Accurate coding is the foundation of successful durable medical equipment (DME) billing. Every claim for items such as wheelchairs, orthotics, or oxygen supplies depends on the correct use of HCPCS and CPT codes to secure timely reimbursement. Errors in code selection can lead to denials, compliance issues, and payment delays that disrupt a supplier’s cash flow.
This guide explains how to bill durable medical equipment using standardized codes and modifiers. It covers the key differences between CPT and HCPCS codes, lists examples of common DME code categories, and outlines essential documentation requirements to maintain compliance with Medicare and Medicaid guidelines.
What Are DME Billing Codes and Why Are They Important?
DME billing codes identify and classify durable medical equipment and supplies used for patient care. These standardized codes ensure that every item billed to Medicare, Medicaid, and commercial insurers is recognized, priced, and reimbursed correctly. The two main coding systems used are HCPCS (Healthcare Common Procedure Coding System) and CPT (Current Procedural Terminology).
Correct code usage is crucial for claim accuracy and payer compliance. DME suppliers rely on these codes to describe items such as prosthetics, oxygen supplies, and mobility aids, helping insurers verify medical necessity and process reimbursements efficiently.
What Are HCPCS Codes in DME Billing?
Healthcare Common Procedure Coding System (HCPCS) codes in DME medical billing are alphanumeric identifiers used to describe medical equipment and supplies billed to insurance payers. These codes, maintained by the Centers for Medicare & Medicaid Services (CMS), allow consistent claim submission and reimbursement across all healthcare providers.
Durable medical equipment typically falls under HCPCS Level II codes, which begin with a letter (A–V) followed by four numbers. Each category covers a specific equipment type, such as wheelchairs (E1000–E1399) or prosthetics (L5000–L9900). Accurate coding ensures compliance, reduces denials, and supports proper documentation during audits.
Codes for Home Equipment
Home equipment codes represent essential medical supplies used in a patient’s residence for ongoing care. These include items like hospital beds, commode chairs, and suction pumps.
| HCPCS Code | Description | Billable | Notes / Modifier Requirements |
| E0194 | Bed, powered air flotation (low air loss therapy), per day | Yes | 1 unit = 1 day rental. Bill with RR modifier. Required: F2F, Q1, Q2. |
| E0250 | Hospital bed, fixed height, with any type side rails, with mattress | Yes | Required: F2F, Q1. Subject to CMS DME UPL. |
| E0255 | Hospital bed, variable height, Hi-Lo, with any type side rails, with mattress | Yes | Required: F2F, Q1. |
| E0260 | Hospital bed, semi-electric, head and foot adjustment, with mattress | Yes | Required: F2F, Q1. |
| E0271 | Mattress, innerspring | Yes | Covered with physician documentation. |
Codes for Wound Care Supplies
Wound care codes identify products and devices used to treat chronic or surgical wounds. This includes dressings, compression garments, and negative pressure wound therapy devices.
| HCPCS Code | Description | Billable | Notes / Modifier Requirements |
| A6203 | Gauze dressing, sterile, pad size 16 sq. in. or less | Yes | Must include physician order and wound type. |
| A6222 | Gauze dressing, non-impregnated, pad size >16 sq. in. | Yes | For chronic or post-surgical wound management. |
| A6196 | Hydrocolloid dressing, sterile, pad size ≤16 sq. in. | Yes | Replace as needed; documentation of frequency required. |
| A6258 | Hydrogel dressing, pad form, sterile | Yes | Medical necessity documentation required. |
| E2402 | Negative pressure wound therapy (vacuum-assisted system) | Yes | Billable with RR modifier for rental. Prior authorization may apply. |
Codes for Orthopedic Equipment
Orthopedic DME codes apply to braces, supports, and devices that aid musculoskeletal function. These items typically require a detailed written order prior to delivery (DWOPD) and proof of medical necessity. Common codes include:
| HCPCS Code | Description | Billable | Notes / Modifier Requirements |
| L1830 | Knee orthosis, adjustable joint, prefabricated | Yes | Use RT/LT modifier for side-specific billing. |
| L3807 | Wrist-hand orthosis, rigid, custom-fabricated | Yes | Must include detailed written order (DWO). |
| L0650 | Lumbar support orthosis, prefabricated, with panels | Yes | Include medical necessity for spinal support. |
| L3761 | Elbow orthosis, custom-fabricated, rigid joint | Yes | Requires proof of fitting. |
| L1902 | Ankle-foot orthosis, prefabricated | Yes | Covered if used for stability or support post-injury. |
Codes for Prosthetics and Orthotics
Prosthetic and orthotic codes identify custom-fitted devices that replace or support body parts. Examples include L5000–L5600 for lower limb prosthetics and L5700–L5780 for upper limb devices. Orthotic codes, such as L1902–L1990, cover ankle-foot orthoses and knee-ankle-foot braces.
