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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 Health First Colorado updates and makes available to all enrolled DME providers at least annually. Refer to the HCPCS Code Table section 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 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.

Over-the-counter rapid COVID tests may also be prescribed by a pharmacist. 

Breast pumps may also be prescribed by a certified nurse midwife. 

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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 of Health Care Policy & Financing (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 Code 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 first month of rental must also include the KH modifier.
  • In addition to the RR modifier, claims for the second month (and if applicable, the third 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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Osteogenic Stimulators

The following criteria applies to osteogenic stimulators effective for prior authorization requests submitted on or after February 1, 2024.

This equipment is considered medically necessary in the treatment of nonunion fractures, when:

  • A minimum of two sets of radiographs are obtained at least 90 days apart, prior to starting treatment with the equipment. Each radiograph set must include multiple views of the fracture site accompanied with a written interpretation by a physician stating that there has been no clinically significant evidence of fracture healing between the 2 sets of radiographs; and,
  • Documentation that the member had a least one unsuccessful surgical intervention for the treatment of the fracture. 
  • For Adults with nonunion fractures of the skull, vertebrae, and those that are tumor-related are excluded from coverage. 
  • Ultrasonic osteogenic stimulators may not be used concurrently with other non-invasive osteogenic devices. 

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Speech Generating Devices (SGDs)

Colorado Medicaid covers Augmentative and Alternative Communication Devices (AACD) which allows a client with an expressive speech language disorder to electronically represent vocabulary and express thoughts or ideas to meet the client’s speech needs, as an in-home benefit.

AACD are covered for members who have a condition that inhibits communication. AACDs are provided upon recommendation by a speech-language pathologist after the client has completed a comprehensive assessment and medical necessity for the device has been well documented. 

They may be approved to support communication and improve health outcomes for clients with severe dysarthria, apraxia, aphasia, and other conditions that severely inhibit communication.

A speech-language pathology assessment must provide evidence that alternative, natural communication methods have been ineffective before an AACD will be considered. The assessment documentation should support the recommended AACD by including the client’s medical need, ability to operate the device both cognitively and physically, and expected improvement in the following. 

  • Ability to communicate medical needs;
  • Ability to express basic needs;
  • Ability to provide feedback on treatment or therapy programs;
  • Prevention of secondary impairments;
  • Independence and personal safety.

Digitized speech devices, synthesized speech devices and tablet computers are described below. Certain speech-generating software and necessary accessories are also covered once a client is approved for an AACD.

Digitized Speech Devices (Procedure Codes E2500, E2502, E2504, and E2506)

Digitized speech devices, sometimes referred to as “whole message” speech output devices, use words or phrases that have been recorded by someone other than the AACD system user. The following four options describe the types of digitized speech devices available:

  • A speech generating device using pre-recorded messages, less than or equal to eight (8) minutes recording time.
  • A speech generating device using pre-recorded messages, greater than eight minutes but less than or equal to 20 minutes recording time.
  • A speech generating device using pre-recorded messages, greater than 20 minutes but less than or equal to 40 minutes recording time.
  • A speech generating device using pre-recorded messages, greater than 40 minutes recording time.

Synthesized Speech Devices (Procedure Codes E2508 and E2510)

Synthesized speech devices utilize technology that allows input from the AACD system user in order to generate speech. These devices are not limited to pre-recorded messages, allowing the AACD system user to independently create messages. The following two options describe the types of synthesized speech devices available:

  • A speech generating device that formulates messages through letters and requires direct selection with the device.
  • A speech generating device that formulates messages through multiple methods of message creation and device access.
    • Message creation capabilities of the device must include two or more of the following: letters, words, pictures or symbols; and
    • Device access must be through direct selection with a keyboard or touch screen and one of more of the following indirect selection techniques: joystick/switches, head mouse, touch-enter, optical head pointer, light pointer, infrared pointed, scanning device or morse code.

Tablet Computers (Procedure Code E1399 with AV Modifier)

For this policy, “tablet computer” refers to a portable, integrated speech-generating device contained in a single panel that utilizes touch screen technology as the primary input for operation. As technology advances and becomes available, other primary input capabilities developed for tablet computers will be considered, e.g. operation by eye gaze/eye control. 

  • Tablet computers are a benefit when all AACD medical necessity criteria defined in this policy have been met.
  • The speech language pathologist will determine the AACD features necessary for effective communication through the assessment. The client must trial a minimum of three devices that have the necessary capabilities determined in the assessment before the recommendation for a tablet computer is submitted. 
    • The assessment documentation must support the trial findings and the final recommendation for a tablet computer. 
    • Tablet computer requests must specify that the device has a primary use as an AACD and that the client or client’s caretaker/representative acknowledges and agrees with the usage requirement.
    • Prior authorization requests must be submitted using the designated modifier. Requests should also include the recommended software or application, and any necessary accessories designated for the protection and effective use of the device such as a protective case, head pointer, mounting device, etc.
    • Note: tablet computers approved for the integrated use as an AACD should be received by the recommended provider/speech language pathologist who can assist the client with loading the approved software and instructing the client on its proper use.
  • The minimum replacement timeline for a tablet computer is five (5) years.
    • Stolen devices may be replaced within the five-year timeline; however, the client is limited to one-time replacement due to theft, and a police report must be provided for verification of the incident.
    • Replacement will not be granted within the five-year timeline for devices that are damaged, lost, misused, abused, or neglected.
    • Devices may not be sold or given away during the expected lifetime of use.

Software (Procedure Code E2511)

  • Speech generating software and applications are a covered benefit upon approval for an AACD and for client-owned equipment that will primarily be used as a communication device.
    • The appropriate software or application must be determined by the speech language pathologist in the assessment with a supporting diagnosis; and
    • The recommended software or application must be compatible with the personal computer, tablet computer or personal digital mobile device being used as the client’s AACD.
    • The software or application being requested for a client-owned equipment should be supported by detailed trial information as outlined in the previous Tablet Computers section of this policy.

Accessories (Procedure Codes A4601 E1902, E2511, E2512, E2599, and L9900)

  • Replacement lithium-ion batteries.
  • Non-electric AACD communication board.
  • Mounting systems designated for securing the AACD within reach of the client.
  • Safety and protection accessories designated to maintain the life expectancy of the device. 
  • Accessories not otherwise classified may be approved to enhance the use of the AACD system as the client’s condition changes.
  • Orthotic and prosthetic supplies and accessories, and/or service components of another HCPCS L code.

Non-Covered Services and General 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 AACD or are unrelated to the AACD.

Items that will not be covered include but are not limited to the following:

  • Printers
  • Laptop or desktop computers
  • Other portable, electronic devices that are not designated to have a primary use as an AACD
  • Modems, routers or other items used for internet utility services
  • Internet, phone or data services
  • Accessories that are not designated to have a primary purpose of protecting the AACD
  • Applications, software or programs that have not been recommended by the speech language pathologist or are not designated to have a primary use as a communication tool

Prior Authorization Requirements

Prior authorizations for these devices should follow standard PAR practices, as outlined in this manual. There is no required format, form, or questionnaire for submitting prior authorization requests; but the documentation should be inclusive of the following:

  • A prescription and recommendation for an AACD, AACD accessories and or AACD software by the client’s physician and licenses speech language pathologist. 
  • Speech assessment documentation supporting the AACD recommendations, which includes but is not limited to the following:
    • Medical diagnosis and description of the current functional needs, communication skills/limitations, and prognosis for improvement or deterioration
    • History of communication-related therapies
    • Alternative, natural communication methods were proven ineffective
    • Evidence of cognitive and physical ability to operate the device
    • Medical justification for the recommended device and software
    • Description of any trials required for the recommended device, including how each device trial met or failed to meet the client’s functional communication needs
    • The recommended device should be capable of modification to meet the needs for anticipated improvement or deterioration of functional communication when possible
  • A statement that affirms that the device has a primary use as an AACD and that the client or client’s caretaker/representative acknowledges and agrees with the usage requirement.

