DME Ask the Contractor Meeting (ACM) Questions and Answers - May 21, 2025

The following questions and answers (Q&As) are cumulative from the DMEPOS Ask the Contractor Meeting (ACM). Some questions have been edited for clarity and answers may have been expanded to provide further details. Similar questions were combined to eliminate redundancies. If a question was specific just for one supplier, Noridian addressed directly with the supplier.

Questions Received Prior to ACM

Q: Are there any upcoming policy changes for the ventilator policy?
A: No changes are being made to the ventilators policy.

Q: For capped rental items, is there still a 10-month beneficiary requirement, or does the title just transfer to the beneficiary at month 13?
A: Suppliers must give beneficiaries the option of converting their capped rental equipment to purchase during their 10th continuous rental month. DME MACs will make no further rental payments after the 11th rental month for capped rental items until the supplier notifies the DME MAC that it has contacted the beneficiary and furnished him/her with the option of either purchase or continued rental.

Q: What are the required narratives for code L7510 - Repair of prosthetic device, repair or replace minor parts (e.g., those without specific HCPCS codes)?
A: The claim line narrative must include:

  • HCPCS code of item being repaired
  • Description of each item that is billed
  • Supplier Price List amount

Q: If a sleep lab does not include a Central Apnea-Hypopnea Index (CAHI) calculation on the results, but the data to calculate it is included, is it acceptable?
A: Medicare does not explicitly mention the CAHI in its guidelines, but it does require that sleep studies adhere to its scoring criteria, including the correct definition of hypopneas. If the sleep lab provides the necessary raw data but does not explicitly calculate CAHI, it may still be acceptable if the interpreting physician can derive the necessary information and ensure compliance with Medicare's scoring standards.

  • Noridian Medicare website > Policies > Clinicians Corner > Clinician Resource Letters > Sleep Test Scoring and Medicare

Q: For billing parenteral nutrition, when is a new order needed?
A: A new order is required:

  • For all claims for purchases or initial pump rentals.
  • If there is a change in the DMEPOS order/prescription (e.g., HCPCS or quantity).
  • On a regular basis (even if there is no change in the order/prescription).
  • When an item is replaced.
  • When there is a change in the supplier, and the new supplier is unable to obtain a copy of a valid order/prescription for the DMEPOS item from the transferring supplier.

See the Noridian Medicare website > Browse by Topic > Documentation > Standard Written Order (SWO) for more information.

Q: What are the criteria for the E0469 (Lung expansion airway clearance, continuous high frequency oscillation, and nebulization device)?
A: The E0469 HCPCS code represents a specialized respiratory device that integrates three essential functions: lung expansion, airway clearance with continuous high frequency oscillation, and nebulization. As a capped rental item, this equipment must be billed with the modifier RR, along with a monthly rental modifier (KH, or KI, or KJ). Since there is no specific policy for E0469, each claim is reviewed on a claim-by-claim basis, making it crucial that treating practitioners provide thorough documentation to substantiate the medical necessity and appropriate use of this device.

Q: A beneficiary receives one daytime lymphedema garment per month in January, February, and March. Lymphedema supplies follow a six-month schedule. When can they get a full refill of three if we billed them in different months?
A: Whether dispensing all three items per body part on the same date or individually at different dates within the appropriate period, the six-month period begins when the first item ships. In this scenario, the member would be eligible for another set of three garments in July. The supplier is permitted to bill all three garments at once for the refill, using the billing date of the first garment as the reference point.

Q: Can a collagen dressing (A6023) be used for an at-risk beneficiary after a total knee replacement?
A: Collagen dressings, such as A6023, are indicated for full-thickness wounds. According to the Local Coverage Determination (LCD), collagen-based dressings are covered for wounds that are full thickness (e.g., stage 3 or 4 ulcers), have light to moderate exudate, or have stalled in the healing process. The treating physician is responsible for determining the appropriate treatment for the beneficiary. Coverage criteria is found in Local Coverage Determination (LCD) L33831.

Q: For K0606 (automatic external defibrillator), does the physician who signs the Standard Written Order (SWO) also need to be the treating physician who signs the medical record?
A: The SWO may be prepared by someone other than the treating practitioner, but it must be signed by the treating practitioner: Standard Documentation Requirements Article A55426.

Q: Does Medicare allow coverage for electric breast pump E0603?
A: Electric breast pumps are not classified as DME and are non-covered by Medicare. Therefore, no payment will be made.

