E0188 E0463 E0749 E1008 E1392 E2366 K0042 K0864

E0189 E0464 E0760 E1010 E1405 E2367 K0043 L3964

E0191 E0470 E0762 E1014 E1406 E2368 K0044 L3965

E0193 E0471 E0764 E1015 E1700 E2369 K0045 L3966

E0194 E0472 E0765 E1016 E1800 E2370 K0046 L3968

E0196 E0480 E0776 E1020 E1801 E2371 K0047 L3969

E0197 E0482 E0779 E1028 E1802 E2373 K0050 L3970

E0198 E0483 E0780 E1029 E1805 E2374 K0051 L3971

E0199 E0484 E0781 E1030 E1806 E2375 K0052 L3972

E0200 E0500 E0782 E1031 E1810 E2376 K0053 L3974

E0202 E0550 E0783 E1035 E1811 E2377 K0056 L8040

E0205 E0555 E0784 E1036 E1812 E2381 K0065 L8041

E0210 E0560 E0785 E1037 E1815 E2382 K0069 L8042

E0215 E0561 E0786 E1038 E1816 E2383 K0070 L8043

E0217 E0562 E0791 E1039 E1818 E2384 K0071 L8044

E0218 E0565 E0840 E1050 E1820 E2385 K0072 L8045

E0221 E0570 E0849 E1060 E1821 E2386 K0073 L8046

E0225 E0571 E0850 E1070 E1825 E2387 K0077 L8047


DME Items Eligible 4 Rental Onl

2019A DME Items Eligible for Rental Only

E0424E0431E0433E0434E0439E1392K0738

bjack36File AttachmentWorksheet in U Policy Managers State information State information LA 8.1.19 LA Versions Completed by RPMU DME, Orthotics and Prosthetics Policy, Professional for Louisiana.xlsx