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.

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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.

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Prior Authorization Request (PAR) Process

As stated above, three (3) trials of three separate SGDs must be done prior to requesting a device. These trials should also include at least two (2) different manufacturers’ software.

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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.

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Replacement (10 CCR 2505-10, § 8.590.2.K)

The minimum replacement timeline for an SGD is five (5) 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.

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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.

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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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Cochlear Implant Processor/Bone-Anchored Hearing Aids (BAHA) Replacements

For lost/stolen processors:

  • If stolen, a police report must be filed, and confirmation of the report should be submitted with the PAR. 
  • Documentation of the product’s warranty must be submitted with the new Prior Authorization Request to verify that a replacement is not covered by the manufacturer. PARs may be pended to verify the purchase date and warranty expiration. 
  • Documentation related to how the member/caretaker will prevent the situation from occurring again. 
  • Replacements are covered once per device, per side. 
  • If the missing device is less than 5 years old, upgrades will not be authorized as part of the replacement. If the device is greater than 5 years old and an upgrade is being requested as the replacement, refer to the upgrade policy below.

    For upgrades:

  • Upgrades can be considered medically necessary for processors that are more than 5 years old and in the following situations:
  • There is documentation that the current device is no longer functional to produce adequate sound, or
  • The member has had a documented medical or lifestyle change that has resulted in the current device no longer being appropriate, or
  • The device requires repairs that are no longer possible because it is obsolete. PARs may be pended to gather additional details regarding how the device is obsolete. 
  • All requests must meet the definition of medical necessity as stated in CCR 2505-10 8.076.8
  • In all cases, an upgrade must be expected to have at least one of the following:
    • Significantly enhance auditory performance
    • Decrease possible safety concerns
    • Improve member’s quality of life 

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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.
  • Requests for replacement devices solely due to the device being older than 5 years are not medically necessary and will not be covered. 

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Mobility Equipment (Manual Wheelchairs, Power Wheelchairs and Scooters)

Refer to the Wheelchair Benefit Coverage Policy for wheelchair-specific coverage policy.

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.

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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. Refer to the Used and Refurbished DME and P&O section in this manual for additional information.

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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.

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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.

PARs for wheelchair repair no longer require a prescription or signature from the physician.  The DME supplier must have either supplied the member with the initial equipment and have all corresponding medical documentation on file or must obtain a written order prior to delivery (WOPD) that has the make, model, and serial number of the equipment requiring repair.  A new WOPD is not required for each repair as long as the above listed criteria is met.

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. Refer to the CRT HCPCS Code Table section in this manual for the CRT procedure codes.

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CRT Adaptive Seating Systems

The following are considered Adaptive Seating Systems and are therefore considered CRT as stated above.

  • Special bathing, toileting, showering, and or combination systems.
  • Adaptive Car Seats
  • Activity Chairs

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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.

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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.

Pursuant to HB22-1290 Changes to Medicaid for Wheelchair Repairs, the department will no longer require prior authorization requests (PARs) for repairs of Complex Rehabilitative Technology (CRT) equipment. Effective July 1, 2022, claims related to the repair of CRT will not require a PAR when billed with modifier RB.

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Enclosed/Safety Bed Coverage

Effective May 1, 2022, Questionnaire #19 will no longer be used for these Prior Authorization Requests (PARs). 
Requests for these items will now consist of a single attestation within Keystone Peer Review Organization (Acentra’s) electronic system, Atrezzo. Providers will be asked to confirm that caregivers have been educated on safe and proper use of the bed. 

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Bed Rails

Bed rails are a covered benefit for hospital beds only and must be from the same manufacturer as the bed they will be installed on.

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Vocational Items

Durable Medical Equipment is reviewed for medical necessity on an individual basis. Requests determined to be primarily for vocational purposes are not considered a medical benefit and will not be covered.

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Hip Kits

Hip kits may be covered using procedure code E1399 and are therefore manually priced. When requesting a hip kit, pricing information should be submitted for a pre-packaged kit. Submitting invoices for individual items and referring to them as a kit will not be approved. If pricing is submitted for individual items, each item must be listed on the PAR with a separate HCPCS code for each. In these cases, medical necessity will also be determined for each item separately. When requesting a pre-packaged hip kit as one item, medical necessity will be determined for the kit, only when it contains any combination of the following items:

  • Reacher
  • Leg lifter
  • Sock aid
  • Shoehorn
  • Dressing stick
  • Long scrub sponge

If a hip kit is requested and includes items not listed, they may be pended for additional justification.

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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 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. Refer to Appendix P located on the Billing Manuals web page under the Appendices drop-down for coverage information on Naloxone and Midazolam.

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Trans-Anal Irrigation Systems

Effective April 1, 2022, the following table should be used when billing for these products. Prior authorization is required for these HCPCS codes. Please be aware that different manufacturers may provide a different number of catheters with the system included in A4459. Providers should keep this in mind when determining how many units of A4453 are needed. 

HCPCSItem DescriptionUnit Limits

A4459

 

Manual pump-operated enema system includes balloon, catheter and all accessories, reusable, any type.4 units per year
A4453Rectal catheter for use with the manual pump-operated enema system, replacement only1 unit of service = 1 catheter
 

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Irrigation Supplies

As part of the 2022 new HCPCS procedure codes, A4397 has been discontinued and replaced by A4436 (reusable irrigation sleeve) and A4437 (disposable irrigation sleeve). A4437 has specific coverage criteria that providers will be asked to verify during the PAR process. At least one of the following must be true for A4437 to be medically necessary:

  1. 1. Difficult pouching situations requiring better fit of disposable irrigation sleeve; 
    • Challenging abdominal contours, or
    • Concerns with leakage / infection 
  2. Type of pouching system individual uses when not irrigating is not compatible with reusable sleeves .
  3. Thick and pasty stool consistency is a clinical reason to use a disposable irrigation sleeve.

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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 and Children (WIC) program as a primary resource for medically necessary enteral nutrition products. Enteral nutrition products are a covered benefit when a member has been prescribed over the WIC limit and or WIC is unable to fulfill the prescription due to supply. 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.

Questionnaire #10 for Oral and Enteral Nutrition Formula is not a required form as of 2018. However, it is still accepted as a form of documentation when signed by a physician. For accessibility, the questionnaire is located on the Provider Forms web page under the DMEPOS Forms drop-down. However, this form is optional and is still only acceptable when signed by a physician.

Human Milk Fortifier products are a covered benefit.

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

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Breast Pump Coverage

Single User Breast Pumps

Effective for dates of service June 8, 2022, or later, DMEPOS providers may bill Health First Colorado as the primary payer for manual and or single user electric breastfeeding pumps.
 
The Women, Infant and Children (WIC) program was previously the primary payer of breast pumps for Health First Colorado members. Health First Colorado only covered pumps under specific circumstances related to infant hospitalization of at least 54 days.

This limited coverage policy ended on June 7, 2022.

The WIC program has not changed. Members may acquire a breast pump from Health First Colorado or WIC.

