Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Reimbursement - Medicare Advantage

Policy No: 118
Originally Created: 08/01/2014
Section: Administrative
Last Reviewed: 05/01/2018
Last Revised: 05/01/2018
Approved: 05/17/2018
Effective: 10/01/2018

This policy applies only to physicians and other qualified healthcare professionals.

Definitions

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

Policy statement

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.

References

None

Disclaimer

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.