AZ DME (codes) DME Modifier Mis

2019 UnitedHealthcare Community Plan DME Policy Arizona Modifier Required Code List

A4580E0482E1161E2506L0630L2780L5280L6605Q0500

A4590E0483E1170E2508L0631L2785L5301L6610Q0501

A4660E0484E1171E2510L0632L2795L5321L6611Q0502

A4663E0485E1172E2511L0633L2800L5331L6615Q0503

A4670E0486E1180E2512L0634L2810L5341L6616Q0504

A4671E0487E1190E2599L0635L2820L5400L6620Q0506

A4672E0500E1195E2601L0636L2830L5410L6621Q0507

A4673E0550E1200E2602L0637L2840L5420L6623Q0508

A4674E0555E1220E2603L0638L2850L5430L6624Q0509

A4680E0560E1221E2604L0639L2861L5450L6625Q0510

A4690E0561E1222E2605L0640L2999L5460L6628Q0511

A4706E0562E1223E2606L0700L3000L5500L6629Q0512

A4707E0565E1224E2607L0710L3001L5505L6630Q3001

A4708E0570E1225E2608L0810L3002L5510L6632S1040

A5500E0572E1226E2609L0820L3003L5520L6635S5035

A5501E0574E1227E2610L0830L3010L5530L6637S5036

A5503E0575E1228E2611L0859L3020L5535L6638S5160

A5504E0580E1229E2612L0861L3030L5540L6640S5161

A5505E0585E1230E2613L0970L3031L5560L6641S8270

A5506E0600E1231E2614L0972L3040L5570L6642S8420

A5507E0601E1232E2615L0974L3050L5580L6645S8421

A5508E0602E1233E2616L0976L3060L5585L6646S8422

A5510E0603E1234E2617L0978L3070L5590L6647S8423

A6530E0604E1235E2619L0980L3080L5595L6648S8424

A6531E0605E1236E2620L0982L3090L5600L6650S8425

A6532E0606E1237E2621L0984L3100L5610L6655S8426

A6533E0607E1238E2622L0999L3140L5611L6660S8427

A6534E0610E1239E2623L1000L3150L5613L6665S8428

A6535E0615E1240E2624L1001L3160L5614L6670S8429

A6536E0616E1250E2625L1005L3170L5616L6672S9001

A6537E0617E1260E2626L1010L3201L5617L6675S9007

A6538E0618E1270E2627L1020L3202L5618L6676T5001

A6539E0619E1280E2628L1025L3203L5620L6677T5999

A6540E0620E1285E2629L1030L3204L5622L6680V2020

A6541E0621E1290E2630L1040L3206L5624L6682V2025

A6544E0625E1295E2631L1050L3207L5626L6684V2100

A6545E0627E1296E2632L1060L3208L5628L6686V2101

A6549E0628E1297E8000L1070L3209L5629L6687V2102

A7025E0629E1298E8001L1080L3211L5630L6688V2103

A7026E0630E1300E8002L1085L3212L5631L6689V2104

A8000E0635E1310K0001L1090L3213L5632L6690V2105

A8001E0636E1353K0002L1100L3214L5634L6691V2106

A8002E0637E1354K0003L1110L3215L5636L6692V2107

A8003E0638E1355K0004L1120L3216L5637L6693V2108

A8004E0639E1356K0005L1200L3217L5638L6694V2109

A9280E0640E1357K0006L1210L3219L5639L6695V2110

A9281E0641E1358K0007L1220L3221L5640L6696V2111

A9284E0642E1372K0009L1230L3222L5642L6697V2112

A9300E0650E1390K0010L1240L3224L5643L6698V2113

A9999E0651E1391K0011L1250L3225L5644L6703V2114

B9000E0652E1392K0012L1260L3230L5645L6704V2115

B9002E0655E1399K0014L1270L3250L5646L6706V2118

B9004E0656E1405K0015L1280L3251L5647L6707V2121

B9006E0657E1406K0017L1290L3252L5648L6708V2199

E0100E0660E1500K0018L1300L3253L5649L6709V2200

E0105E0665E1510K0019L1310L3254L5650L6711V2201

E0110E0666E1520K0020L1499L3255L5651L6712V2202

E0111E0667E1530K0037L1600L3257L5652L6713V2203

E0112E0668E1540K0038L1610L3260L5653L6714V2204

E0113E0669E1550K0039L1620L3265L5654L6721V2205

E0114E0671E1560K0040L1630L3300L5655L6722V2206

E0116E0672E1570K0041L1640L3310L5656L6805V2207

E0117E0673E1575K0042L1650L3320L5658L6810V2208

E0118E0675E1580K0043L1652L3330L5661L6881V2209

E0130E0676E1590K0044L1660L3332L5665L6882V2210

E0135E0691E1592K0045L1680L3334L5666L6883V2211

E0140E0692E1594K0046L1685L3340L5668L6884V2212

E0141E0693E1600K0047L1686L3350L5670L6885V2213

E0143E0694E1610K0050L1690L3360L5671L6890V2214

E0144E0700E1615K0051L1700L3370L5672L6895V2215

E0147E0705E1620K0052L1710L3380L5673L6900V2218

E0148E0710E1625K0053L1720L3390L5676L6905V2219

E0149E0720E1630K0056L1730L3400L5677L6910V2220

E0153E0730E1632K0065L1755L3410L5678L6915V2221

E0154E0731E1634K0069L1810L3420L5679L6920V2299

E0155E0740E1635K0070L1820L3430L5680L6925V2300

E0156E0744E1636K0071L1830L3440L5681L6930V2301

E0157E0745E1637K0072L1831L3450L5682L6935V2302

E0158E0746E1639K0073L1832L3455L5683L6940V2303

E0159E0747E1699K0077L1834L3460L5684L6945V2304

E0160E0748E1700K0098L1836L3465L5685L6950V2305

E0161E0749E1701K0105L1840L3470L5686L6955V2306

E0162E0755E1702K0108L1843L3480L5688L6960V2307

E0163E0760E1800K0195L1844L3485L5690L6965V2308

E0165E0761E1801K0606L1845L3500L5692L6970V2309

E0167E0762E1802K0607L1846L3510L5694L6975V2310

E0168E0764E1805K0608L1847L3520L5695L7007V2311

E0170E0765E1806K0609L1850L3530L5696L7008V2312

E0171E0769E1810K0669L1860L3540L5697L7009V2313

E0172E0770E1811K0672L1900L3550L5698L7040V2314

E0175E0776E1812K0730L1902L3560L5699L7045V2315

E0181E0779E1815K0733L1904L3570L5700L7170V2318

E0182E0780E1816K0738L1906L3580L5701L7180V2319

E0184E0781E1818K0800L1907L3590L5702L7181V2320

E0185E0782E1820K0801L1910L3595L5703L7185V2321

E0186E0783E1821K0802L1920L3600L5704L7186V2399

E0187E0784E1825K0806L1930L3610L5705L7190V2410

E0188E0785E1830K0807L1932L3620L5706L7191V2430

E0189E0786E1831K0808L1940L3630L5707L7360V2499

E0190E0791E1840K0812L1945L3640L5710L7362V2500

E0191E0830E1841K0813L1950L3649L5711L7364V2501

E0193E0840E1902K0814L1951L3650L5712L7366V2502

E0194E0849E2000K0815L1960L3660L5714L7400V2503

E0196E0850E2100K0816L1970L3670L5716L7401V2510

E0197E0855E2101K0820L1971L3671L5718L7402V2511

E0198E0856E2120K0821L1980L3674L5722L7403V2512

E0199E0860E2201K0822L1990L3675L5724L7404V2513

E0200E0870E2202K0823L2000L3677L5726L7405V2520

E0202E0880E2203K0824L2005L3702L5728L7499V2521