Verbal Questions During ACM

Q: In the same way that you don't need to specifically write a HCPCS code on a Standard Written Order (SWO), but instead write the narrative, does the same thing hold true for supply codes?
A: Yes. Either a HCPCS code or a narrative is acceptable, as long as each item being provided is listed on an order.

Q: We understand that continuous passive motion (CPM) devices are covered for 21 days post-surgery. We have beneficiaries who want to keep it beyond the 21 days. Can I use a GY modifier for the additional days, or do I need to get an Advance Beneficiary Notice of Noncoverage (ABN) and use the GA modifier?
A: Because it's statutorily excluded, the GY modifier can be used.

Q: When can nurse practitioners (NPs) and physician assistants (PAs) sign off on the therapeutic shoes Statement of Certifying Physician?
A: NPs and PAs can sign off when they are working within incident to guidelines. NPs participating in the Primary Care First demonstration project are eligible to serve as the certifying physician. More information is available on the Noridian Medicare website > Browse by DMEPOS Category > Therapeutic Shoes.

Q: If the beneficiary has not had a foot exam but has seen the Doctor of Medicine/Doctor of Osteopathic Medicine (MD/DO) for their diabetes within the last six months, does the MD/DO need to sign off on the Doctor of Podiatric Medicine (DPM) notes?
A: The MD/DO needs to sign off on the certification statement indicating coverage items have been met.

Written Questions Received During ACM

Q: If a beneficiary receives a lymphedema garment in January, February, and March, when can they get the next three?
A: They are eligible to receive all three daytime garments in July. You can find this information by going to the Noridian Medicare website > Browse by DMEPOS Category > Lymphedema Compression Treatment.

Q: How can I verify the last date of service (DOS) for a beneficiary using A4353 (intermittent urinary catheter kit)? He mentioned switching to us this month after being dissatisfied with his previous provider over the past year.
A: This information is available under the Same or Similar function in the Noridian Medicare Portal.

Q: For E0601 (PAP device), if a beneficiary was assessed for symptoms of obstructive sleep apnea (OSA), didn't have any sleep-related symptoms, but has atrial fibrillation (AFib), would that alone be an acceptable reason to get a sleep test?
A: Medicare coverage for a sleep test (E0601 device qualification) requires documented symptoms of sleep-disordered breathing or other qualifying criteria. While AFib is a significant medical condition, it alone may not be sufficient to qualify for a Medicare-covered sleep test unless the physician documents additional symptoms or medical necessity. If the physician believes a sleep study is warranted based on AFib and other risk factors, they may need to provide supporting documentation to justify the test.

Q: If a beneficiary was provided a PAP machine but did not pass the initial 90-day compliance but then decides to purchase the machine instead of renting for the remaining 10 months, can we still provide supplies for that machine that they purchased? And if so, what would be required?
A: If a beneficiary is non-compliant with CPAP therapy and purchases a CPAP machine, coverage for CPAP supplies (like masks, tubing, filters, etc.) by Medicare will be denied. The beneficiary must meet all Medicare's coverage, coding, and documentation requirements effective on the date of service (DOS) of the claim for coverage to be considered.

  • Noridian Medicare website > Billing, Claims, and Appeals > Billing Situations > Beneficiary-Owned Equipment When Billing for Accessories and Supplies

Q: According to the respiratory assist device (RAD) policy, a diagnosis of central sleep apnea (CSA) requires a CAHI of greater than five. We find some sleep labs do not include the CAHI, but the data is available for us to calculate it. Is it ok for the DME supplier to calculate the CAHI based on the data in the sleep study?
A: Medicare's RAD policy requires a Central Apnea-Hypopnea Index (CAHI) greater than five for a central sleep apnea (CSA) diagnosis. However, some sleep labs may not explicitly report the CAHI, even though the necessary data is available. The CAHI must be calculated by either the treating physician or through the sleep study lab. See Noridian Medicare website > Policies > Clinicians Corner > Clinician Resource Letters > Sleep Test Scoring and Medicare for more information.

Q: If a beneficiary has breast cancer in the right breast but decides to get a bilateral mastectomy and needs a prosthesis for both left and right prosthesis, will that be covered? If so, what diagnosis can be used for the left prosthesis since right breast cancer won't work for the left breast?
A: We are unable to provide a specific diagnosis. Individuals who have undergone bilateral mastectomies are permitted to receive two prostheses, one for each side. This guidance is outlined in the LCD L33317. Additional details on diagnosis information can be found in Policy Article A52478.

