Billing for HCPCS code E0255 can be challenging due to its specific documentation, modifier, and reimbursement requirements under Medicare’s capped rental policy. This guide simplifies the process by explaining what E0255 covers, which modifiers to use, how to document medical necessity, and what Medicare reimburses. By following these steps, DME suppliers can minimize denials and ensure faster claim approval for variable-height hospital beds.
What is HCPCS Code E0255
HCPCS code E0255 refers to a hospital bed, variable height (Hi-Lo), with any type of side rails and mattress. This code applies when a patient requires adjustable positioning for medical reasons, such as improving circulation, reducing pressure sores, or assisting with transfers.
According to the Centers for Medicare & Medicaid Services (CMS), this equipment is considered durable medical equipment (DME) and is typically billed as a capped rental. It includes both the bed frame and the mattress as part of a complete system.
Required Documentation for E0255 Billing
Billing HCPCS code E0255 requires precise documentation to verify medical necessity and ensure Medicare compliance. Each claim must include supporting evidence that the variable height bed is essential for the patient’s care and mobility needs.
The following documents are mandatory for clean and payable claim submission:
| Document | Requirement | Purpose |
| Physician’s Order | Must be signed and dated by the treating physician | Confirms that the hospital bed is medically necessary for the patient |
| Face-to-Face Encounter (F2F) | Conducted within 6 months prior to the order | Validates that the patient’s condition requires a variable height hospital bed |
| Certificate of Medical Necessity (CMN) | Includes diagnosis, justification, and physician signature | Provides medical reasoning why a standard bed is insufficient |
| Proof of Delivery (POD) | Signed by the patient or caregiver upon delivery | Verifies that the equipment was received and set up properly |
| Ongoing Medical Need Documentation | Periodically updated in patient’s records | Demonstrates the continued requirement for the hospital bed |
Correct Modifiers for E0255
Using the correct modifiers when billing HCPCS code E0255 ensures that claims are processed accurately under Medicare’s capped rental policy. Modifiers identify the billing month, equipment type, and rental status. Incorrect or missing modifiers can lead to denials or payment delays.
Below is a breakdown of modifiers required for E0255 (Variable Height, Hi-Lo Hospital Bed) billing:
| Modifier | Description | Use Case |
| RR | Rental | Indicates the bed is being rented rather than purchased |
| KH | First rental month | Used for the initial rental month of a capped rental item |
| KI | Second and third rental months | Used for months 2 and 3 of the capped rental |
| KJ | Fourth to thirteenth rental months | Used for months 4–13 until ownership transfers to the patient |
If the bed is replaced, lost, or stolen during the rental period, modifiers RA (replacement) or RB (replacement of part) must be applied, depending on the situation.
Tip: CMS requires consistent modifier use across all months of rental. Any inconsistency may trigger claim review or partial reimbursement.
Common Billing Errors to Avoid
Even minor mistakes in E0255 hospital bed billing can lead to denials, delayed reimbursements, or audit flags. Understanding and avoiding these errors ensures claim approval and consistent revenue flow for DME suppliers.
Here are the most frequent billing issues to avoid:
- Incorrect Modifier Usage: Using the wrong rental month modifier (e.g., KI instead of KH) results in claim rejection.
- Missing or Expired CMN: Failing to provide a valid Certificate of Medical Necessity invalidates the claim.
- Incomplete Proof of Delivery: Medicare requires signed delivery receipts as evidence that the equipment was received by the patient.
- No Continued Medical Need Documentation: Lack of periodic reassessment may lead to claim recoupment.
- Incorrect Place of Service (POS): DME suppliers must ensure the correct POS code—typically 12 (Home)—is entered.
- Duplicate Billing: Submitting claims for months already billed violates Medicare rental guidelines.
Tip: Always cross-verify patient eligibility and authorization status before submission to prevent denials from private payers or Medicare Administrative Contractors (MACs).
Medicare Reimbursement Guidelines for E0255
HCPCS codes like E0255 are covered under Medicare’s capped rental category, which means payment is issued monthly for up to 13 continuous rental months. After this period, ownership of the equipment transfers to the patient.
To qualify for reimbursement:
- The patient’s condition must justify the need for a variable height (Hi-Lo) hospital bed.
- The ordering physician must document the medical necessity, including mobility restrictions, positioning needs, or skin integrity concerns.
- The supplier must comply with all Medicare Supplier Standards, including correct modifier usage (RR, KH, KI, KJ).
- The claim must include a signed and dated Certificate of Medical Necessity (CMN) and proof of delivery.
| Reimbursement Type | Billing Method | Payment Duration | Average Medicare Rate | Ownership Transfer |
| Capped Rental | Monthly (RR modifier) | 13 months | $115–$135/month (varies by region) | After 13 months |
Tip: Always verify current rates and regional policies using the Medicare DMEPOS Fee Schedule Tool before submitting claims.
How QHS Ensures Accurate E0255 Billing
At Quality Healthcare Systems, our DME billing experts specialize in managing complex claims for HCPCS code E0255 with precision and compliance. We follow a comprehensive workflow designed to eliminate errors, ensure proper modifier use, and maximize reimbursement for suppliers in High Point, North Carolina.
Here’s how we ensure every E0255 claim is processed accurately:
- End-to-End Documentation Review: Every claim is verified for completeness, including CMNs, prescriptions, and proof of delivery.
- Accurate Modifier Application: Our team ensures correct modifier sequencing (RR, KH, KI, KJ) for rental cycles to prevent denials.
- Compliance with Payer Guidelines: QHS aligns billing with Medicare, Medicaid, and private payer rules, avoiding compliance pitfalls.
- Automated Claim Tracking: Real-time analytics help monitor AR days, payment trends, and claim statuses.
- Denial Prevention and Management: Potential issues are identified before submission, maintaining high first-pass acceptance rates.
- Expert Support and Consultation: Providers receive continuous updates on DME regulations and payer policy changes.
Frequently Asked Questions
What is CPT code E0255?
E0255 is a HCPCS code (not CPT) that identifies a variable height (Hi-Lo) hospital bed with side rails and mattress used for patients requiring adjustable positioning or mobility support.
What is denial code 255?
Denial code 255 indicates a missing, incomplete, or invalid Certificate of Medical Necessity (CMN) for the billed DME item. Submitting updated documentation or corrected forms typically resolves the issue.
What diagnosis qualifies for a hospital bed?
A hospital bed may be covered when the patient has mobility limitations, severe weakness, pressure ulcer risk, or requires positioning not feasible in a standard bed. The physician must clearly document the medical necessity in the order.
How often will Medicare pay for a hospital bed mattress?
Medicare covers a hospital bed mattress under E0255 once every 5 years (or sooner if damage or medical necessity requires replacement). The supplier must document the reason for replacement and obtain a new physician order.