  • Prior authorization requests (PARs) are not required.
  • Members may receive a breast pump as early as the 28th week of pregnancy. Per EPSDT policy, deliveries prior to 28 weeks qualify for a breast pump immediately following the birth. 
  • Postpartum members may receive a pump at any time.
  • Breast pumps may be prescribed by a physician, physician assistant, nurse practitioner, or certified nurse midwife. 
  • As is required for all DMEPOS, a prescription from a physician, physician assistant, or nurse practitioner is needed.
  • Claims will not be denied based on the diagnosis code used. However, diagnosis code Z39.1 is appropriate.
  • The Colorado interChange has been updated to allow for these changes.

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Multi-User Breast Pumps

  • Procedure code E0604 with modifier RR should be used when billing for multi-user breast pumps. 
  • Effective January 1, 2023, the reimbursement rate for E0604RR is $219.67. The interChange has been updated for the rate and code combination. 
  • This is a continuous rental item that will not be converted to purchase. 
  • Prior authorization requests are required.  
  • Prescriptions should include information on why a single user pump is not sufficient for the member.  
  • Multi-user pumps may be rented for up to two years, but a PAR will need to be submitted for continuation of services after one year.
  • Providers are required to provide members with any necessary material and training on appropriate cleaning, storage, and use.  
  • A single user collection kit specifically made for the corresponding pump must also be provided to each user and is not to be billed separately. 
  • Additional accessories and supplies needed during the usage period, including replacement parts, are inclusive of the monthly rate and should not be billed separately. 
  • All rented pumps must be FDA approved as a multi-user breast pump. 
  • Single user breast pumps (electric and manual) remain a covered benefit, prior authorization requests not required.  
  • Members may receive a breast pump as early as the 28th week of pregnancy. Per EPSDT policy, deliveries prior to 28 weeks qualify for a breast pump immediately following the birth.

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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.

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Continuous Glucose Monitor (CGM) Benefit Coverage

CGMs and related supplies are covered by Health First Colorado when all of the following coverage criteria (1-5) are met:

  1. The beneficiary has diabetes mellitus; and
  2. The beneficiary is insulin-treated with multiple (three or more) daily administrations of insulin or a continuous subcutaneous insulin infusion (CSII) pump; and,
  3. The beneficiary’s insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of BGM or CGM testing results; and,
  4. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with the beneficiary to evaluate their diabetes control and determines that criteria (1-3) above are met; and,
  5. Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan.

CGM Prior Authorization Requests (PARs) must be submitted to the Department’s third-party utilization management vendor. PARs, including requests for CGM supplies, will be limited to a 6-month period.

When requesting a CGM in the online PAR portal, providers will be asked whether the member has received or if there is documented plan to receive diabetes education specifically related to CGMs. 

CGM replacement policy per 8.590.2.J. Repairs and replacement parts are covered under the following conditions:

  • The item was purchased by Medicaid; or

  • The item is owned by the member, member’s family or guardian; and

  • The item is used exclusively by the member; and

  • The item’s need for repair was not caused by member misuse or abuse; and

  • The item is no longer under the manufacturer warranty.

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Initial Coverage Criteria

  1. The beneficiary has diabetes mellitus; and
  2. The beneficiary is insulin-treated with multiple (three or more) daily administrations of insulin or a continuous
  3. subcutaneous insulin infusion (CSII) pump; and
  4. The beneficiary’s insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of BGM or CGM testing results; and
  5. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person or telehealth visit with the beneficiary to evaluate their diabetes control and determines that criteria (1-3) above are met; and
  6. Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-person or telehealth visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan; and
  7. Receipt of, or documented plan to receive, diabetes education specific to the use of CGMs; and,
  8. Be able to hear and view the CGM alerts and respond accordingly, or have a caregiver who is able to do so, and
  9. Providers should verify that the patient meets the manufacturer’s recommendations for appropriate age range, testing and calibration requirements, etc. before prescribing the CGM device.
  10. Or has an otherwise qualifying circumstance or is otherwise deemed medically necessary.

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Reauthorization Criteria + Supplies

  • Individual meets all the initial criteria (except for the SMBG requirement), and
  • In-person or telehealth visit with treating practitioner within at least six (6) months of CGM renewal prescription, and
  • Provider determines that the individual is regularly utilizing the device.
  • Individual receives ongoing instruction and evaluation of technique, results, and their ability to use data from CGM to adjust therapy, or
  • Has an otherwise qualifying circumstance or is otherwise deemed medically necessary.

An upgrade to a new model or different brand of CGM may be deemed medically necessary in the following situations:

  • There is documentation that the current device is no longer functional either partially or entirely, and therefore is no longer clinically effective, or

  • The requested upgrade is different in its capability and would be expected to provide better clinical outcomes than the current device, and

  • The member has been using their current device for at least three years.

  • If the current CGM requires repair or replacement that is no longer possible because it is obsolete, requests may be approved in cases where use is less than three years. PARs may be pended to gather additional details regarding the device being obsolete.

  • All requests must meet the definition of medical necessity as stated in CCR 2505-10 8.076.8.

  • For requests to upgrade a CGM where the new device has the same manufacturer and procedure code as the current device, the upgrade request may be approved regardless of the devices condition, functionality and length of use. Cases will continue to be reviewed for medical necessity and may include ensuring compatibility of the new device with the member’s insulin pump.

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Covered Devices

ManufacturerProduct
AbbottFreeStyle Libre 2
AbbottFreeStyle Libre 3
AbbottFreeStyle Libre 2 Plus
DexcomG6
DexcomG7
MedtronicGuardian Sensor 3
MedtronicGuardian Sensor 4
InsuletOmnipod DASH
InsuletOmnipod 5

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Billing for Omnipod®

Procedure code A9274 with modifier U1 is a covered service and requires prior authorization for Omnipod® 5 and DASH® products. This code and modifier combination is manually priced.  Claims must be submitted via the provider web portal with an invoice or manufacturer’s suggested retail price (MSRP) attached and the appropriate modifier for pricing.

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Over-The-Counter, At-Home COVID-19 Tests

Effective January 15, 2022, OTC at-home COVID-19 rapid tests are a covered benefit for Health First Colorado Members. Providers should use HCPCS procedure code E1399+U1 to bill for these tests. 
Coverage Criteria:

  • Member co-pays are not required.
  • Prior Authorization is not required. 
  • Test coverage is limited to 15 units of service per month per member.
  • Span-billing is permitted for monthly allowance. 
  • One unit of service is equal to one individual test. If a package includes two tests, the provider should bill for two units of service.
  • Providers must bill Health First Colorado the same amount as the retail price on a per-test basis. For example, if the provider sells a two-test pack for $14, they would bill two units of service at $7 each to Health First Colorado.
  • A prescription is necessary to receive reimbursement, as is required for all DMEPOS. However, the Public Readiness and Emergency Preparedness Act allows for pharmacists to order these tests. 
  • Providers must use the NPI of the ordering provider, such as the pharmacist, on all claims. 
  • All claims for tests should also be billed to Gainwell Technologies (GWT) Fee-For-Service (FFS), including for members enrolled in the Denver Health and Rocky Mountain Health Plan managed care networks.
  • Tests are a benefit for members regardless of diagnosis. However, diagnosis code Z20.822 for potential COVID exposure is also appropriate.

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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 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 360 per calendar month in any combination of diapers, liners, and undergarments. Medically necessary usage above that amount requires prior authorization.

Medically necessary wipes are a benefit under EPSDT, wipes for incontinence only are not medically necessary. Wipes for use by a Home Health provider are not a benefit. Prior Authorization Requests are not required. Effective July 1, 2021, providers must use HCPCS A9286 for this 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 section 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 Code Table section, 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 ventilator 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.