| HCPCS Code | Description | Billable | Notes / Modifier Requirements |
| L5000 | Partial foot prosthesis, molded socket | Yes | Documentation must show medical necessity. |
| L5100 | Below knee prosthesis, endoskeletal, alignment system | Yes | Prior authorization may apply. |
| L5700 | Upper limb prosthesis, body-powered, hook type | Yes | Covered with physician documentation. |
| L5976 | Foot, energy-storing, flex-walk system | Yes | Include gait training documentation. |
| L8460 | Socket insert for lower limb prosthesis | Yes | Replacement frequency limited per policy. |
Learn more:
The Biggest Billing Mistakes That Cost DME Providers Thousands
Codes for Respiratory Equipment
Respiratory DME codes apply to oxygen systems, ventilators, and CPAP devices used in respiratory therapy. Common HCPCS codes include E1390 for oxygen concentrators, E0470–E0471 for bi-level devices, and E0601 for CPAP machines.
| HCPCS Code | Description | Billable | Notes / Modifier Requirements |
| L5000 | Partial foot prosthesis, molded socket | Yes | Documentation must show medical necessity. |
| L5100 | Below knee prosthesis, endoskeletal, alignment system | Yes | Prior authorization may apply. |
| L5700 | Upper limb prosthesis, body-powered, hook type | Yes | Covered with physician documentation. |
| L5976 | Foot, energy-storing, flex-walk system | Yes | Include gait training documentation. |
| L8460 | Socket insert for lower limb prosthesis | Yes | Replacement frequency limited per policy. |
Codes for Mobility Equipment
Mobility equipment codes represent devices that help patients move independently. This includes manual and power wheelchairs, scooters, and walking aids. Typical HCPCS codes are E1000–E1399 for wheelchairs, E2365–E2390 for power components, and E0143 for walkers.
| HCPCS Code | Description | Billable | Notes / Modifier Requirements |
| E1390 | Oxygen concentrator, single delivery port | Yes | Bill with KX when coverage criteria are met. |
| E0431 | Portable gaseous oxygen system | Yes | Requires physician documentation of hypoxia. |
| E0601 | CPAP machine, continuous airway pressure | Yes | Requires F2F evaluation and sleep study documentation. |
| E0470 | Bi-level respiratory assist device (spontaneous mode) | Yes | Documentation must confirm need beyond CPAP. |
| E0570 | Nebulizer, with compressor | Yes | Must include prescription and medical diagnosis. |
What Are CPT Codes in DME Billing?
CPT (Current Procedural Terminology) codes are five-digit numeric identifiers maintained by the American Medical Association (AMA) to describe medical procedures and services. In DME billing, these codes represent procedures linked to equipment setup, adjustments, and maintenance rather than the items themselves.
DME suppliers use CPT codes to bill for services like equipment fitting, repairs, and patient training. Accurate CPT use helps prevent denials and ensures compliance with payer-specific guidelines.
According to the AMA, CPT codes standardize reporting across providers and support transparency in healthcare billing.
Common DME/HME CPT Codes
| CPT Code | Description | Billable | Notes / Requirements |
| 94799 | Unlisted pulmonary service or procedure | Yes | Used for services not described by specific codes. Requires detailed documentation. |
| 94660 | Continuous positive airway pressure ventilation (CPAP) initiation and management | Yes | Common for sleep apnea equipment training. |
| 94664 | Demonstration and/or evaluation of patient’s use of nebulizer, inhaler, or IPPB device | Yes | Billable when performed by qualified healthcare personnel. |
| 99070 | Supplies and materials provided (e.g., tubing, dressings) | Yes | Bill separately when used in conjunction with another service. |
| 97542 | Wheelchair management (assessment, fitting, training) | Yes | Must include time spent and level of patient interaction. |
| 97597 | Wound debridement, first 20 sq. cm or less | Yes | Applicable to wound care equipment use. |
| A7013 | Nebulizer administration set with filter | Yes | Billable when supplied as part of respiratory therapy. |
Common DME Billing Modifiers
DME billing modifiers are two-character codes added to HCPCS or CPT codes to provide extra details about the service, equipment condition, or billing circumstance. These modifiers help payers determine coverage eligibility and payment levels.
Accurate use of modifiers ensures proper claim processing, prevents denials, and maintains compliance with Medicare, Medicaid, and private payer policies. Each modifier communicates a specific condition, such as whether an item is rented, replaced, or new.