E0203E0890E2204K0825L2010L3710L5780L7510V2522

E0205E0900E2205K0826L2020L3720L5781L7520V2523

E0210E0910E2206K0827L2030L3730L5782L7600V2530

E0215E0911E2207K0828L2034L3740L5785L7900V2531

E0217E0912E2208K0829L2035L3760L5790L8000V2599

E0218E0920E2209K0830L2036L3762L5795L8001V2600

E0221E0930E2210K0831L2037L3763L5810L8002V2610

E0225E0935E2211K0835L2038L3764L5811L8010V2615

E0231E0936E2212K0836L2040L3765L5812L8015V2623

E0232E0940E2213K0837L2050L3766L5814L8020V2625

E0235E0941E2214K0838L2060L3806L5816L8030V2626

E0236E0942E2215K0839L2070L3807L5818L8031V2627

E0239E0944E2216K0840L2080L3808L5822L8032V2628

E0240E0945E2217K0841L2090L3891L5824L8035V2629

E0241E0946E2218K0842L2106L3900L5826L8039V2630

E0242E0947E2219K0843L2108L3901L5828L8040V2631

E0243E0948E2220K0848L2112L3904L5830L8041V2632

E0244E0950E2221K0849L2114L3905L5840L8042V2700

E0245E0951E2222K0850L2116L3906L5845L8043V2702

E0246E0952E2224K0851L2126L3908L5848L8044V2710

E0247E0955E2225K0852L2128L3912L5850L8045V2715

E0248E0956E2226K0853L2132L3913L5855L8046V2718

E0249E0957E2227K0854L2134L3915L5856L8047V2730

E0250E0958E2228K0855L2136L3917L5857L8048V2744

E0251E0959E2230K0856L2180L3919L5858L8049V2745

E0255E0960E2231K0857L2182L3921L5910L8300V2750

E0256E0961E2291K0858L2184L3923L5920L8310V2755

E0260E0966E2292K0859L2186L3925L5925L8320V2756

E0261E0967E2293K0860L2188L3927L5930L8330V2760

E0265E0968E2294K0861L2190L3929L5940L8400V2761

E0266E0969E2295K0862L2192L3931L5950L8410V2762

E0270E0970E2300K0863L2200L3933L5960L8415V2770

E0271E0971E2301K0864L2210L3935L5961L8417V2780

E0272E0973E2310K0868L2220L3956L5962L8420V2781

E0273E0974E2311K0869L2230L3960L5964L8430V2782

E0274E0978E2312K0870L2232L3961L5966L8435V2783

E0275E0980E2313K0871L2240L3962L5968L8440V2784

E0276E0981E2321K0877L2250L3967L5970L8460V2786

E0277E0982E2322K0878L2260L3971L5971L8465V2797

E0280E0983E2323K0879L2265L3973L5972L8470V2799

E0290E0984E2324K0880L2270L3975L5973L8480V5030

E0291E0985E2325K0884L2275L3976L5974L8485V5040

E0292E0986E2326K0885L2280L3977L5975L8499V5050

E0293E0990E2327K0886L2300L3978L5976L8500V5060

E0294E0992E2328K0890L2310L3980L5978L8501V5070

E0295E0994E2329K0891L2320L3982L5979L8505V5080

E0296E0995E2330K0898L2330L3984L5980L8507V5095

E0297E1002E2331K0899L2335L3995L5981L8509V5100

E0300E1003E2340L0112L2340L3999L5982L8510V5120

E0301E1004E2341L0113L2350L4000L5984L8511V5130

E0302E1005E2342L0120L2360L4002L5985L8512V5140

E0303E1006E2343L0130L2370L4010L5986L8513V5150

E0304E1007E2351L0140L2375L4020L5987L8514V5170

E0305E1008E2360L0150L2380L4030L5988L8515V5180

E0310E1009E2361L0160L2385L4040L5990L8600V5190

E0315E1010E2362L0170L2387L4045L5999L8609V5210

E0316E1011E2363L0172L2390L4050L6000L8610V5220

E0325E1014E2364L0174L2395L4055L6010L8612V5230

E0326E1015E2365L0180L2397L4060L6020L8613V5242

E0328E1016E2366L0190L2405L4070L6050L8614V5243

E0329E1017E2367L0200L2415L4080L6055L8615V5244

E0350E1018E2368L0220L2425L4090L6100L8616V5245

E0352E1020E2369L0450L2430L4100L6110L8617V5246

E0370E1028E2370L0452L2492L4110L6120L8618V5247

E0371E1029E2371L0454L2500L4130L6130L8619V5248

E0372E1030E2372L0456L2510L4205L6200L8691V5249

E0373E1031E2373L0458L2520L4210L6205L8692V5250

E0424E1035E2374L0460L2525L4350L6250L8693V5251

E0425E1036E2375L0462L2526L4360L6300L8695V5252

E0430E1037E2376L0464L2530L4370L6310L8699V5253

E0431E1038E2377L0466L2540L4386L6320L9900V5254

E0433E1039E2381L0468L2550L4392L6350Q0480V5255

E0434E1050E2382L0470L2570L4394L6360Q0481V5256

E0435E1060E2383L0472L2580L4396L6370Q0482V5257

E0439E1070E2384L0480L2600L4398L6380Q0483V5258

E0440E1083E2385L0482L2610L4631L6382Q0484V5259

E0441E1084E2386L0484L2620L5000L6384Q0485V5260

E0442E1085E2387L0486L2622L5010L6386Q0486V5261

E0443E1086E2388L0488L2624L5020L6388Q0487V5262

E0444E1087E2389L0490L2627L5050L6400Q0488V5263

E0445E1088E2390L0491L2628L5060L6450Q0489V5264

E0446E1089E2391L0492L2630L5100L6500Q0490V5265

E0455E1090E2392L0621L2640L5105L6550Q0491V5266

E0457E1092E2394L0622L2650L5150L6570Q0492V5267

E0459E1093E2395L0623L2660L5160L6580Q0493

E0462E1100E2396L0624L2670L5200L6582Q0494

E0470E1110E2397L0625L2680L5210L6584Q0495

E0471E1130E2402L0626L2750L5220L6586Q0496

E0472E1140E2500L0627L2755L5230L6588Q0497

E0480E1150E2502L0628L2760L5250L6590Q0498

E0481E1160E2504L0629L2768L5270L6600Q0499

bjack36File AttachmentWorksheet in U Policy Managers State information State information LA 8.1.19 LA Versions Completed by RPMU DME, Orthotics and Prosthetics Policy, Professional for Louisiana.xlsx

Modifier Description

LL Lease/rental

NR New when Rented

NU New equipment

RA Replacement of DME item

RB Replacement of a part of DME

RR DME Rental

2019A UnitedHealthcare Community Plan DME Policy

Arizona Modifier List


A4281 A4595 A4640 A7029 A7038 E0157 E0245 K0601

A4282 A4602 A4660 A7030 A7039 E0158 E0246 K0602

A4283 A4604 A4663 A7031 A7044 E0159 E0555 K0603

A4284 A4615 A4670 A7032 A7045 E0167 E0607 K0604

A4285 A4619 A7005 A7033 A7046 E0182 E0621 K0605

A4286 A4620 A7015 A7034 A7048 E0241 E0710 S8265

A4556 A4635 A7020 A7035 A9281 E0242 E0780

A4557 A4636 A7027 A7036 E0155 E0243 E1355

A4566 A4637 A7028 A7037 E0156 E0244 K0552

2019A UnitedHealthcare Community Plan California New Purchase Codes list


E1012 E2378 K0008 K0013

2019A UnitedHealthcare Community Plan California New Purchase and Rental Codes list


