Change in Bill Processing of Miscellaneous DMEPOS Codes

August 2015

Effective for dates of service beginning September 1, 2015, WSI will deny durable medical equipment, prosthetics, orthotics, supplies (DMEPOS) billed with a miscellaneous code if a more specific code is available. 

When billing for DMEPOS, a provider should select the most specific and inclusive CPT® or HCPCS code available.  If a provider bills a miscellaneous code when a more specific code is available, WSI will deny with Reason Code 224: 

“This charge is denied because the code submitted is invalid per WSI coding guidelines. Resubmit the charge using the appropriate code. If you disagree with the denial, you may complete the provider request for adjustment form (M6) and submit to WSI within 30 days from the date of the remittance advice. You may also supply any supporting documentation. The patient may not be billed for this reduced or denied charge.”

In certain circumstances, the use of a miscellaneous code is appropriate as indicated below:

  • No specific listed code is available (e.g., equipment that cannot be grouped into other like items because it is new and unique in kind or form).
  • Custom equipment that is uniquely constructed or substantially modified to meet the specific needs of an individual patient.  In this case, the bill should be itemized, not a grouping of all parts into one unlisted code.
  • Labor charges related to the servicing of DMEPOS.

When billing a miscellaneous DMEPOS code, a provider must include a description of the item or part. 

If you have questions about this article, please send an email to wsipr@nd.gov.  To receive provider news, subscribe to our Email Updates list.