Continuous rental items require a Face-to-Face visit for both initial requests and renewals. Refer to the Face-To-Face (F2F) Requirements section in this manual. 

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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. Refer to the Federal Upper Payment Limit (UPL) Requirement section in this manual.

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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, only if the claim’s date of service is before the member’s date of death. Health First Colorado will make recoveries for all DMEPOS services following the date of the member's death.

The interChange operationalizes this policy in the following ways:

  • If the claim's 'date of service' occurs before the member's 'date of death' within the same month, the claim will be paid and not recouped. 
  • If the claim's 'date of service' occurs on/after the member's 'date of death' within the same month, and for all following months, the claim will be denied or eventually recouped.

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Span Billing for Certain Supplies

The following items may have a date span of up to 30 calendar days on claims submitted to the Department:

  • Diabetic testing supplies (i.e., test strips, lancets)
  • Continuous passive motion devices (CPM)
  • Parenteral and enteral nutrition
  • Parenteral and enteral administration kits
  • External infusion pump supplies
  • Over the Counter, at-home COVID-19 tests
  • Other supplies that have an NCCI MUE limit (refer to the January 2024 Provider Bulletin (2400503) located on the Bulletins web page)

Suppliers must span the dates of service using "From" and "To" dates on any claim for the items listed above. The "From" date is when the items were provided to the member. The "To" date is the last date the supplies are expected to be used. For example, if you are providing a 30-day supply of diabetic testing strips to a member, the "From" date on the claim would be "01/01/2021" and the "To" date would be "01/30/2021”.

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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 date the member receives the equipment.

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.

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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.

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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.

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Six-Month Requirement

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.

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Start of Services

As defined in 10 CCR 2505-10, § 8.590.1 the start of services means the date that the ordering practitioner signs the written order for durable medical equipment following the face-to-face encounter with the member.

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.

For items that are continuous rental, F2F within 6 months is a requirement on both initial requests as well as renewals.

Repair and replacement do not require the F2F.

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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.

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Telehealth

F2F encounters may be performed via telehealth if available.

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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.

Refer to the fee schedule located on the Provider Rates and Fee Schedule web page for the majority of the DMEPOS codes.

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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 in the HCPCS Code Table in the Comments column with the following notation:

*Code is subject to the 2019 DME UPL

Refer to the fee schedule located on the Rates and Fee Schedules web page under the Durable Medical Equipment, Upper Payment Limit section for the DME UPL codes.

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Manufacturer Suggested Retail Price (MSRP)

Effective July 1, 2023, if the fee schedule states, "Code is Manually Priced", reimbursement is the lower of (MSRP less 15.49%) 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 PARs and 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

Effective July 1, 2023, 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 23.59% 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 with the 'UB' modifier must be included on the claim. The Submitted Charge should reflect the provider's U&C minus the Actual Acquisition Cost.

Effective July 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.

Providers must attach a copy of the invoice on all PARs and 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).

Effective July 1, 2018, maximum allowable is:

1E1399 UB$1229.00 (actual invoice cost + 23.59%) 

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 1.2359 = $1235.90, or
  • $1000 x .2359 = $235.90 + $1000 = $1235.90
  • 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 10, 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. In reviewing for medical necessity, the Utilization Management Vendor may deny an item that has been deemed unsafe for the member. 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 the PAR portal. 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, contact the ColoradoPAR Program at 888-801-9355 or visit the Department's ColoradoPAR Program web page.

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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.

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DME Safety Equipment Policy

As part of the Prior Authorization Request (PAR) process, Health First Colorado’s PAR vendor reviews requests for safety of the member. It is the member’s responsibility to ensure safe installation of any safety equipment that modifies the home and or their environment. This would refer to items such as rails that attach to a wall, toilet, or other part of the home. The department refers to these items as permanently affixed safety equipment. Due to substantial risk of safety for the member, the department will not approve of safety items that are not permanently affixed. This includes but is not limited to items attached by means of a suction cup or tension mechanism. 

However, PARs are still reviewed for safety on an individual basis and this policy should not be used to assume that all permanently affixed items are safe for every member. 

  • DME most commonly impacted by this policy: 
  • E0241 Bathtub wall rail, each
  • E0242 Bathtub rail, floor base, each
  • E0243 Toilet rail, each
  • E0246 Transfer tub rail attachment, each

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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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Early and Periodic Screening, Diagnostic and Treatment (EPSDT)

8.280.4.E Other EPSDT Benefits

Other health care services may include other EPSDT benefits if the need for such services is identified. The services are a benefit when they meet the following requirements:

  1. All goods and services described in Section 1905(a) of the Social Security Act are a covered benefit under EPSDT when medically necessary as defined at 10 C.C.R. 2505-10, Section 8.076.1.8, regardless of whether such goods and services are covered under the Colorado Medicaid State Plan.
  2. For the purposes of EPSDT, medical necessity includes a good or service that will, or is reasonably expected to, assist the client to achieve or maintain maximum functional capacity in performing one or more Activities of Daily Living; and meets the criteria set forth at Section 8.076.1.8.b - g.
  3. The service provides a safe environment or situation for the child.
  4. The service is not for the convenience of the caregiver.
  5. The service is medically necessary.
  6. The service is not experimental or investigational and is generally accepted by the medical community for the purpose stated.
  7. The service is the least costly.

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Questionnaires

Visit the Provider Forms web page under the DMEPOS Forms drop-down for all questionnaires.

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Complex Rehabilitation Technology (CRT)

Complex Rehabilitation Technology Suppliers must comply with additional regulations for repair orders created on or after October 1, 2023. Pursuant to 10 C.C.R. 2505-10 8.590.5.E. the following required metrics are to be reported by suppliers on all CRT repairs, including members also enrolled in Medicare coverage. Members with additional coverage other than Medicare, such as private insurance, are excluded from these reports.

  1. Quality of CRT repairs shall be reported to the Department using the data points 2: a-i detailed below.
    1. At the time the repair is fulfilled, regardless of the location, members will be asked to confirm that the equipment has been repaired to their satisfaction.
    2. Members, their legal guardian or other authorized representative may be asked to confirm verbally or in writing, provided that the answers can be verified by a signature and date.
    3. This information may be obtained on a delivery ticket or as a separate form. This metric will be used to measure the number of repairs that were reported as satisfactory, not satisfactory or where an answer was not obtained.
  2. Metrics must be reported using the following:
    1. Medicaid Identification Number
    2. Type of equipment being repaired: Manual wheelchair, power wheelchair, non-wheelchair mobility device or other equipment
    3. Does the member also have Medicare? Yes or no
    4. Order creation date
    5. Date of first available evaluation appointment (optional)
    6. Date evaluation occurred
    7. Does the member have secondary/back up equipment? Yes or no
    8. Quality of repair answer: Satisfactory, not satisfactory or answer not obtained
    9. Repair fulfillment date

CRT Suppliers must send their reports to HCPF_DME@state.co.us twice per calendar year following this deadline table:

Date of Repair FulfillmentReport Submission Deadline
December 1 – May 31June 30
June 1 – November 30December 31

 

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 section represents an overview of the specialty evaluation requirement and is not intended to limit or restrict access to Specialty Evals. 