E0465 E0466 E0766 E1392

2019A UnitedHealthcare Community Plan California Rental Codes List


E1230 E1239 E2373 K0010 K0011 K0012 K0014

2019A UnitedHealthcare Community Plan California Repair Codes List


A4565 E1012 E2341 K0007 K0869 L2070 L5105 L5695

A4635 E1014 E2342 K0008 K0870 L2080 L5150 L5696

A4636 E1015 E2343 K0009 K0871 L2090 L5160 L5697

A4637 E1016 E2351 K0010 K0877 L2106 L5200 L5698

A4640 E1017 E2359 K0013 K0878 L2108 L5210 L5699

A7020 E1018 E2360 K0015 K0879 L2112 L5220 L5703

A8000 E1020 E2361 K0017 K0880 L2114 L5230 L5710

A8001 E1028 E2362 K0018 K0884 L2116 L5250 L5711

A8002 E1029 E2363 K0019 K0885 L2126 L5270 L5712

A8003 E1030 E2364 K0020 K0886 L2128 L5280 L5714

A8004 E1031 E2365 K0037 K0890 L2132 L5301 L5716

A9270 E1037 E2366 K0038 K0891 L2134 L5312 L5718

A9999 E1038 E2367 K0039 K0898 L2136 L5321 L5722

E0140 E1161 E2368 K0040 K0900 L2387 L5331 L5724

E0149 E1227 E2369 K0041 L0113 L2390 L5341 L5726

E0167 E1228 E2370 K0042 L0120 L3650 L5460 L5728

E0168 E1229 E2371 K0043 L0130 L3660 L5500 L5780

E0181 E1231 E2372 K0044 L0140 L3670 L5505 L5785

E0182 E1232 E2373 K0045 L0150 L3671 L5510 L5790

E0240 E1233 E2374 K0046 L0160 L3702 L5520 L5795

E0250 E1234 E2375 K0047 L0170 L3710 L5530 L5810

E0251 E1235 E2376 K0050 L0172 L3720 L5535 L5811

E0255 E1236 E2377 K0051 L0174 L3730 L5540 L5812

E0260 E1237 E2378 K0052 L0180 L3740 L5560 L5816

E0265 E1238 E2381 K0053 L0190 L3763 L5570 L5818

E0290 E1239 E2382 K0056 L0200 L3764 L5580 L5822

E0300 E1296 E2383 K0065 L0220 L3765 L5585 L5824

E0328 E1297 E2384 K0069 L0700 L3766 L5590 L5828

E0329 E1298 E2385 K0070 L0710 L3806 L5595 L5830

E0445 E1399 E2386 K0071 L0810 L3808 L5600 L5845

E0470 E1800 E2387 K0072 L0820 L3905 L5610 L5850

E0471 E1805 E2388 K0073 L0830 L3906 L5611 L5858

E0482 E1810 E2389 K0077 L0859 L3908 L5613 L5910

E0500 E1815 E2390 K0098 L1000 L3912 L5616 L5920

E0550 E1820 E2391 K0105 L1300 L3913 L5617 L5930

E0570 E1825 E2392 K0108 L1310 L3915 L5618 L5940

E0572 E1830 E2394 K0733 L1600 L3916 L5620 L5950

E0575 E1902 E2395 K0739 L1610 L3918 L5622 L5960

E0585 E2201 E2396 K0800 L1620 L3919 L5624 L5970

E0600 E2202 E2397 K0801 L1630 L3921 L5626 L5971

E0601 E2203 E2402 K0802 L1640 L3923 L5628 L5972

E0630 E2204 E2500 K0806 L1650 L3924 L5629 L5974

E0638 E2205 E2502 K0807 L1660 L3925 L5630 L5976

E0770 E2206 E2504 K0808 L1680 L3927 L5631 L5978

E0910 E2207 E2506 K0812 L1685 L3929 L5632 L5980

E0940 E2208 E2508 K0813 L1686 L3930 L5634 L5982

E0950 E2209 E2510 K0814 L1700 L3931 L5636 L5984

E0951 E2210 E2511 K0815 L1710 L3933 L5637 L5985

E0952 E2211 E2512 K0816 L1720 L3935 L5638 L5986

E0955 E2212 E2599 K0820 L1730 L3960 L5639 L6000

E0956 E2213 E2601 K0821 L1755 L3961 L5640 L6010

E0957 E2214 E2602 K0822 L1810 L3967 L5642 L6020

E0958 E2215 E2603 K0823 L1820 L3971 L5643 L6050

2019A UnitedHealthcare Community Plan Missouri DME Repair Code list

2019A UnitedHealthcare Community Plan Missouri DME Repair Code list

E0959 E2216 E2604 K0824 L1830 L3973 L5644 L6055

E0960 E2217 E2605 K0825 L1832 L3975 L5645 L6100

E0961 E2218 E2606 K0826 L1834 L3976 L5646 L6110

E0966 E2219 E2607 K0827 L1840 L3977 L5647 L6120

E0967 E2220 E2608 K0828 L1845 L3978 L5648 L6130

E0968 E2221 E2609 K0829 L1846 L3980 L5649 L6200

E0969 E2222 E2611 K0835 L1850 L3982 L5650 L6205

E0970 E2224 E2612 K0836 L1860 L3984 L5651 L6250

E0971 E2225 E2613 K0837 L1900 L4000 L5652 L6300

E0973 E2226 E2614 K0838 L1902 L4010 L5653 L6310

E0974 E2228 E2615 K0839 L1904 L4020 L5654 L6320

E0978 E2231 E2616 K0840 L1906 L4030 L5655 L6350

E0980 E2291 E2617 K0841 L1910 L4040 L5656 L6360

E0981 E2292 E2619 K0842 L1920 L4045 L5658 L6370

E0982 E2293 E2620 K0843 L1930 L4050 L5660 L6400

E0983 E2294 E2621 K0848 L1940 L4055 L5661 L6450

E0984 E2295 E2622 K0849 L1945 L4060 L5665 L6500

E0986 E2310 E2623 K0850 L1950 L4070 L5666 L6550

E0988 E2311 E2624 K0851 L1960 L4080 L5668 L6570

E0990 E2312 E2625 K0852 L1970 L4090 L5670 L6580

E0992 E2313 E2626 K0853 L1980 L4100 L5671 L6582

E0994 E2321 E2627 K0854 L1990 L4110 L5672 L6584

E0995 E2322 E2628 K0855 L2000 L4130 L5676 L6586

E1002 E2323 E2629 K0856 L2010 L4205 L5677 L6588

E1003 E2324 E2630 K0857 L2020 L4210 L5678 L6590

E1004 E2325 E2631 K0858 L2030 L4392 L5680 L6621

E1005 E2326 E2632 K0859 L2034 L4394 L5682 L6677

E1006 E2327 K0001 K0860 L2036 L5000 L5684 L6711

E1007 E2328 K0002 K0861 L2037 L5010 L5686 L6712

E1008 E2329 K0003 K0862 L2038 L5020 L5688 L7510

E1009 E2330 K0004 K0863 L2040 L5050 L5690 L7520

E1010 E2331 K0005 K0864 L2050 L5060 L5692 L8500

E1011 E2340 K0006 K0868 L2060 L5100 L5694 T2029





Attachments

UnitedHealthcare Community Plan MO Medicaid DME Purchase Code List

Missouri Medicaid list of codes that are allowed as purchase only and require a purchase (NU) modifier for reimbursement.

UnitedHealthcare Community Plan MO Medicaid DME Purchase or Rental Code List

Missouri Medicaid list of codes that are allowed as purchase or rental only and require a purchase (NU) or rental (RR) modifier for reimbursement.

UnitedHealthcare Community Plan MO Medicaid DME Purchase or Repair Code List

Missouri Medicaid list of codes that are allowed as purchase or repair only and require a purchase (NU) or repair (RB) modifier for reimbursement.

UnitedHealthcare Community Plan MO Medicaid DME Purchase, Rental or Repair Code List

Missouri Medicaid list of codes that are allowed as purchase, rental or repair only and require a purchase (NU), rental (RR) or repair (RB) modifier for reimbursement.

UnitedHealthcare Community Plan MO Medicaid DME Rental Code List

Missouri Medicaid list of codes that are allowed as rental only and require a rental (RR) modifier for reimbursement.

UnitedHealthcare Community Plan MO Medicaid DME Rental or Repair Code List

Missouri Medicaid list of codes that are allowed as rental or repair only and require a rental (RR) or repair (RB) modifier for reimbursement.

UnitedHealthcare Community Plan DME Policy Nebraska KR Modifier List

List of codes that are allowed with KR modifier to denote partial month rental for Nebraska

Ohio DME Modifier Bypass List

List of codes that do not require a rental or purchase modifier for Ohio

Resources

Individual state Medicaid regulations, manuals & fee schedules

American Medical Association, Current Procedural Terminology ( CPT® ) Professional Edition and associated publications

