Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Reimbursement - Medicare Advantage
Policy No: 118
Originally Created: 08/01/2014
Last Reviewed: 05/01/2018
Last Revised: 05/01/2018
This policy applies only to physicians and other qualified healthcare professionals.
Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) are classified by the Centers for Medicare & Medicaid (CMS) into 10 categories below:
- IN - Inexpensive and Other Routinely Purchased Items
- FS - Frequently Serviced Items
- CR - Capped Rental Items
- OX - Oxygen and Oxygen Equipment
- OS - Ostomy, Tracheostomy & Urological Items
- PO - Prosthetics & Orthotics
- SD - Surgical Dressings
- SU - Supplies
- TE - Transcutaneous Electrical Nerve Stimulators
- TS - Therapeutic Shoes
- IL - Intra Ocular lens
SC - Splinting and Casting
Medicare Advantage reimbursement of DMEPOS codes will be at the lesser of billed charges or 100% of current DMEPOS fee schedule amount published by CMS.
Parenteral and Enteral Nutrition (PEN) codes will be reimbursed at the lesser of billed charges or 80% of the current DMEPOS fee schedule published by CMS.
Our health plan reserves the right to set a fee schedule amount for a DMEPOS code which is different from the amount published in the CMS DMEPOS fee schedule. For codes which do not have CMS fees, we may assign a payment rate that is a fee schedule amount or a percentage of billed charges.