Q: Does a loaner wheelchair have to be an equal replacement? For example, if a beneficiary has a K0822 (power wheelchair, group 2 standard, sling/solid seat/back) and all we have as a loaner is a K0823 (power wheelchair, group 2 standard, captain's chair), can we bill for that loaner?
A: The loaner item must meet the beneficiary's medical needs. Additionally, when billing code K0462 for loaner equipment, be sure to include a narrative in the claim indicating the wheelchair that was supplied.

  • Noridian Medicare website > Browse by DMEPOS Category > Power Mobility Devices (PMDs)
  • Noridian Medicare website > Browse by Topic > Repairs, Maintenance and Replacement > Repairs > Loaner Equipment and Service Charge for Beneficiary-Owned Equipment

Q: If a beneficiary gets a power mobility device (PMD) and then two years later meets medical criteria for a K0005 (ultralightweight wheelchair) but still uses the PMD as well, can we bill for repairs on the PMD though the most recent qualifying piece of equipment is a manual chair?
A: If the wheelchair on file with Medicare is for a K0005, it is possible the repairs may deny for a different wheelchair. If this happens an appeal can be submitted for review.

Q: Can Medicare increase the quantity of continuous glucose monitor (CGM) supplies in a 90-day period?
A: Suppliers can submit an LCD Reconsideration request for this. More information on this process can be found on Noridian Medicare website > Policies > Local Coverage Determination (LCD).

Q: When supplying incontinence supplies to members, we must bill Medicare for the denial for a noncovered service. With that denial of PR96, we can then bill the state's Medicaid insurance for coverage. When a beneficiary is on home health, physical therapy, occupational therapy, or palliative care and an incontinence claim is submitted by a DME supplier, the claim for the DME is denied for payment being bundled in a payment for another service. Even though the services are not covered, the claim denied as a contractual write off. Is there a way around this denial so beneficiaries can still get their incontinence supplies from the DME supplier?
A: When the beneficiary is on Home Health, incontinence supplies will deny as included in Home Health as a bundled payment. The supplier will need to work with the Home Health provider to receive reimbursement of items provided to beneficiaries in a home health episode. Please utilize the Consolidated Billing / SNF / Home Health / Hospice Lookup tool. You can find additional information and the tool on the Noridian Medicare website > Billing, Claims, and Appeals > Billing Situations > Consolidated Billing.

Q: Regarding E0601 (PAP device) or E0470 (RAD) and the face-to-face (F2F) evaluation needed prior to the diagnostic sleep study, if it's documented that the beneficiary is not symptomatic (i.e., no snoring/fatigue) but has heart conditions and the completed sleep study is done with AHI qualifying for PAP, is that acceptable or does the beneficiary have to have symptoms?
A: Medicare requires a face-to-face evaluation before a sleep study to assess the beneficiary for OSA. Symptoms such as snoring, fatigue, excessive daytime sleepiness, or impaired cognition are documented to justify the need for a sleep study. However, certain comorbid conditions, including heart disease, may also support medical necessity for testing. If the beneficiary does not have typical sleep-related symptoms but has heart conditions, the physician may need to provide additional documentation supporting the medical necessity of a sleep study. If the AHI qualifies for PAP therapy, Medicare may still cover the device, but the lack of symptoms could require stronger justification in the medical records.

Q: If a beneficiary's PAP machine is from a vendor that doesn't do repairs or the cost of repairs exceeds replacement of the machine, would Medicare pay for a replacement before the five-year reasonable useful lifetime (RUL)?
A: Any supplier can complete the repair on the PAP machine prior to the RUL. If the repair will exceed the cost of a new PAP machine then coverage could occur for a new PAP. For more information, review the Repairs, Maintenance and Replacement webpage under the Browse by Topic tile on the Noridian Medicare website.

Q: Has the extension for telehealth been extended?
A: Yes. Recent legislation has authorized an extension of many Medicare telehealth flexibilities through September 30, 2025.

Q: Regarding the five-year RUL when Medicare did not pay for the initial machine, we notice older studies do not always indicate hypopnea scoring nor apnea index. Is it acceptable for the DME supplier to calculate the Apnea Index using the data from the sleep study formula: Total Apneas x 60% TST?
A: Medicare's guidelines for the five-year RUL of positive airway pressure (PAP) devices depend on whether Medicare originally paid for the device or not. If Medicare did not pay for the initial machine, the replacement process follows different documentation requirements.

Regarding the Apnea Index calculation, Medicare's policies emphasize the need for proper documentation of obstructive sleep apnea (OSA) diagnosis and treatment. However, older studies may lack hypopnea scoring or apnea index details. While the formula you mentioned, Total Apneas × 60 ÷ Total Sleep Time (TST), is a standard method for calculating the Apnea Index, Medicare's specific acceptance of a DME supplier using sleep study data for this calculation is not explicitly outlined in the available policies.