    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.
  • Modification to a seating system
  • An addition of power seating or alternative drive control to a wheelchair.
  • 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.
  1. 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:

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 seven (7) 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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General Billing Information

Refer to the General Provider Information Manual located on the Billing Manuals web page under the General Provider Information drop-down menu 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:

AVItem furnished in conjunction with a prosthetic device, prosthetic or orthotic
BOOrally administered nutrition, not by feeding tube
KHDMEPOS item, initial claim, purchase or first month rental
KIDMEPOS item, second or third month rental.
KRRental item, billing for partial month
MSSix (6) month maintenance and servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warranty
RRRental (use the RR modifier when DME is to be rented)
SCMedically Necessary Service or Supply - To be used with MSRP priced codes only
TTIndividualized service provided to more than one (1) member in same setting
TWSecondary or back-up equipment
UBInvoice cost - To be used with "By Invoice" priced codes only
NUNew Equipment
UEUsed Equipment
Effective July 1, 2017
RAReplacement of a DME, orthotic or prosthetic item
RBReplacement of part of a DME, orthotic or prosthetic item furnished as part of a repair
Effective June 1, 2018:
KFItem designated by the FDA as a Class III device

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Procedure/HCPCS Codes Overview

The Department 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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National Correct Coding Initiative

Note that Medically Unlikely Edits (MUEs) may apply for some codes. Visit the National Correct Coding Initiative (NCCI) web page.

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Paper PAR Instructional Reference

Field LabelCompletion FormatInstructions
The upper margin of the PAR form must be left blank. This area is for authorizing agency use only.
Invoice/Pat Account NumberTextOptional

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

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 Number7 charactersRequired

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

Example: A123456
3. SexCheck box
MF		Required

Enter an "X" in the appropriate box.
4. Date of Birth6 digitsRequired

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

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

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

Enter the member's telephone number.
7. Prior Authorization NumberNoneLeave Blank

This field is automatically system assigned
8. Dates Covered by This Request6 digits for From date and 6 digits for Through dateOptional

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 HomeTextConditional

Complete if member resides in a group home.

Enter the name of the group home or residence.
11.DiagnosisTextRequired

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 RepairsTextConditional

Complete if requesting repairs for equipment owned by the member.

Enter the serial number of the equipment.
13.Indicate Length of NecessityTextConditional

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

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 AuthorizedNonePreprinted

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 ProvidedTextRequired

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 Code5 digitsRequired

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 ServicesDigitsRequired

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 ServicesNoneLeave 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		NoneLeave Blank

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

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

Enter the PCP's telephone number.
22.Primary Care Physician AddressTextConditional

Complete if member has a PCP. Enter the PCP's complete address.
23.PCP Provider Number8 DigitsConditional

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 AuthorizationTextRequired

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 ServiceTextRequired

Enter the name and telephone number of the supplier who will render the service.
26.SignatureTextRequired

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 8¬Ω 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 NumberTextRequired

Enter the telephone number of the requesting provider.
27. Date Signed6 DigitsRequired

Enter the date the PAR form is signed by the requesting provider.
28. Requesting Provider Number8 DigitsRequired

Enter the eight-digit Health First Colorado provider number of the requesting provider.
Telephone NumberTextRequired

Enter the telephone number of the requesting provider.
29. Billing Provider Number8 DigitsRequired

Enter the eight (8)-digit Health First Colorado provider number of the billing provider. The billing provider must be enrolled in Health First Colorado.
30. Comments or Reasons For Denial of BenefitsNoneLeave Blank

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

This field is completed by the authorizing agency.

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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 (on the Electronic Data Interchange (EDI) Support web page of the Department's website), and in the Web Portal User Guide (via within the portal).

CMS Field Number and LabelField is?Instructions
1. Insurance TypeRequiredPlace an "X" in the box marked as Medicaid.
1a. Insured's ID NumberRequiredEnter the member's Health First Colorado seven-digit Medicaid ID number as it appears on the Medicaid Identification card. Example: A123456.
2. Patient's NameRequiredEnter the member's last name, first name, and middle initial.
3. Patient's Date of Birth/SexRequiredEnter 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 NameConditionalComplete 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 AddressNot Required 
6. Client Relationship to InsuredConditionalComplete if the member is covered by a commercial health care insurance policy.
7. Insured's AddressNot Required 
8. Reserved for NUCC Use  
9. Other Insured's NameConditionalIf field 11d is marked "yes", enter the insured's last name, first name, and middle initial.
9a. Other Insured's Policy or Group NumberConditionalIf 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 NameConditionalIf field 11d is marked "yes", enter the insurance plan or program name.
10a-c. Is patient's condition related to?ConditionalWhen 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 NumberConditionalComplete if the member is covered by a Medicare 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, SexConditionalComplete if the member is covered by a Medicare 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 IDNot Required 
11c. Insurance Plan Name or Program NameNot Required 
11d. Is there another Health Benefit Plan?ConditionalWhen appropriate, place an "X" in the correct box. If marked YES, complete 9, 9a and 9d
12. Patient's or Authorized Person's signatureRequiredEnter "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 SignatureNot Required 
14. Date of Current Illness Injury or PregnancyConditionalComplete 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 NotNot Required 
16. Date Patient Unable to Work in Current OccupationNot Required 
17. Name of Referring PhysicianRequiredProviders are required to include the NPI of the referring provider in this field. In the Provider Web Portal, this field may be labeled as “referring provider”. 
18. Hospitalization Dates Related to Current ServiceConditionalComplete 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 InformationConditionalDurable 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 InjuryRequiredEnter 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 CodeConditionalList 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 AuthorizationConditionalComplete 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 DetailInformationThe 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 ServiceRequired

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.

FromTo
010119   

or

FromTo
010119010119

Span dates of service

FromTo
010119013119

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 ServiceRequired

Enter the Place of Service (POS) code that describes the location where services were rendered. Health First Colorado accepts the CMS place of service codes.

04Homeless Shelter
11Office
12Home
15Mobile Unit
20Urgent Care Facility
21Inpatient Hospital
22Outpatient Hospital
23Emergency Room Hospital
25Birthing Center
26Military Treatment Center
31Skilled Nursing Facility
32Nursing Facility
33Custodial Care Facility
34Hospice
41Transportation - Land
52Psychiatric Facility Partial Hospitalization
53Community Mental Health Center
54Intermediate Care Facility - MR
60Mass Immunization Center
61Comprehensive IP Rehab Facility
62Comprehensive OP Rehab Facility
65End Stage Renal Dialysis Treatment Facility
71State - Local Public Health Clinic
99Other Unlisted
24C. EMGNot Required 
24D. Procedures, Services, or SuppliesRequiredEnter 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. ModifierConditional

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.

BOOrally administered nutrition, not by feeding tube
KHDMEPOS item, initial claim, purchase or first month rental KI DMEPOS item, second- or third-month rental.
KRRental item, billing for partial month
MSSix (6) month maintenance and servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warranty
RRRental (use the RR modifier when DME is to be rented)
SCMedically Necessary Service or Supply - To be used with MSRP priced codes only
TTIndividualized service provided to more than one (1) member in same setting TW Secondary or back-up equipment
UBInvoice cost - To be used with "By Invoice" priced codes only
NUNew Equipment
UEUsed Equipment
Effective July 1, 2017
RAReplacement of a DME, orthotic or prosthetic item
RBReplacement of part of a DME, orthotic or prosthetic item furnished as part of a repair
Effective June 1, 2018:
KFItem designated by the FDA as a Class III device
24E. Diagnosis PointerRequiredEnter 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. $ ChargesRequiredEnter 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 UnitsRequiredEnter the number of services provided for each procedure code.

