Medicare AdvantageBilling CodesHigh impact
[Ohio] Claim Edits for Durable Medical Equipment
CareSource·OH · Orthopedics, Physical Therapy, Occupational Therapy +3 more·Claims & Billing
Effective date
Jan 15, 2026
We identified it
May 9, 2026
Summary
CareSource is implementing new claim edits for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) effective January 15, 2026, aligning with CMS payment policies. Billing teams must ensure correct use of modifiers (rental, anatomical, functional, and surgical dressing modifiers) on all DMEPOS claims to prevent denials. Key restrictions include limiting breast pumps to one unit per delivery (240 days/eight months) and applying state guidelines.
Action Required
By January 15, 2026: Billing team must audit and update all DMEPOS billing workflows to ensure correct modifier application. (1) Update billing software to enforce use of rental modifiers (RR), anatomical modifiers (LT, RT), functional modifiers (K0-K4), surgical dressing modifiers (A1-A9, GY), and other required modifiers (KF, KX, GA, GY, GZ) based on DMEPOS item type. (2) Implement system edits to allow only one breast pump code (E0602, E0603, or E0604) per patient per delivery period (240 days/eight months) across all providers. (3) Review and update encounter forms and billing instructions to remind providers of correct modifier requirements. (4) Train billing staff on modifier requirements for wheelchairs/accessories, hospital beds, oxygen equipment, respiratory assist devices, orthosis, orthopedic footwear, urological supplies, surgical dressings, and capped rentals. (5) Apply Ohio state guidelines for DMEPOS billing. Failure to use correct modifiers will result in claim denials. Contact CareSource Provider Services with questions: D-SNP 1-833-230-2176, Marketplace 1-833-230-2101, Medicaid 1-800-488-0134, MyCare 1-800-488-0134 (M-F, hours vary by plan).