You can find more information regarding replacements following the path below.

Noridian Medicare website > Browse by DMEPOS Category > Positive Airway Pressure (PAP) Devices > Clinician Letter - PAP Device Replacements.

Q: If a beneficiary received a PAP device from another payer prior to entering Medicare and is now Medicare eligible and in need of supplies, is it correct to follow the coverage criteria in the LCD for patients entering Medicare for the supplies?
A: Yes. If the beneficiary was on CPAP therapy prior to entering Medicare, then the Beneficiary Entering Medicare criteria in the LCD would need to be met. More information is available on the Noridian Medicare website > Billing, Claims, and Appeals > Billing Situations > Beneficiaries Entering Medicare.

Q: For a beneficiary who owns their PAP device that was paid for by Medicare, the Standard Documentation Requirements indicate continued need documentation is required for supplies. In addition to a new SWO, are there any other documentation requirements for supplies only under this scenario?
A: In addition to the SWO, suppliers also need medical records from the treating physician confirming the ongoing need for PAP therapy and that the beneficiary is actively using the PAP device.

Q: For E0470 (RAD) under Severe COPD for Criteria A and B, can the testing be one on BiPAP in addition to the required criteria?

  1. An arterial blood gas PaCO2, done while awake and breathing the beneficiary's prescribed FIO2, is greater than or equal to 52 mm Hg.
  2. Sleep oximetry demonstrates oxygen saturation less than or equal to 88% for greater than or equal to a cumulative 5 minutes of nocturnal recording time (minimum recording time of 2 hours), done while breathing oxygen at 2 LPM or the beneficiary's prescribed FIO2 (whichever is higher).

A: For an E0470 under Severe COPD, Medicare requires that the beneficiary meet both Criteria A and B for initial coverage. Based on Medicare guidelines, testing is typically conducted while the beneficiary is breathing their prescribed FIO2, but not necessarily on BiPAP unless transitioning to an E0471 device.

Q: We have been told multiple times that we are okay to deliver PMDs with an expired face-to-face (F2F) as long as our Unique Tracking Number (UTN) from the prior authorization request (PAR) is still valid. Does this pass audit?
A: If the UTN is still valid and an approved PAR was received, the claim can be billed. The documentation was valid at the time of review.

Q: The beneficiary received a K0825 (power wheelchair) with a valid UTN. After a month, he returned the unit to us. Three months after the return, he changed his mind. Do we need to start over or are we able to continue billing with the valid UTN?
A: Since there was over a 60-day break in billing/need, a new PAR is required for the beneficiary to meet the requirements of the LCD. For more information, review the Break in Need and Break in Billing webpage under Billing, Claims, and Appeals > Billing Situations on the Noridian website.

Q: If a beneficiary receives bandage wraps for lymphedema, how often can they be replaced? When can they receive a compression garment if they were using bandages, but the doctor now wants a wrap?
A: Payment for up to three gradient compression garments or wraps with adjustable straps per each affected extremity or body part is allowable once every six months. If the beneficiary experiences a change in condition, additional items may be considered. In cases where a claim is denied, a redetermination may be completed. For further details, visit the Noridian Medicare website by following this path: Browse by DMEPOS Category > Lymphedema Compression Treatment.

Q: What happens when a beneficiary wanting a capped rental switched at 13 months to a purchase?
A: If the beneficiary accepts the purchase option, the DME MAC continues making rental payments until a total of 13 continuous rental months have been paid. The DME MAC will not make any additional rental payments beyond the 13th rental month. On the first day after 13 continuous rental months have been paid, the supplier must transfer title of the equipment to the beneficiary. This information can be found in the Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS).

Q: Is there a modifier used to indicate the beneficiary's choice at the 10th month rental?
A: For power mobility devices and enteral/parenteral nutrition, the BR or BP modifiers are used to indicate the beneficiary's choice to continue to rent or purchase the equipment.

Q: Do the bandages (short stretch, foam padding, etc.) count as one garment, or are they not counted as a garment?
A: The short stretch bandage would be considered as one garment. The foam padding would be counted as accessories to the garment. More information is available on the Noridian Medicare website > Browse by DMEPOS Category > Lymphedema Compression Treatment.