and services

Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services

Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code

A4206 A4426 A6222 A7507 E0675 L1499 L3222 L6635

A4207 A4427 A6223 A7508 E0691 L1652 L3224 L6637

A4208 A4428 A6224 A7509 E0692 L1690 L3225 L6640

A4209 A4429 A6228 A7520 E0693 L1812 L3230 L6641

A4210 A4430 A6229 A7521 E0694 L1831 L3250 L6642

A4211 A4431 A6230 A7522 E0705 L1833 L3251 L6645

A4212 A4432 A6231 A7523 E0720 L1836 L3252 L6650

A4213 A4433 A6232 A7524 E0730 L1843 L3253 L6655

A4215 A4434 A6233 A7525 E0731 L1847 L3254 L6660

A4216 A4435 A6234 A7526 E0740 L1848 L3255 L6665

A4217 A4450 A6235 A7527 E0746 L1851 L3260 L6670

A4221 A4452 A6236 A9900 E0755 L1852 L3300 L6672

A4222 A4455 A6237 A9901 E0761 L1907 L3310 L6675

A4223 A4458 A6238 B4034 E0762 L1932 L3320 L6676

A4224 A4461 A6239 B4035 E0765 L1951 L3330 L6680

A4225 A4463 A6240 B4036 E0791 L1971 L3332 L6682

A4230 A4465 A6241 B4081 E0855 L2005 L3334 L6684

A4231 A4470 A6242 B4082 E1225 L2035 L3340 L6686

A4232 A4480 A6243 B4083 E1226 L2180 L3350 L6687

A4244 A4481 A6244 B4087 E1310 L2182 L3360 L6688

A4245 A4483 A6245 B4088 E1355 L2184 L3370 L6689

A4246 A4490 A6246 B4100 E1700 L2186 L3380 L6690

A4247 A4495 A6247 B4103 E1701 L2188 L3390 L6691

A4248 A4500 A6248 B4104 E1702 L2190 L3400 L6692

A4250 A4510 A6250 B4149 E1801 L2192 L3410 L6693

A4253 A4520 A6251 B4150 E1802 L2200 L3420 L6694

A4255 A4550 A6252 B4152 E1806 L2210 L3430 L6695

A4256 A4554 A6253 B4153 E1811 L2220 L3440 L6696

A4257 A4556 A6254 B4154 E1812 L2230 L3450 L6697

A4258 A4557 A6255 B4155 E1816 L2232 L3455 L6698

A4259 A4558 A6256 B4157 E1818 L2240 L3460 L6706

A4265 A4561 A6257 B4158 E1821 L2250 L3465 L6707

A4280 A4562 A6258 B4159 E1831 L2260 L3470 L6805

A4281 A4575 A6259 B4160 E1840 L2265 L3480 L6810

A4282 A4595 A6260 B4161 E1841 L2270 L3485 L6883

A4283 A4605 A6261 B4162 E2101 L2275 L3500 L6884

A4284 A4606 A6262 B4164 K0552 L2280 L3510 L6885

A4285 A4611 A6266 B4168 K0603 L2300 L3520 L7400

A4286 A4612 A6402 B4172 K0607 L2310 L3530 L7401

A4290 A4613 A6403 B4176 K0608 L2320 L3540 L7402

A4310 A4614 A6404 B4178 K0609 L2330 L3550 L7403

A4311 A4618 A6407 B4180 K0669 L2335 L3560 L7404

A4312 A4623 A6441 B4185 K0672 L2340 L3570 L7405

A4313 A4624 A6442 B4189 K0901 L2350 L3580 L7499

A4314 A4625 A6443 B4193 K0902 L2360 L3590 L7600

A4315 A4626 A6444 B4197 L0112 L2370 L3595 L8000

2019A UnitedHealthcare Community Plan Missouri DME Purchase Code list


A4316 A4627 A6445 B4199 L0450 L2375 L3600 L8010

A4320 A4628 A6446 B4216 L0452 L2380 L3610 L8020

A4322 A4629 A6447 B4220 L0454 L2385 L3620 L8030

A4326 A4630 A6448 B4222 L0455 L2395 L3630 L8031

A4327 A4633 A6449 B4224 L0456 L2397 L3640 L8041

A4328 A4634 A6450 B5000 L0457 L2405 L3649 L8044

A4330 A4639 A6451 B5100 L0458 L2415 L3674 L8400

A4331 A4649 A6452 B5200 L0460 L2425 L3675 L8410

A4332 A4657 A6453 B9998 L0462 L2430 L3760 L8415

A4333 A4660 A6454 B9999 L0464 L2492 L3762 L8417

A4334 A4663 A6455 E0100 L0466 L2500 L3808 L8420

A4335 A4670 A6456 E0105 L0467 L2510 L3891 L8430

A4338 A4927 A6457 E0110 L0468 L2520 L3900 L8435

A4340 A4928 A6501 E0111 L0469 L2525 L3901 L8440

A4344 A4930 A6502 E0112 L0470 L2526 L3917 L8460

A4346 A5051 A6503 E0113 L0472 L2530 L3923 L8465

A4349 A5052 A6504 E0114 L0480 L2540 L3956 L8470

A4351 A5053 A6505 E0116 L0482 L2550 L3981 L8480

A4352 A5054 A6506 E0118 L0484 L2570 L3999 L8485

A4353 A5055 A6507 E0155 L0486 L2580 L4002 L8499

A4354 A5056 A6508 E0156 L0488 L2600 L4360 L8501

A4355 A5057 A6509 E0158 L0490 L2610 L4361 L8505

A4356 A5061 A6510 E0159 L0491 L2620 L4386 L8507

A4357 A5062 A6511 E0170 L0492 L2622 L4387 L8511

A4358 A5063 A6512 E0172 L0621 L2624 L4396 L8512

A4361 A5071 A6513 E0184 L0622 L2627 L4397 L8513

A4362 A5072 A6530 E0186 L0623 L2628 L4398 L8514

A4363 A5073 A6531 E0187 L0624 L2630 L4631 L8515

A4364 A5081 A6532 E0188 L0625 L2640 L5400 S1002

A4366 A5082 A6533 E0189 L0626 L2650 L5410 S1015

A4367 A5083 A6534 E0190 L0627 L2660 L5420 S1040

A4368 A5093 A6535 E0191 L0628 L2670 L5430 S5560

A4369 A5102 A6536 E0193 L0629 L2680 L5450 S5561

A4371 A5105 A6537 E0196 L0630 L2750 L5614 S8096

A4372 A5112 A6538 E0203 L0631 L2755 L5673 S8097

A4373 A5113 A6539 E0217 L0632 L2760 L5679 S8100

A4375 A5114 A6540 E0218 L0633 L2780 L5681 S8101

A4376 A5120 A6541 E0221 L0634 L2785 L5683 S8185

A4377 A5121 A6544 E0247 L0635 L2795 L5685 S8186

A4378 A5122 A6545 E0248 L0636 L2800 L5700 S8189

A4379 A5126 A6549 E0274 L0637 L2810 L5701 S8265

A4380 A5131 A6550 E0275 L0638 L2820 L5702 S8420

A4381 A5200 A7000 E0276 L0639 L2830 L5704 S8421

A4382 A5500 A7001 E0316 L0640 L2840 L5705 S8422

A4383 A5501 A7002 E0325 L0641 L2850 L5706 S8423

A4384 A5503 A7003 E0326 L0642 L2861 L5707 S8424


A4385 A5504 A7004 E0352 L0643 L2999 L5814 S8425

A4387 A5505 A7005 E0370 L0648 L3000 L5826 S8426

A4388 A5506 A7006 E0441 L0649 L3001 L5840 S8427

A4389 A5507 A7007 E0442 L0650 L3002 L5848 S8428

A4390 A5512 A7008 E0443 L0651 L3003 L5855 S8429

A4391 A5513 A7009 E0444 L0861 L3010 L5856 S8430

A4392 A6010 A7010 E0455 L0970 L3020 L5857 S8431

A4393 A6011 A7012 E0457 L0972 L3030 L5925 S9434

A4395 A6021 A7013 E0459 L0974 L3031 L5961 S9435

A4396 A6022 A7014 E0462 L0976 L3040 L5962 T1999

A4397 A6023 A7015 E0485 L0978 L3050 L5964 T2028

A4398 A6024 A7016 E0486 L0984 L3060 L5966 T4521

A4399 A6025 A7017 E0561 L0999 L3070 L5968 T4522

A4400 A6154 A7025 E0562 L1010 L3080 L5975 T4523

A4402 A6196 A7026 E0574 L1020 L3090 L5979 T4524

A4404 A6197 A7027 E0580 L1025 L3100 L5981 T4525

A4405 A6198 A7028 E0606 L1030 L3140 L5987 T4526

A4406 A6199 A7029 E0610 L1040 L3150 L5988 T4527

A4407 A6203 A7030 E0615 L1050 L3160 L5990 T4528

A4408 A6204 A7031 E0620 L1060 L3170 L5999 T4529

A4409 A6205 A7032 E0621 L1070 L3201 L6380 T4530

A4410 A6206 A7033 E0625 L1080 L3202 L6382 T4531

A4411 A6207 A7034 E0627 L1085 L3203 L6384 T4532

