Aligning commercial DME coding / billing guidelines with CMS effective Aug. 1, 2024

We’re aligning our commercial billing and coding requirements for durable medical equipment (DME) supplies to those defined by the Centers for Medicare and Medicaid Services (CMS).

The following policies – which establish reimbursable limits / frequency guidelines pulled directly from CMS local coverage determinations (LCD) and coding articles – will go into effect on Aug. 1, 2024:

• Ostomy supplies
• Urological supplies
• Surgical dressings
• Tracheostomy care supplies

Exceptions & appeals

Any exceptions to these policies will be specifically outlined in our Provider Manual or in our commercial medical policies. Providers may appeal denials for units exceeding the defined limits – appeals must be supported with medical record documentation.

Medicare & Medicaid

For Medicare claims, we’ll continue to follow CMS-defined guidelines as outlined by the Medical Affairs Committee (MAC) in national coverage determinations (NCD), LCD and Articles. Our Medicaid products will continue to follow MDHHS- and CHAMPS-defined guidelines.

See our Provider Manual’s payment policies page and continue to monitor these PriorityActions emails for additional policy alignment information.