Q: Charting indicates a beneficiary has chronic obstructive pulmonary disease (COPD), but the physician also indicates wanting to conduct an overnight pulse oximetry to "screen" for possible sleep apnea, and if any abnormalities are found he will proceed with a formal sleep study. He then follows up indicating no indication of sleep apnea and orders oxygen from the overnight pulse oximetry results. Can we move forward with oxygen set up, or do we need to have the sleep study to rule out OSA?
A: Provider Outreach and Education cannot pre-approve medical records. If the beneficiary does not have a diagnosis of OSA and requires oxygen, the beneficiary must meet the requirements of the oxygen policy to set the patient up with oxygen. A titration study in the absence of a diagnosis of OSA is not required.

Follow-up Question: Could we set the beneficiary up with the follow-up visit indicating no indication of sleep apnea, or do we need to request a formal sleep study to rule out?
A: If there is no indication of OSA within the medical records, the beneficiary will not meet for the PAP device. The beneficiary can be seen again if they believe a PAP device is required.

Q: A beneficiary was on a BiPAP but couldn't tolerate it and purchased an AirMini CPAP. The doctor documents that the beneficiary is using it and that is what is working for them. Now they want to order an E0601. Under Medicare, do they need a new sleep study, either split night or titration that shows the BiPAP is no longer needed?
A: If the original sleep study already demonstrated AHI/RDI greater than or equal to 15 events per hour (or AHI/RDI between 5-14 with documented symptoms), and the physician confirms that CPAP is now effective, a new sleep study may not be required. However, if the original sleep study was conducted for BiPAP qualification due to ineffective CPAP therapy, Medicare may require a new titration study to confirm that CPAP is now appropriate. The physician's documentation should clearly state that CPAP is effective and that BiPAP is no longer necessary.

Q: If billing Medicare strictly for denial, is an SWO required or can an order that's missing some of the SWO elements be used? Does an order need to be submitted at all?
A: All items billed to Medicare must have a valid order on file. For more information, review the Standard Documentation Requirements Article A55426. If the order does not meet the SWO requirements or there is not an SWO, the claims should be billed with the EY modifier which indicates that a prescription was not received for the item billed. The supplier may also acquire an ABN to ensure the claim is denied beneficiary liable.

Q: During months 42-60 of oxygen rental, if the stationary concentrator is exchanged for a new unit, is that considered maintenance to bill the maintenance charge?
A: Maintenance can be billed six months after the 36-month rental has been completed. Actual maintenance would have to be performed on the unit.

Q: Other than when a beneficiary changes their minds after signing, is there ever allowance for an ABN to have corrections, or must we always obtain a new correct ABN that is only applicable to services provided after the new correct ABN is obtained?
A: Suppliers cannot make changes to the ABN after the item has been dispensed. Beneficiaries can make changes to the choices of the ABN to bill Medicare or not.

Q: For PMDs, after the base SWO is completed fully by the physician, does it matter what date we have as the start date on our SWO for the accessories that is signed later? For example, the base SWO is signed 1/1/25, SWO for accessories is signed by physician 1/2/2025, but has a start date of 12/15/25, matching their face-to-face visit date. Does the start date matter?
A: This depends on when all medical necessity for the PMD is met. Is there a licensed/certified medical professional (LCMP) record? The order is the last item to be completed after medical necessity has been met.

Q: A Certificate of Medical Necessity (CMN) is on file for E0486 (custom fitted mandibular device), but the beneficiary has since switched to using E0601 they've purchased out of pocket. Would they be able to get supplies for the E0601 through Medicare? And if so, what would be needed?
A: The beneficiary would have to meet the coverage criteria for the E0601 to have the supplies paid for by Medicare. Also, the E0486 is on file with Medicare and the E0601 is not, therefore, a denial could be received. An appeal with all documentation requirements would need to be submitted for review. See LCD L33611 and Policy Article A52512 for coverage criteria.

Follow-up Question: We do have the documentation on file to qualify the beneficiary for an E0601; however, they don't necessarily need the machine itself since they did already buy one. So, in this case, could they get the supplies for the E0601?
A: In that case, you would have to get the E0601 on file with Medicare. You would have to do a redetermination for this and send in the supporting documentation that the beneficiary meets the coverage criteria in order for Medicare to pay for the supplies.

Q: If a beneficiary was set up on oxygen equipment during the public health emergency (PHE) when clinical requirements were waived, and the beneficiary is now eligible for new five-year equipment, would updated testing be required for the renewal? If medical need had already been established, would documentation from the treating physician supporting the continued need and use be acceptable?
A: In this scenario, the RA/CR modifiers can be added to the first claim billed for the RUL to indicate the beneficiary met for oxygen on a waiver. A SWO for the RUL will be required but no additional testing is required.

Last Updated $dateUtil.getDate( $modifieddate , "MMM dd , yyyy" , $locale , $tzone )