Medicaid Managed Care
Child Health Plus
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Medicaid. Amerigroup Partnership Plan, LLC brinda servicios administrativos para Medicaid administrado de Highmark Blue Cross Blue Shield
of Western New York.
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NYWEST-CD-RP-036228-23-CPN36166 September 2023
Reimbursement Policy
Subject: DME Modifiers for New, Rented and Used Equipment
Policy Number: G-06053
Policy Section: Coding
Last Approval Date: 06/09/2023 Effective Date: 09/14/2020
**** Visit our provider website for the most current version of the reimbursement policies. If you
are using a printed version of this policy, please verify the information by going to
https://providerpublic.mybcbswny.com. ****
Disclaimer
These reimbursement policies serve as a guide to assist you in accurate claims submissions
and to outline the basis for reimbursement if Highmark Blue Cross Blue Shield of Western New
York (Highmark BCBSWNY) covered the service for the member's benefit plan. The
determination that a service, procedure, item, etc. is covered under a member’s benefit plan is
not a determination that you will be reimbursed. Services must meet authorization and medical
necessity guidelines appropriate to the procedure and diagnosis as well as to the member’s
state of residence.
You must follow proper billing and submission guidelines. You are required to use industry
standard, compliant codes on all claim submissions. Services should be billed with Current
Procedure Terminology
®
(CPT) codes, Healthcare Common Procedure Coding System
(HCPCS) codes, and/or revenue codes. These codes denote the services and/or procedures
performed and, when billed, must be fully supported in the medical record and/or office notes.
Unless otherwise noted within the policy, our reimbursement policies apply to both participating
and non-participating professional providers and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
Highmark BCBSWNY may:
• Reject or deny the claim.
• Recover and/or recoup claim payment.
• Adjust the reimbursement to reflect the appropriate services and/or procedures performed.
These reimbursement policies may be superseded by mandates in provider, state, federal, or
Centers for Medicare & Medicaid Services (CMS) contracts and/or requirements. Highmark
BCBSWNY strives to minimize delays in policy implementation. If there is a delay, we reserve
the right to recoup and/or recover claims payment to the effective date in accordance with the
policy. We reserve the right to review and revise these policies when necessary. When there is
an update, we will publish the most current policy to the website.
Highmark Blue Cross Blue Shield of Western New York
Medicaid Managed Care | Child Health Plus
DME Modifiers for New, Rented and Used Equipment
Page 2 of 3
Policy
Highmark BCBSWNY allows reimbursement for new, rented, or used equipment appended
with the appropriate modifier unless provider, state, federal, or CMS contracts or requirements
indicate otherwise. The listed modifiers are considered reimbursement modifiers and must be
billed in the primary or first modifier field to determine appropriate reimbursement:
• Modifier NU: new equipment
• Modifier RR: rented equipment
• Modifier UE: purchase of used equipment
These modifiers are appropriate for durable medical equipment (DME), prosthetics, and
orthotics. These modifiers are inappropriate for supplies unless required under State or CMS
guidelines. Claims for supplies appended with the Modifiers NU, RR, or UE may be denied.
Reimbursement will be based on the applicable fee schedule or contracted/negotiated rate for
claims submitted for the equipment with the valid modifier identifying new, rented, or used
equipment. Claims submitted for equipment without the appropriate reimbursement modifier
may be denied.
Related Coding
Standard correct coding applies
Policy History
06/09/2023
Review approved: updated policy template
09/14/2020
Review approved and effective
10/26/2018
Review approved: policy template updated
01/01/2017
Initial approval and effective
References and Research Materials
This policy has been developed through consideration of the following:
• CMS
• State contract
• State Medicaid
Definitions
Durable Medical
Equipment (DME)
Items that meet the following criteria:
• Are primarily and customarily used to serve a medical purpose
rather than convenience or comfort
• Can withstand repeated use
• Generally, are not useful to a person without an illness or injury
• Are appropriate for use in the home
• Are prescribed by a licensed physician/practitioner
Prosthetic Device
An artificial structural and functional replacement of a limb/appendage
or internal organ, or all or part of the function of a permanently
inoperative or malfunctioning internal body organ.
Orthotic Device
A brace with rigid metal or plastic stays applied to the body for
support or immobilization of a body part, to correct or prevent
deformity, or to assist or restore function.
Highmark Blue Cross Blue Shield of Western New York
Medicaid Managed Care | Child Health Plus
DME Modifiers for New, Rented and Used Equipment
Page 3 of 3
General Reimbursement Policy Definitions
Related Policies and Materials
Durable Medical Equipment (Rent to Purchase)
Modifier Usage
Prosthetic and Orthotic Devices
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