The codes DME suppliers bill every day — with the prior-auth flags, rental/purchase logic, and documentation traps that drive DME's 15–20% denial rates.
| Code | Item (Plain English) | Medicare PA | Billing Notes & Denial Traps |
|---|---|---|---|
| Respiratory / Sleep (E04xx–E06xx) | |||
| E0601 | CPAP device for obstructive sleep apnea | Varies | Capped rental (RR + KH/KI/KJ). Requires face-to-face eval, sleep study meeting AHI thresholds, and 90-day adherence proof (KX after compliance). Non-adherence at 90 days stops payment. |
| E0470 | BiPAP without backup rate | Varies | Requires documented CPAP failure/intolerance for OSA, or restrictive/COPD criteria. Same adherence machinery as CPAP. |
| E0471 | BiPAP with backup rate | Varies | Higher clinical bar (central apnea, hypoventilation). Expect documentation requests on every claim. |
| E1390 | Oxygen concentrator, stationary | Varies | 36-month rental, 5-year RUL. Qualifying blood gas/oximetry within 30 days of initial claim; CMN/standard written order required. Retesting rules trip renewals. |
| E0431 | Portable gaseous oxygen system | Varies | Add-on to stationary; requires documented mobility need within the home. |
| A7030–A7039 | CPAP masks, cushions, tubing, filters | No | Strict replacement frequency schedules (e.g., mask 1/3 months, cushions 2/month). Billing ahead of schedule = CO-151/N362. |
| E0570 | Nebulizer with compressor | No | Dx must support (asthma/COPD). Pair with A7003/A7005 supplies on schedule. |
| Mobility (E11xx, K00xx) | |||
| K0001 | Standard manual wheelchair | No | Capped rental. Home assessment: must be usable within the home (Medicare's in-the-home rule). |
| K0003 | Lightweight manual wheelchair | No | Justify why standard weight doesn't meet the need — comparative documentation. |
| K0823 | Power wheelchair, group 2 standard, captain's chair | Required | On Medicare's PA list. Face-to-face mobility exam, home assessment, specialty evaluation. The densest documentation package in DME. |
| K0856 | Power wheelchair, group 3, single power option | Required | Group 3 = neurological/myopathy-level justification; ATP involvement required. |
| E0143 | Folding walker, wheeled | No | Inexpensive/routinely purchased — bill NU. Simple, but dx must support ambulation deficit. |
| E0630 | Patient lift, hydraulic | No | Requires documentation that transfers need assistance and caregiver is available/trained. |
| Hospital Beds & Support Surfaces (E02xx–E03xx) | |||
| E0260 | Semi-electric hospital bed with rails | Varies | Medical need for positioning documented (not convenience). Capped rental. Full-electric (E0265/E0266) beds: the electric height feature is considered convenience by Medicare — expect patient upgrade paperwork (ABN). |
| E0277 | Powered pressure-reducing air mattress | Required | On Medicare's PA list. Group 2 support surface criteria: existing ulcers with staging documented, or recent flap/graft. |
| E0193 | Powered air flotation bed (low air loss) | Required | Group 3 criteria are stringent — most denials here are truly non-qualifying patients. |
| Diabetic Supplies (A42xx, E0784, K0553/K0554) | |||
| A4253 | Blood glucose test strips (per 50) | No | Frequency limits by insulin status (insulin: 3/day baseline; non-insulin: 1/day). Above-limit needs KX + documented testing logs. |
| E0784 | External insulin infusion pump | Varies | C-peptide/antibody criteria, specialist follow-up. High-dollar — expect full medical review. |
| K0553 | CGM supply allowance (therapeutic CGM), monthly | Varies | One unit per month — unit errors are the classic denial. Patient must meet CGM coverage criteria (insulin or hypoglycemia history per current policy). |
| K0554 | Therapeutic CGM receiver | Varies | Pairs with K0553 supply stream; device replacement timing rules apply. |
| Orthotics & Prosthetics (L codes) | |||
| L0650 | Lumbar-sacral orthosis (LSO), off-the-shelf | Required | On Medicare's PA list after widespread abuse. OTS vs custom-fit coding (L0650 vs L0637) depends on documented fitting work — upcoding here is an OIG focus area. |
| L1832 | Knee orthosis, adjustable, off-the-shelf | Required | PA list item. Dx and functional need documentation; telehealth-ordered braces draw extra scrutiny. |
| L3806 | Wrist-hand-finger orthosis, custom fabricated | No | Custom fabrication documentation (molding/impressions) must exist — OTS billed as custom is a false claim pattern. |
| L8000 | Mastectomy bra | No | Frequency limits; pair with prosthesis codes (L8020/L8030) appropriately. |
| Wound Care & Miscellaneous | |||
| E2402 | Negative pressure wound therapy (wound vac) pump | Varies | Monthly documentation of wound measurements and healing progress — stalled healing ends coverage. Supplies (A6550) tie to pump months. |
| A6531 | Compression stocking, 30–40 mmHg, below knee | No | Covered only with open venous stasis ulcer for Medicare (dx-driven) — cosmetic/preventive use is GY territory. |
| B4034–B4162 | Enteral feeding supply kits & formula | Varies | Tube-feeding dependence documented; calorie calculations must match units billed. Unit math errors are the top denial. |
No codes match your filter.
DME claims carry modifier stacks. The core set:
Rental / New purchase / Used purchase — the payment-category modifier every DME line needs.
Capped rental month markers: first month (KH), months 2–3 (KI), months 4–13 (KJ). Wrong month marker = wrong payment.
Documentation-on-file attestation (e.g., CPAP adherence met). Only when the file actually supports it.
ABN on file / no ABN when needed — controls whether the patient can be billed after denial.
HCPCS Level II codes are maintained by CMS and are public domain. Item descriptions are plain-English paraphrases; coverage criteria summarized here follow Medicare DME MAC policy at time of writing and change with LCD updates — verify against current policy articles before billing. Commercial and Medicaid PA rules are broader than Medicare's list. Updated July 2026. See our methodology and the full DME billing guide.