Enter whole numbers only- do not enter fractions or decimals.
24H. EPSDT/Family PlanConditional

EPSDT (shaded area)
For Early and Periodic Screening, Diagnosis and Treatment related services, enter the response in the shaded portion of the field as follows:

AVAvailable- Not Used
S2Under Treatment
STNew Service Requested NU Not Used

Family Planning (unshaded area)
Not Required

24I. ID QualifierNot Required 
24J. Rendering Provider ID #RequiredIn 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 NumberNot Required 
26. Patient's Account NumberOptionalEnter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA).
27. Accept Assignment?RequiredThe accept assignment indicates that the provider agrees to accept assignment under the terms of the payer's program.
28. Total ChargeRequiredEnter 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 PaidConditionalEnter 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 CredentialsRequiredEach 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 #		RequiredEnter 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 #		RequiredEnter 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 NumberRequired 
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

Refer to the General Provider Information Manual located on the Billing Manuals web page under the General Provider Information drop-down menu for more information on timely filing policy, including the resubmission rules for denied claims.

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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. Health First Colorado reserves the right to amend the coding for any approved item.

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Description Column

A description of the item as provided by Centers for Medicare & 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.

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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.

YesPARs for these items are reviewed by the ColoradoPAR Program.
NoThe 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. Refer to 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 are located on the Provider Forms web page under the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Forms drop-down menu. 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, and there are links back to this section of this manual.

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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, note the following definitions.

Pursuant to HB22-1290 Changes to Medicaid for Wheelchair Repairs, the department will no longer require prior authorization requests (PARs) for repairs of Complex Rehabilitative Technology (CRT) equipment. Effective July 1, 2022, claims related to the repair of CRT will not require a PAR when billed with modifiers RB. Refer to the definition of repair below to clarify what is included in this policy.

Note: The PAR column in the table below is for purchase only and not repair. 

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.

Repair

Repair is fixing any part of the equipment so that it performs in a way that is safe and functional for the member. Repair can include replacement where the replacement part was original to the equipment base. Adding equipment that was not part of the original base is a modification.

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.

