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:
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:
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.