According to CMS, correct modifier use directly affects reimbursement accuracy and helps providers avoid claim audits.
| Modifier | Meaning | Usage Example | Notes / Payer Requirements |
| RR | Rental | Used when billing for rental equipment like hospital beds or oxygen units. | 1 unit = 1 day or month rental, depending on payer. |
| NU | New Equipment | For new DME purchased by the patient or supplier. | Cannot be billed with RR. |
| UE | Used Equipment | Applies to previously used or refurbished DME items. | Documentation of prior use required. |
| KX | Requirements Met | Indicates medical necessity and documentation are on file. | Required for oxygen, CPAP, and mobility devices. |
| GA | Waiver of Liability on File | Patient has signed an ABN (Advance Beneficiary Notice). | Used when coverage is expected to be denied. |
| GY | Non-covered Service | Item or service not covered by Medicare. | Helps differentiate non-billable claims. |
| LT / RT | Left / Right Side | Specifies which limb or side of the body is affected. | Common in orthotic and prosthetic billing. |
| KH / KI / KJ | Rental Sequence | KH: First month; KI: Second–Third month; KJ: Fourth–Thirteenth month. | Required for oxygen and enteral nutrition rentals. |
Key Insight
Modifiers like KX, RR, and NU are among the most frequently audited by Medicare Administrative Contractors (MACs). Suppliers should ensure documentation supports modifier use to avoid repayment demands.
Documentation Requirements for DME Code Submissions
Accurate documentation is the foundation of successful DME billing. Every claim must prove that the prescribed medical equipment is medically necessary, ordered by a licensed provider, and delivered according to payer guidelines. Proper documentation helps prevent denials, supports audits, and ensures full reimbursement.
The following records are essential for all DME claims:
| Document Type | Purpose | Key Details Required |
| Detailed Written Order (DWO) | Serves as the physician’s prescription for the DME item. | Must include item description, dosage or frequency (if applicable), physician signature, and date. |
| Face-to-Face (F2F) Encounter Notes | Verifies the patient’s clinical need for the equipment. | Required for Medicare-covered DME within six months before the order date. |
| Proof of Delivery (POD) | Confirms that the equipment was received by the patient. | Must include date, signature, and item description. |
| Prior Authorization | Ensures coverage approval before dispensing the item. | Required for select DME such as CPAP devices and orthotics. |
| Supplier Standards Compliance Form | Demonstrates adherence to CMS supplier rules. | Needed for DMEPOS accreditation maintenance. |
| Medical Necessity Documentation | Validates the clinical justification for the prescribed equipment. | Includes physician notes, test results, or diagnostic reports. |
Conclusion
Every claim depends on the correct use of HCPCS, CPT codes, and billing modifiers to reflect medical necessity and payer-specific requirements. Consistency in documentation and code assignment minimizes denials, accelerates reimbursements, and strengthens revenue flow for suppliers nationwide.
Quality Healthcare Systems (QHS) in High Point, North Carolina provides specialized dme billing services that ensures accuracy and compliance across all billing processes. With AAPC certified coders, 15+ years of regulatory expertise, and advanced reporting tools, we help durable medical equipment suppliers simplify claims, reduce AR days, and maintain full alignment with Medicare and Medicaid standards.
FAQs
What are DME billing codes?
DME billing codes are standardized identifiers for durable medical equipment used in insurance claims. They ensure accurate reimbursement by classifying items like wheelchairs, orthotics, and oxygen systems under HCPCS Level II codes, which describe equipment type, usage, and payer eligibility.
What CPT codes are used for DME?
CPT codes for DME represent services related to equipment setup, training, or maintenance. Examples include 94660 for CPAP initiation, 97542 for wheelchair fitting, and 94664 for nebulizer training. These codes ensure providers are reimbursed for professional services linked to DME use.
What is the DME code?
A DME code is an HCPCS Level II identifier used to bill specific medical equipment. For instance, E1390 covers oxygen concentrators, while E0260 represents hospital beds. Each code aligns with CMS fee schedules to determine reimbursement rates.
What are category 1, 2, and 3 codes?
Category 1, 2, and 3 codes are classifications within the CPT system used for reporting medical procedures and services.
- Category 1 includes established medical procedures and technologies.
- Category 2 codes are performance tracking measures used for quality reporting.
- Category 3 codes represent emerging or experimental medical procedures.
DME billing primarily uses Category 1 codes for approved procedures linked to equipment use.
What is the difference between CPT and HCPCS codes in DME billing?
CPT codes describe medical procedures, while HCPCS codes identify equipment and supplies. CPT is managed by the AMA, and HCPCS by CMS. In DME billing, HCPCS codes cover devices, while CPT codes cover setup or patient training services.
Which DME codes are reimbursable by Medicare?
Medicare reimburses DME codes that meet coverage and documentation criteria. Common examples include E0601 for CPAP machines, E1390 for oxygen concentrators, and L1830 for knee braces. Claims must include a DWO, POD, and proof of medical necessity.