CodeDescriptionPARUnit LimitsCommentsSpecialty Eval
NewMod
E0637Combination sit to stand/table system, any size including pediatric, with seat lift feature, with or without wheelsYes  YesYes
E0638Standing frame/table system, one (1) position (e.g. upright, supine or prone stander), any size including pediatric, with or without wheelsYes  YesYes
E0641Standing frame/table system, multi-position (e.g. three-way stander), any size including pediatric, with or without wheelsYes  YesYes
E0642Standing frame/table system, mobile (dynamic stander), any size including pediatricYes  YesYes
E0986Manual wheelchair accessory, push activated power assist, eachYes Required: F2FNoNo
E1002Wheelchair accessory, power seating system, tilt onlyYes Required: Q15YesYes
E1003Wheelchair accessory, power seating system, recline only, without shear reductionYes Required: Q15YesYes
E1004Wheelchair accessory, power seating system, recline only, with mechanical shear reductionYes Required: Q15YesYes
E1005Wheelchair accessory, power seating system, recline only, with power shear reductionYes Required: Q15YesYes
E1006Wheelchair accessory, power seating system, combination tilt and recline, without shear reductionYes Required: Q15YesYes
E1007Wheelchair accessory, power seating system, combination tilt and recline, with mechanical shear reductionYes Required: Q15YesYes
E1008Wheelchair accessory, power seating system, combination tilt and recline, with power shear reductionYes Required: Q15YesYes
E1009Wheelchair accessory, addition to power seating system, mechanically linked leg elevation system, including pushrod and leg rest, eachYes  YesYes
E1010Wheelchair accessory, addition to power seating system, power leg elevation system, including pushrod and leg rest, eachYes  YesYes
E1011Modification to pediatric size wheelchair width adjustment package (not to be dispensed with initial chair)Yes For modification of existing wheelchair onlyNoNo
E1012Wheelchair accessory, addition to power seating system, center mount power elevating leg rest/platform, complete system, any type, eachYes  YesYes
E1014Reclining back, addition to pediatric size wheelchairYes Required: F2F, Q15NoNo
E1037Transport chair, pediatric sizeYes Required: F2F
*Code is subject to the 2019 DME UPL		NoNo
E1161Manual adult size wheelchair, includes tilt- in-spaceYes Required: F2F
*Code is subject to the 2019 DME UPL		NoNo
E1220Wheelchair, specially sized or constructed (indicate brand name, model number, if any, and justification)Yes  YesNo
E1228Special back height for wheelchairYes Required: F2FNoNo
E1229Wheelchair, pediatric size, not otherwise specifiedYes  YesNo
E1231Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, with seating systemYes  NoNo
E1232Wheelchair, pediatric size, tilt-in-space, folding, adjustable, with seating systemYes Required: F2F
*Code is subject to the 2019 DME UPL		NoNo
E1233Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, without seating systemYes Required: F2F
*Code is subject to the 2019 DME UPL		NoNo
E1234Wheelchair, pediatric size, tilt-in-space, folding, adjustable, without seating systemYes Required: F2F
*Code is subject to the 2019 DME UPL		NoNo
E1235Wheelchair, pediatric size, rigid, adjustable, with seating systemYes Required: F2F
*Code is subject to the 2019 DME UPL		NoNo
E1236Wheelchair, pediatric size, folding, adjustable, with seating systemYes Required: F2F
*Code is subject to the 2019 DME UPL		NoNo
E1237Wheelchair, pediatric size, rigid, adjustable, without seating systemYes Required: F2F
*Code is subject to the 2019 DME UPL		NoNo
E1238Wheelchair, pediatric size, folding, adjustable, without seating systemYes Required: F2F
*Code is subject to the 2019 DME UPL		NoNo
E1239Power wheelchair, pediatric size, not otherwise specifiedYes  YesNo
E2209Accessory, arm trough, with or without hand support, eachYes 1 unit = 1 arm troughNoNo
E2291Back, planar, for pediatric size wheelchair including fixed attaching hardwareYes  NoNo
E2292Seat, planar, for pediatric size wheelchair including fixed attached hardwareYes  NoNo
E2293Back, contoured, for pediatric size wheelchair including fixed attaching hardwareYes  NoNo
E2294Seat, contoured, for pediatric size wheelchair including fixed attaching hardwareYes  NoNo
E2295Manual wheelchair accessory, for pediatric size wheelchair, dynamic seating frame, allows coordinated movement of multiple positioning featuresYes  YesNo
E2300Wheelchair accessory, power seat elevation, system, any typeYes Required: Q17YesYes
E2301Wheelchair accessory, power standing system, any typeYes  YesYes
E2310Power 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 hardwareYes  YesNo
E2311Power 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 hardwareYes  YesNo
E2312Power wheelchair accessory, hand or chin control interface, mini-proportional remote joystick, proportional, including fixed mounting hardwareYes  YesNo
E2313Power wheelchair accessory, harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware, eachYes  YesNo
E2321Power wheelchair accessory, hand control interface, remote joysticks, non- proportional, including all related electronics, mechanical stop switch, and fixed mounting hardwareYes  YesNo
E2322Power wheelchair accessory, hand control interface, multiple mechanical switches, non-proportional, including all related electronics, mechanical stop switch, and fixed mounting hardwareYes  YesNo
E2323Power wheelchair accessory, specialty joystick handle for hand control interface, prefabricatedYes  YesNo
E2324Power wheelchair accessory, chin cup for chin control interfaceYes  NoNo
E2325Power wheelchair accessory, sip and puff interface, non-proportional, including all related electronics, mechanical stop switch, and manual swing away mounting hardwareYes  YesYes
E2326Power wheelchair accessory, breath tube kit for sip and puff interfaceYes  NoNo
E2327Power wheelchair accessory, head control interface, mechanical, proportional, including all related electronics, mechanical direction change switch, andYes  YesCon
E2328Power wheelchair accessory, head control or extremity control interface, electronic, proportional, including all related electronics and fixed mounting hardwareYes  YesCon
E2329Power 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 hardwareYes  YesCon
E2330Power 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 hardwareYes  YesCon
E2331Power wheelchair accessory, attendant control, proportional, including all related electronics and fixed mounting hardwareYes  YesYes
E2351Power wheelchair accessory, electronic interface to operate speech generating device using power wheelchair control interfaceYes  NoNo
E2373Power wheelchair accessory, hand or chin control interface, compact remote joystick, proportional, including fixed mounting hardwareYes  YesNo
E2374Power wheelchair accessory, hand or chin control interface, standard remote joystick (not including controller), proportional, including all related electronics and fixed mounting hardware, replacement onlyCon1 per 3 YPAR required for more than 1 per 3 YNoNo
E2376Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, replacement onlyCon1 per YOver 1 unit requires PARNoNo
E2377Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issueYes  NoNo
E2609Custom fabricated wheelchair seat cushion, any sizeYes Identify specific brand/name of cushion requested on prior authorization requestYesYes
E2610Wheelchair seat cushion, poweredYes Identify specific brand/name of cushion requested on prior authorization requestYesYes
E2617Custom fabricated wheelchair back cushion, any size, including any type mounting hardwareYes Identify specific brand/name of cushion requested on prior authorization requestYesYes
E8000Gait trainer, pediatric size, posterior support, includes all accessories and componentsYes Use for adults alsoYesYes
E8001Gait trainer, pediatric size, upright support, includes all accessories and componentsYes Use for adults alsoYesYes
E8002Gait trainer, pediatric size, anterior support, includes all accessories and componentsYes Use for adults alsoYesYes
K0005Ultra-lightweight wheelchairYes Required: F2F
*Code is subject to the 2019 DME UPL		YesNo
K0008Custom manual wheelchair baseYes  YesNo
K0009Other manual wheelchair/baseYes Do not use for titanium manual wheelchairs, see K0005 or K0008.
*Code is subject to the 2019 DME UPL		YesNo
K0669Wheelchair accessory wheelchair seat or back cushion does not meet specific code criteria or no written coding verification from DME PDACYes  YesYes
K0835Power wheelchair, group 2 standard, single power option, single power option, sling/solid seat/back, patient weight capacity up to and including 300 poundsYes *Code is subject to the 2019 DME UPLYesNo
K0836Power wheelchair, group 2 standard, single power option, captain's chair. Member weight capacity up to and including 300 poundsYes *Code is subject to the 2019 DME UPLYesNo
K0837Power wheelchair, group 2 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 poundsYes *Code is subject to the 2019 DME UPLYesNo
K0838Power wheelchair, group 2 heavy duty, single power option, captain's chair, patient weight capacity 301 to 450 poundsYes *Code is subject to the 2019 DME UPLYesNo
K0839Power wheelchair, group 2 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 poundsYes *Code is subject to the 2019 DME UPLYesNo
K0840Power wheelchair, group 2 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 601 pounds or moreYes *Code is subject to the 2019 DME UPLYesNo
K0841Power wheelchair, group 2 standard, multiple power option, sling/solid seat/back, patient weight capacity up to including 300 poundsYes *Code is subject to the 2019 DME UPLYesNo
K0842Power wheelchair, group 2 standard, multiple power option, captain's chair, patient weight capacity up to and including 300 poundsYes *Code is subject to the 2019 DME UPLYesNo
K0843Power wheelchair, group 2 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 poundsYes *Code is subject to the 2019 DME UPLYesNo
K0848Power wheelchair, group 3 standard, sling/solid seat/back, patient weight capacity up to and including 300 poundsYes *Code is subject to the 2019 DME UPLYesNo
K0849Power wheelchair, group 3 standard, captain's chair, patient weight capacity up to and including 300 poundsYes *Code is subject to the 2019 DME UPLYesNo
K0850Power wheelchair, group 3 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 poundsYes *Code is subject to the 2019 DME UPLYesNo
K0851Power wheelchair, group 3 heavy duty, captain's chair, patient weight capacity 301 to 450 poundsYes *Code is subject to the 2019 DME UPLYesNo
K0852Power wheelchair, group 3 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 poundsYes *Code is subject to the 2019 DME UPLYesNo
K0853Power wheelchair, group 3 very heavy duty, captain's chair, patient weight capacity, 451 to 600 poundsYes *Code is subject to the 2019 DME UPLYesNo
K0854Power wheelchair, group 3 extra heavy duty, sling/solid seat/back, patient weight capacity 601 pounds or moreYes  YesNo
K0855Power wheelchair, group 3 extra heavy duty, captain's chair, patient weight capacity 601 pounds or moreYes  YesNo
K0856Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 poundsYes *Code is subject to the 2019 DME UPLYesNo
K0857Power wheelchair, group 3 standard, single power option, captain's chair, patient weight capacity up to and including 300 poundsYes *Code is subject to the 2019 DME UPLYesNo
K0858Power wheelchair, group 3 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 poundsYes *Code is subject to the 2019 DME UPLYesNo
K0859Power wheelchair, group 3 heavy duty, single power option, captain's chair, patient weight capacity 301 to 450 poundsYes *Code is subject to the 2019 DME UPLYesNo
K0860Power wheelchair, group 3 very heavy duty, single power option, sling/solid seat/back. Member weight capacity 451 to 600 poundsYes *Code is subject to the 2019 DME UPLYesNo
K0861Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to including 300 poundsYes *Code is subject to the 2019 DME UPLYesNo
K0862Power wheelchair, group 3 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 poundsYes *Code is subject to the 2019 DME UPLYesNo
K0863Power wheelchair, group 3 very heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 451 to 600 poundsYes *Code is subject to the 2019 DME UPLYesNo
K0864Power wheelchair, group 3 extra heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 601 pounds or moreYes  YesNo
K0868Power wheelchair, group 4 standard, sling/solid seat/back, patient weight capacity up to and including 300 poundsYes  YesNo
K0869Power wheelchair, group 4 standard, captain's chair, patient weight capacity up to and including 300 poundsYes  YesNo
K0870Power wheelchair, group 4 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 poundsYes  YesNo
K0871Power wheelchair, group 4 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 poundsYes  YesNo
K0877Power wheelchair, group 4 standard, single power option, sling/solid seat/back, patient weight capacity up to including 300 poundsYes  YesNo
K0878Power wheelchair, group 4 standard, single power option, captain's chair, patient weight capacity up to and including 300 poundsYes  YesNo
K0879Power wheelchair, group 4 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 poundsYes  YesNo
K0880Power wheelchair, group 4 very heavy duty, single power option, sling/solid seat/back, patient weight 451 to 600 poundsYes  YesNo
K0884Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 poundsYes  YesNo
K0885Power wheelchair, group 4 standard, multiple power option, captain's chair weight capacity up to and including 300 poundsYes  YesNo
K0886Power wheelchair, group 4 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 poundsYes  YesNo
K0890Power wheelchair, group 5 pediatric, single power option, sling/solid seat/back, patient weight capacity up to and including 125 poundsYes  YesNo
K0891Power wheelchair, group 5 pediatric, multiple power option, sling/solid seat/back, patient weight capacity up to and including 125 poundsYes  YesNo
K0898Power wheelchair, not otherwise classifiedYes  YesNo