A4412 A6208 A7035 E0629 L1090 L3204 L6386 T4533

A4413 A6209 A7036 E0636 L1100 L3206 L6388 T4534

A4414 A6210 A7037 E0637 L1110 L3207 L6600 T4535

A4415 A6211 A7038 E0639 L1120 L3208 L6605 T4536

A4416 A6212 A7039 E0640 L1200 L3209 L6610 T4537

A4417 A6213 A7044 E0641 L1210 L3211 L6615 T4541

A4418 A6214 A7045 E0642 L1220 L3212 L6616 T4542

A4419 A6215 A7046 E0652 L1230 L3213 L6620 T4543

A4420 A6216 A7501 E0667 L1240 L3214 L6623 T4544

A4421 A6217 A7502 E0668 L1250 L3215 L6625 T5001

A4422 A6218 A7503 E0669 L1260 L3216 L6628 T5999

A4423 A6219 A7504 E0671 L1270 L3217 L6629

A4424 A6220 A7505 E0672 L1280 L3219 L6630

A4425 A6221 A7506 E0673 L1290 L3221 L6632


A6000 E0165 E0239 E0291 E0480 E0710 E0890 E1353

B9002 E0171 E0241 E0292 E0484 E0744 E0900 E1372

E0117 E0175 E0242 E0293 E0555 E0745 E0911 E2000

E0130 E0185 E0243 E0294 E0560 E0747 E0912 E2100

E0135 E0194 E0244 E0295 E0605 E0748 E0920 E8000

E0141 E0197 E0245 E0301 E0607 E0760 E0930 E8001

E0143 E0200 E0246 E0302 E0609 E0764 E0935 E8002

E0147 E0202 E0249 E0303 E0617 E0769 E0941 K0455

E0148 E0205 E0256 E0304 E0635 E0776 E0942 K0606

E0153 E0210 E0261 E0305 E0650 E0781 E0944 K0730

E0154 E0215 E0270 E0310 E0651 E0784 E0945 Y9050

E0157 E0225 E0271 E0315 E0655 E0830 E0946 Y9051

E0160 E0231 E0272 E0350 E0660 E0840 E0947 Y9054

E0161 E0232 E0273 E0371 E0665 E0860 E0948 Y9055

E0162 E0235 E0277 E0372 E0666 E0870 E1035

E0163 E0236 E0280 E0373 E0700 E0880 E1300

2019A UnitedHealthcare Community Plan Missouri DME Purchase or Rental Code list


A4565 E2206 E2616 L0170 L2034 L3948 L5618 L5811

A8000 E2207 E2617 L0172 L2036 L3950 L5620 L5812

A8001 E2208 E2619 L0174 L2037 L3952 L5622 L5816

A8002 E2209 E2620 L0180 L2038 L3954 L5624 L5818

A8003 E2211 E2621 L0190 L2040 L3960 L5626 L5822

E0598 E2212 E2622 L0200 L2050 L3961 L5628 L5824

E0638 E2213 E2623 L0220 L2060 L3964 L5629 L5828

E0950 E2214 E2624 L0700 L2070 L3965 L5630 L5830

E0951 E2215 E2625 L0710 L2080 L3966 L5631 L5845

E0952 E2216 K0008 L0810 L2090 L3967 L5632 L5850

E0955 E2217 K0009 L0820 L2106 L3968 L5634 L5858

E0956 E2218 K0013 L0830 L2108 L3969 L5636 L5910

E0957 E2219 K0015 L0859 L2112 L3970 L5637 L5920

E0960 E2220 K0017 L0860 L2114 L3971 L5638 L5930

E0961 E2221 K0018 L0900 L2116 L3972 L5639 L5940

E0967 E2222 K0019 L0910 L2126 L3973 L5640 L5950

E0969 E2224 K0020 L0920 L2128 L3974 L5642 L5960

E0970 E2228 K0037 L0930 L2132 L3975 L5643 L5970

E0971 E2231 K0038 L0940 L2134 L3976 L5644 L5971

E0974 E2291 K0039 L0950 L2136 L3977 L5645 L5972

E0978 E2292 K0040 L1000 L2387 L3978 L5646 L5974

E0980 E2293 K0041 L1300 L2390 L3980 L5647 L5976

E0983 E2294 K0042 L1310 L3650 L3982 L5648 L5978

E0984 E2295 K0043 L1600 L3660 L3984 L5649 L5980

E0986 E2310 K0044 L1610 L3670 L3985 L5650 L5982

E0990 E2311 K0045 L1620 L3671 L5000 L5651 L5984

E0992 E2312 K0046 L1630 L3702 L5010 L5652 L5985

E0994 E2313 K0047 L1640 L3710 L5020 L5653 L5986

E0995 E2321 K0050 L1650 L3720 L5050 L5654 L6000

E1002 E2322 K0051 L1660 L3730 L5060 L5655 L6010

E1003 E2323 K0052 L1680 L3740 L5100 L5656 L6020

E1004 E2324 K0053 L1685 L3763 L5105 L5658 L6050

E1005 E2325 K0056 L1686 L3764 L5150 L5661 L6055

E1006 E2326 K0065 L1700 L3765 L5160 L5665 L6100

E1007 E2327 K0069 L1710 L3766 L5200 L5666 L6110

E1008 E2328 K0070 L1720 L3800 L5210 L5668 L6120

E1009 E2329 K0071 L1730 L3805 L5220 L5670 L6130

E1010 E2330 K0072 L1750 L3806 L5230 L5671 L6200

E1011 E2331 K0073 L1755 L3905 L5250 L5672 L6205

E1014 E2340 K0077 L1810 L3906 L5270 L5676 L6250

E1015 E2341 K0098 L1820 L3907 L5280 L5677 L6300

E1016 E2342 K0105 L1830 L3908 L5300 L5678 L6310

E1017 E2343 K0733 L1832 L3910 L5301 L5680 L6320

E1018 E2351 K0734 L1834 L3912 L5310 L5682 L6350

E1020 E2359 K0735 L1840 L3913 L5312 L5684 L6360

E1028 E2360 K0736 L1845 L3914 L5320 L5686 L6370

2019A UnitedHealthcare Community Plan Missouri DME Purchase or Repair Code list

2019A UnitedHealthcare Community Plan Missouri DME Purchase or Repair Code list

E1029 E2361 K0737 L1846 L3915 L5321 L5688 L6400

E1066 E2362 K0812 L1850 L3916 L5330 L5690 L6450

E1227 E2363 K0868 L1855 L3918 L5331 L5692 L6500

E1228 E2364 K0869 L1858 L3919 L5340 L5694 L6550

E1231 E2365 K0870 L1860 L3920 L5341 L5695 L6570

E1232 E2366 K0871 L1870 L3921 L5460 L5696 L6580

E1233 E2371 K0877 L1880 L3922 L5500 L5697 L6582

E1234 E2372 K0878 L1900 L3924 L5505 L5698 L6584

E1235 E2373 K0879 L1902 L3925 L5510 L5699 L6586

E1237 E2377 K0880 L1904 L3926 L5520 L5703 L6588

E1238 E2397 K0884 L1906 L3927 L5530 L5710 L6590

E1296 E2601 K0885 L1910 L3928 L5535 L5711 L6621

E1297 E2602 K0886 L1920 L3929 L5540 L5712 L6677

E1298 E2603 K0890 L1930 L3930 L5560 L5714 L6711

E1800 E2604 K0891 L1940 L3931 L5570 L5716 L6712

E1805 E2605 K0898 L1945 L3932 L5580 L5718 L8500

E1810 E2606 K0900 L1950 L3933 L5585 L5722 Z0050

E1815 E2607 L0100 L1960 L3934 L5590 L5724 Z0051

E1820 E2608 L0110 L1970 L3935 L5595 L5726

E1825 E2609 L0113 L1980 L3936 L5600 L5728

E1830 E2611 L0120 L1990 L3938 L5610 L5780

E2201 E2612 L0130 L2000 L3940 L5611 L5785

E2202 E2613 L0140 L2010 L3942 L5613 L5790

E2203 E2614 L0150 L2020 L3944 L5616 L5795

E2204 E2615 L0160 L2030 L3946 L5617 L5810


A9270 E0298 E0770 E1161 E2510 K0815 K0837 K0855

A9999 E0300 E0910 E1212 E2511 K0816 K0838 K0856

E0140 E0328 E0940 E1213 E2512 K0820 K0839 K0857

E0149 E0329 E0958 E1229 E2599 K0821 K0840 K0858

E0168 E0445 E0959 E1236 K0005 K0822 K0841 K0859

E0181 E0482 E0966 E1239 K0108 K0823 K0842 K0860

E0182 E0500 E0968 E1399 K0800 K0824 K0843 K0861

E0240 E0550 E0973 E1902 K0801 K0825 K0848 K0862

E0250 E0570 E0988 E2402 K0802 K0826 K0849 K0863

E0251 E0572 E1012 E2500 K0806 K0827 K0850 K0864

E0255 E0575 E1030 E2502 K0807 K0828 K0851 T2029

E0260 E0585 E1031 E2504 K0808 K0829 K0852 Z0910

E0265 E0600 E1037 E2506 K0813 K0835 K0853

E0290 E0630 E1038 E2508 K0814 K0836 K0854

2019A UnitedHealthcare Community Plan Missouri DME Purchase, Rental or Repair Code list


