Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) pricing

DMEPOS prices are established by using the Medicare fee schedules, reasonable charges or state-prevailing rates and average wholesale price. Most Durable Medical Equipment (DME) payments are based on the fee schedule established for each DMEPOS item by state. The services and/or supplies are coded using CMS Healthcare Common Procedure Coding System (HCPCS) Level II codes that begin with the following letters:

• A (medical and surgical supplies)
• B (enteral and parenteral therapy)
• E (DME)
• K (temporary codes)
• L (orthotics and prosthetic procedures)
• V (vision services and hearing aids)

Inclusion or exclusion of a fee schedule amount for an item or service does not imply TRICARE coverage or non-coverage. Use the following modifiers to identify repair or replacement of an item:

• RA (replacement of an item): The RA modifier on claims denotes instances where an item is furnished as a replacement for the same item that has been lost, stolen or irreparably damaged
• RB (replacement of a part of DME furnished as part of a repair): The RB modifier indicates replacement parts of an item furnished as part of the service of repairing the item

Luxury/Upgraded DME that does not have supporting documentation for medical necessity will be the responsibility of the beneficiary to pay the difference. Please be sure to have a TRICARE noncovered service waiver form on file in order to bill the beneficiary for the cost above the approved DME item.

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