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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 DateSection/ActionMade by
12/1/2016Manual revised for interChange implementation. For manual revisions prior to 12/01/2016, please refer to Archive.HPE (now DXC)
12/27/2016Updates based on Colorado iC Stage II Provider Billing Manual Comment Log v0_2.xlsxHPE (now DXC)
1/10/2017Updates based on Colorado iC Stage Provider Billing Manual Comment Log v0_3.xlsxHPE (now DXC)
1/19/2017Updates based on Colorado iC Stage Provider Billing Manual Comment Log v0_4.xlsxHPE (now DXC)
1/26/2017Updates based on Department 1/20/2017 approval emailHPE (now DXC)
5/22/2017Updates based on Fiscal Agent name change from HPE to DXCDXC
2/22/2018Minor style/formatting editsHCPF
3/26/2018TENS/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
6/25/2018Updated general billing and timely to point to general manualHCPF
2/11/2019Updated Manufacturer Suggested Retail Price (MSRP) section with new percentage calculation examples.DXC
3/9/2019Updated 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
7/10/2019Updated Appendices' links and verbiageDXC
7/18/2019Added new rates for lesser-ofHCPF
2/26/2020Converted to web pageHCPF
9/10/2020Added Line to Box 32 under the CMS 1500 Paper Claim Reference TableHCPF
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
3/2/2021
  • Added the ‘span billing for certain supplies’ guidance first published in the April 2021 provider bulletin.
  • Ended continuous rental allowance for E0471 on 6-30-2021.
  • Updated Manual pricing percentages for MSRP and Invoice Acquisition to match Rule 8.590.7.K.
  • Added CGM coverage details.
  • Added to coding manual: K1005, A9276, A9277, A9278, K0553, K0554, E0467
  • Added modifier AV to modifier table (use of AV is allowed prior to this update).
  • Clarified wheelchair repair prescription policy.
  • Removed the policy of “PAR required for purchase but not for repair” for the following list of codes. These codes are still limited to the extent described in their notes, such as some being allowed for “2 per year, more require a PAR”. For such codes if the repair falls inside the limit of 2 per year then a PAR is not required.
  • E2211, E2212 ,E2213, E2214, E2215, E2216, E2217, E2218, E2219, E2220, E2221, E2222, E2224, E2225, E2226, E2227, E2228, E2366, E2367, E2371, E2372, E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2394, E2395, E2396, E2397, K0069, K0070, K0071, K0072, K0077, K0733.
HCPF
5/6/2021
  • Revised policy around member date of death.
  • Updated procedure codes E2366, E2371, E2372, K0069, K0733 to allow 2 units per fiscal year before PAR is needed for more units, effective 5-1-21.
  • Updated Peristeen coding to remove use of A9270. Product only uses A4459 now.
  • Effective 7-1-2021, B9998+U1 used for cholesterol products with fee schedule rate. 
  • Added CGM coding table to CGM section and clarified required device capabilities.
  • Updated EPSDT wipes coding, A9286 to be used on/after 7-1-2021. 
HCPF
8/26/2021
  • Revised formatting error to add modifiers KI and TW as individual line items.
  • EPSDT citation added
  • Updated Peristeen temporary policy
  • Clarified that human milk fortifier products are covered, in the Enteral Nutrition Products section.
  • Revised CGM policy and included exception for non-therapeutic CGMs for adults.
  • Clarified policy regarding billing for ventilator accessories and supplies under Special Considerations section.
  • Added B4105 Relizorb to HCPCS section.
  • Added hyperlinks to the Wheelchair and AAC coverage policies.
HCPF
10/5/2021Updated CGM product tableHCPF
1/15/2022

•    Updated manual pricing percentages.
•    Amended EPSDT Wipes policy, code A9286 to discontinue PAR requirement.
•    Added HCPCS codes to reflect coverage (codes were already covered prior to this manual update)
•    Clarified PAR medical necessity language for unsafe item review.

  • Added COVID-19 tests to span billing
  • Included COVID-19 test coverage policy.
HCPF
3/1/2022•    Specific coverage criteria for A4437 added.
•    DME safety policy added.
•    Cochlear Implant Processor replacement criteria added.
•    Diagnosis code information added to COVID-19 test coverage.
•    Enclosed/safety bed criteria added. 
•    SGD coverage updated (additions made were previously enforced).
•    E2300 in CRT code table updated to include Q17 as a requirement (was previously removed by accident).
•    Peristeen coding has been updated.
•    F2F requirement removed from codes E0973, E0981, and E0982 to be aligned with F2F policy for replacement/repair.		HCPF
7/1/2022•    CGM attestation for education requirement added.
•    DME enclosed/safety bed policy updated.
•    Added clarification that BAHAs are included in Cochlear implant replacement policy.
•    Manual pricing percentages were updated. 
•    Questionnaire #10 added as optional form.
•    New Omnipod billing instructions added. 
•    Clarified CRT policy. 
•    PAR policy on CRT repairs from HB22-1290 added to CRT section and CRT code table.
•    New Omnipod billing instructions added.
•    Added F2F requirements for continuous rental items, policy was previously enforced.
•    Corrected weight from 200lbs to 250lbs for K0006 on HCPCS table.
•    New breast pump coverage added.
 		HCPF
10/01/2022•   Included bed rail policy from October 2022 provider bulletin.
•   Changed ‘electric’ breast pumps to ‘single user’ for clarification.
•   Minor Formatting updates 		HCPF
12/01/2022•   Added FreeStyle Libre 3 to CGM devices.
•   Corrected start of services definition to be aligned with CCR, F2F requirement did not change.
•   Updated eligible prescribers.
•   Midwives added as prescriber in Breast Pump policy.
•   Removed manufacturer specific TAI product language.
•   Edited Enteral Nutrition Products to include WIC supply issues. 
•   Vocational DME added.
 		HCPF
01/01/2023•   Multi-user breast pump policy published
•   Single user policy updated to include early delivery per EPSDT.
•   Clarified CPAP replacement policy does not cover replacements due to age.
•   Details added to field 17 in paper claims reference table. 		HCPF
04/01/2023•   Added Dexcom G7 to CGM covered Devices.
•  CGM Upgrade policy published.
•   Defined repair for CRT PAR policy.
•   Removed AACD policy standard link and embedded it into the manual.
•   Defined Hip Kits.
•   Clarification made to wipes policy.
•   Updated unit limits for procedure codes A4927, A4452, T4521-T4535, T4543, T4544, A4207, A4353, B4087, B4088, A4216 effective April 1, 2023. See provider bulletin for details.
 		HCPF
05/01/2023•  Added procedure codes A4238 and E2102 effective 5-1-2023
•  Added procedure codes from 4-1-2023 CMS update
•  Corrected A4250 coding description to 100 strips per unit
•  Deleted A4649 from HCPCS page, as code was replaced by T5999 see October 2017 provider bulletin for details.
•  Wheelchair benefit coverage standard converted to web format and linked within manual. 		HCPF
07/01/2023•  Updated MSRP and Invoice pricing percentages effective July 1, 2023
•  Corrected manually priced rentals should be divided by 10 months, not 13 to be aligned with how rental rates are established.		HCPF
01/01/2024•  Span billing policy updated to allow for NCCI MUE limits.
•  Osteogenic stimulator criteria added. 
•  Guardian sensor 4 added to CGM covered devices.		HCPF
04/01/2024•  CGM Upgrade policy edited and FreeStyle Libre 2 Plus added to covered devices.
•  CRT provider metrics instructions added.
•  2024 HCPCS added.		HCPF