B9004 E0434 E0464 E0565 E0619 E0850 K0533 Y9277

B9006 E0439 E0465 E0602 E0779 E1390 K0738

E0424 E0450 E0466 E0603 E0780 K0195 S9001

E0431 E0463 E0483 E0608 E0849 K0532 Y9049

2019A UnitedHealthcare Community Plan Missouri DME Rental Code list


E0470 E0471 E0601 K0001 K0002 K0003 K0004 K0006 K0007

2019A UnitedHealthcare Community Plan Missouri DME Rental or Repair Code list


A4614 E0272 E0651 E0974 E1280 E2327 K0065

A4670 E0290 E0652 E0978 E1295 E2328 K0073

B9000 E0291 E0655 E0983 E1296 E2329 K0105

B9002 E0292 E0656 E0984 E1297 E2330 K0108

B9004 E0293 E0657 E0985 E1298 E2331 K0606

B9006 E0294 E0660 E0986 E1310 E2340 K0733

E0100 E0295 E0665 E0990 E1352 E2341 K0738

E0105 E0296 E0666 E0992 E1372 E2342 K0800

E0110 E0297 E0667 E0994 E1390 E2343 K0801

E0111 E0300 E0668 E0995 E1391 E2351 K0802

E0112 E0301 E0669 E1002 E1392 E2360 K0806

E0113 E0302 E0670 E1003 E1399 E2361 K0807

E0114 E0303 E0671 E1004 E1700 E2362 K0808

E0116 E0304 E0672 E1005 E1800 E2363 K0812

E0117 E0305 E0673 E1006 E1801 E2364 K0813

E0118 E0310 E0675 E1007 E1802 E2365 K0814

E0130 E0316 E0691 E1008 E1805 E2366 K0815

E0135 E0328 E0692 E1009 E1806 E2367 K0816

E0140 E0329 E0693 E1010 E1810 E2371 K0820

E0141 E0371 E0694 E1011 E1811 E2372 K0821

E0143 E0373 E0705 E1014 E1812 E2373 K0822

E0144 E0424 E0720 E1015 E1815 E2377 K0823

E0147 E0431 E0730 E1016 E1816 E2402 K0824

E0148 E0434 E0740 E1017 E1818 E2500 K0825

E0149 E0439 E0745 E1018 E1820 E2502 K0826

E0153 E0445 E0746 E1020 E1821 E2504 K0827

E0154 E0450 E0747 E1028 E1825 E2506 K0828

E0155 E0453 E0748 E1029 E1830 E2508 K0829

E0156 E0460 E0760 E1030 E1840 E2510 K0830

E0157 E0461 E0765 E1035 E1841 E2511 K0831

E0158 E0463 E0766 E1037 E1902 E2512 K0835

E0159 E0464 E0776 E1038 E2000 E2601 K0836

E0163 E0470 E0779 E1039 E2100 E2602 K0837

E0165 E0471 E0780 E1050 E2201 E2603 K0838

E0168 E0472 E0781 E1070 E2202 E2604 K0839

E0170 E0480 E0791 E1083 E2203 E2605 K0840

E0171 E0482 E0830 E1084 E2204 E2606 K0841

E0172 E0484 E0840 E1087 E2206 E2607 K0842

E0175 E0485 E0849 E1088 E2207 E2608 K0843

E0181 E0486 E0850 E1092 E2208 E2609 K0848

E0182 E0487 E0855 E1093 E2209 E2611 K0849

E0184 E0500 E0856 E1100 E2211 E2612 K0850

E0185 E0561 E0860 E1110 E2212 E2613 K0851

E0186 E0562 E0870 E1150 E2213 E2614 K0852

E0187 E0565 E0880 E1160 E2214 E2615 K0853

E0190 E0570 E0890 E1170 E2215 E2616 K0854

E0193 E0572 E0900 E1171 E2216 E2617 K0855

E0194 E0574 E0910 E1172 E2217 E2620 K0856

E0196 E0575 E0911 E1180 E2218 E2621 K0857

E0198 E0585 E0912 E1190 E2219 E2623 K0858

E0200 E0600 E0920 E1195 E2220 E8000 K0859

E0202 E0601 E0930 E1200 E2221 E8001 K0860

2019A UnitedHealthcare Community Plan DME Policy Nebraska KR Modifier List

2019A UnitedHealthcare Community Plan DME Policy Nebraska KR Modifier List

E0205 E0604 E0935 E1220 E2222 E8002 K0861

E0217 E0605 E0940 E1221 E2224 K0001 K0862

E0221 E0606 E0941 E1222 E2227 K0002 K0863

E0225 E0607 E0947 E1223 E2228 K0003 K0864

E0235 E0610 E0948 E1224 E2230 K0004 K0868

E0239 E0615 E0950 E1225 E2231 K0005 K0869

E0240 E0617 E0951 E1226 E2291 K0006 K0870

E0243 E0618 E0952 E1227 E2292 K0007 K0871

E0245 E0625 E0955 E1228 E2293 K0009 K0877

E0246 E0627 E0956 E1229 E2294 K0010 K0878

E0247 E0628 E0957 E1230 E2295 K0011 K0879

E0248 E0629 E0958 E1231 E2310 K0012 K0880

E0250 E0630 E0959 E1232 E2311 K0014 K0884

E0251 E0635 E0960 E1233 E2312 K0020 K0885

E0255 E0636 E0961 E1234 E2313 K0037 K0886

E0256 E0637 E0966 E1235 E2321 K0038 K0890

E0260 E0638 E0967 E1236 E2322 K0039 K0891

E0261 E0639 E0968 E1237 E2323 K0040 K0898

E0265 E0641 E0969 E1238 E2324 K0041 S9001

E0266 E0642 E0971 E1239 E2325 K0053

E0271 E0650 E0973 E1270 E2326 K0056


A4611 E0181 E0465 E0850 E0990 E2209 E2607

A4612 E0182 E0466 E0860 E0992 E2211 E2608

A4613 E0184 E0471 E0870 E1002 E2213 E2611

A4618 E0185 E0472 E0880 E1003 E2214 E2612

A4635 E0186 E0480 E0890 E1004 E2310 E2613

A4636 E0187 E0484 E0900 E1005 E2311 E2614

A4637 E0188 E0500 E0910 E1006 E2321 E2615

A4640 E0189 E0561 E0912 E1007 E2322 E2616

E0100 E0191 E0562 E0920 E1008 E2323 E2620

E0105 E0193 E0570 E0930 E1010 E2324 E2621

E0110 E0194 E0575 E0935 E1014 E2325 E2622

E0111 E0196 E0580 E0940 E1015 E2326 E2623

E0112 E0197 E0600 E0942 E1016 E2327 E2624

E0113 E0198 E0602 E0944 E1020 E2328 E2625

E0114 E0199 E0603 E0945 E1028 E2329 K0004

E0116 E0202 E0604 E0950 E1029 E2330 K0005

E0130 E0210 E0605 E0951 E1030 E2340 K0006

E0135 E0215 E0621 E0952 E1161 E2341 K0007

E0140 E0235 E0630 E0955 E1225 E2342 K0010

E0141 E0247 E0638 E0956 E1226 E2343 K0011

E0143 E0271 E0655 E0957 E1230 E2360 K0012

E0144 E0272 E0660 E0958 E1232 E2361 K0020

E0147 E0275 E0665 E0959 E1233 E2362 K0037

E0148 E0276 E0666 E0960 E1234 E2363 K0038

E0149 E0305 E0667 E0961 E1372 E2364 K0039

E0154 E0310 E0668 E0966 E1390 E2365 K0040

E0155 E0325 E0669 E0967 E1391 E2371 K0041

E0156 E0326 E0705 E0968 E1392 E2373 K0052

E0157 E0424 E0747 E0971 E1820 E2377 K0053

E0158 E0431 E0748 E0973 E2201 E2601 K0056

E0159 E0434 E0760 E0974 E2202 E2602 K0065

E0163 E0439 E0776 E0978 E2203 E2603 K0073

E0165 E0457 E0781 E0983 E2204 E2604 K0105

E0167 E0459 E0791 E0984 E2207 E2605 K0730

E0168 E0463 E0840 E0986 E2208 E2606 K0738

2019A UnitedHealthcare Community Plan Ohio DME Modifier Bypass List





Attachments

Sets Noridian Healthcare Solutions, CMS DME MAC Contractor Local Coverage Determinations (LCD) CGS Administrators, CMS DME MAC Contractor Local Coverage Determinations (LCD)

History

7/31/2019 State Exceptions section: Updated exception for Florida regarding code A9900

7/15/2019 State Exceptions section: Updated Wisconsin

5/19/2019 State Exceptions section: Removed Michigan

5/3/2019 Annual Anniversary Date and Version Change

4/22/2019 State Exceptions section: Updated the Iowa state exception

2/10/2019 Policy Version Change Title section: Removed Annual Approval information & moved policy # to the header State Exceptions section: Added place of service 99 language for Washington (WA)

1/1/2019 Policy Version Change History section: Entries prior to 1/1/2017 archived

11/25/2018 State Exceptions section: Updated the Texas state exception

10/1/2018 Removed the wording “Multiple Frequency” from the policy title Reimbursement Guidelines section: Place of Service and Initial Purchase and/or Rental sections added Resources section: Noridian Healthcare Solutions and CGS Administrators added. Questions and Answers section: Q&A #5 removed; new Q&A #5 added DME Suppliers section: removed “such as” and added “or”

9/7/2018 Application section: Removed the verbiage and link for the provider website State Exceptions section: Updated the Iowa state exception to add the following language: Per state regulations, Iowa considers HCPCS E0193, E0277, E0304, E0371, E0372, and E0373 as monthly rentals. The “KR” modifier in addition to the “RR” modifier should be used when this equipment is rented for less than a full month.

8/31/2018 Added the word “Professional” to the policy title (no new version)

8/30/2018 State Exceptions section: Updated the Iowa state exception to add the following language: Effective 09/01/2018 HCPCS E1390 is a monthly rental per IA state guidelines.

7/11/2018 Policy Approval Date Change (no new version)

6/17/2018 Attachments section: Updated the UnitedHealthcare Community Plan MO Medicaid DME Purchase Code List.

6/10/2018 State Exceptions section: Added Virginia

5/20/2018 State Exceptions section: Removed the language “The State of Kansas reimburses code E0463 as a daily rental” from the Kansas exception.

5/7/2018 State Exceptions section: Updated the Iowa state exception to add the following language: “When equipment is rented for less than a full month, the “KR” modifier in addition to the “RR” modifier should be used. The number of units should be the number of days the item was rented.”

4/1/2018 Attachments section: Updated the UnitedHealthcare Community Plan Codes with Each in Description list. Updated the UnitedHealthcare Community Plan Codes with Flexion, Extension, Pronation or Supination in




Attachments

Description list.

3/4/2018 Attachments section: Updated the UnitedHealthcare Community Plan DME Policy Arizona Modifier Required Code List

1/19/2018 State Exceptions section: Added Washington

1/1/2018 Annual Version Change Attachments section: UnitedHealthcare Community Plan Codes with Each in Description updated History section: Entries prior to 1/1/2016 archived

8/27/2017 Attachments section: Updated and added UnitedHealthcare Community Plan CA New Purchase Codes List; updated and added UnitedHealthcare Community Plan CA New Purchase and Rental Codes List; updated and added UnitedHealthcare Community Plan CA Rental Codes List; updated and added UnitedHealthcare Community Plan CA Repair Codes List Table of Contents section: Removed reference to Capped Rentals Policy Section under Rental or Purchase Modifiers: Removed references to Medicare Policy Section: Removed reference titled Capped Rental items (applies to UHC Community Plan Medicare members only)

7/17/2017 Attachments section: Added UnitedHealthcare Community Plan MO Medicaid DME Purchase Code List; added UnitedHealthcare Community Plan MO Medicaid DME Purchase or Rental Code List; added UnitedHealthcare Community Plan MO Medicaid DME Purchase or Repair Code List; added UnitedHealthcare Community Plan MO Medicaid DME Purchase, Rental or Repair Code List; added UnitedHealthcare Community Plan MO Medicaid DME Rental Code List and added UnitedHealthcare Community Plan MO Medicaid DME Rental or Repair Code List.

7/15/2017 Application section: Removed UnitedHealthcare Community Plan Medicare products as applying to this policy. Added location for UnitedHealthcare Community Plan Medicare reimbursement policies. Attachments Section: UnitedHealthcare Community Plan Medicare Codes with Capped Rental Designation removed. UnitedHealthcare Community Plan Medicare DME Policy Modifier Required Code List removed.

7/12/2017 Policy Approval Date Change (No new version)

7/9/2017 State Exceptions Section: Missouri exception verbiage updated Attachments Section: Updated the UnitedHealthcare Community Plan Policy Missouri DME Repair Code list.

5/21/2017 State Exceptions section: Added California Attachments Section: UnitedHealthcare Community Plan DME Policy Arizona Modifier Required Code List updated.

4/13/2017 State Exceptions section: Iowa exception verbiage updated

4/2/2017 Attachments section: UnitedHealthcare Community Plan MEDICARE DME Policy Modifier Required Code List updated. UnitedHealthcare Community Plan MEDICAID DME Policy Modifier Required Code List updated. Ohio DME Modifier Bypass List updated.

3/8/2017 Attachments section: UnitedHealthcare Community Plan Medicare Codes with Capped Rental Designation (attached the correct list)

2/20/2017 State Exceptions section: Texas exception verbiage updated

2/12/2017 State Exceptions section: Added Florida. Updated Mississippi. Added Missouri. Attachments Section: Added DME Items Eligible for Rental Only. Added UnitedHealthcare Community Plan Policy Missouri DME Repair Code list.

1/17/2017 Attachments section: The verbiage for Arizona in the right column updated from APIPA to Arizona

1/8/2017 State Exceptions section: Iowa exception verbiage updated




Attachments

1/1/2017 Annual Version Change Attachments Section: UnitedHealthcare Community Plan Medicare Codes with Capped Rental Designation, UnitedHealthcare Community Plan Codes with Each in Description and UnitedHealthcare Community Plan Codes with Flexion, Extension, Pronation or Supination in Description updated History section: Entries prior to 1/1/2015 archived

3/15/2009 Policy implemented by UnitedHealthcare Community & State

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