TL;DR
Chapter 20 of the Medicare Claims Processing Manual covers durable medical equipment, prosthetics, orthotics and supplies. It explains whether a claim goes to a DME MAC or an A/B MAC, how the DMEPOS fee schedule is calculated and updated, the payment categories such as inexpensive items, capped rentals and oxygen, maintenance and replacement, documentation such as written orders, and the billing rules for supplies, nutrition, home infusion and lymphedema compression items.
Chapter 20 at a glance
- Current revision
- Rev. 12557
- Issued March 28, 2024
- Effective
- January 1, 2024
- Implemented April 29, 2024
- Sections
- 124
- 28 top-level sections
- Transmittals in history
- 59
- Listed at the end of the chapter
- Monthly searches
- 40
- Google Ads, US, October 2026
What chapter 20 governs for billing
Section 10 decides where to bill: most suppliers send DMEPOS claims to the DME MAC for the beneficiary's state of residence, while hospitals, skilled nursing facilities and other institutional providers bill their A/B MAC for items they furnish. The note at the top of the chapter records that, for dates of service on or after January 1, 2023, certificates of medical necessity and DME information forms are no longer submitted with claims. Section 20 explains how fee schedule amounts are calculated and updated, including the adjusted rates in areas outside competitive bidding (20.6).
Section 30 sets the payment categories. Inexpensive or routinely purchased items can be bought or rented (30.1), items needing frequent servicing are rented for as long as they are needed (30.2), customized items are paid as a lump sum (30.3), prosthetics and orthotics are purchased (30.4), and capped rental items are paid monthly until the rental cap is reached; for these, the supplier continues renting until 13 continuous rental months have been paid and then transfers title to the beneficiary (30.5). Oxygen equipment follows its own monthly payment rules (30.6), and replacement of equipment after its reasonable useful lifetime, no shorter than five years, starts a new rental or purchase (50).
The second half covers documentation and billing: written orders before delivery and the older certificates of medical necessity (100), general billing requirements and pre-discharge delivery (110), billing by payment category and showing whether an item is rented or purchased (130), supplies used with equipment (140), parenteral and enteral nutrition (160), home infusion therapy (180), the lymphedema compression treatment benefit added in 2024 (181), and how consolidated billing in skilled nursing facilities and home health limits what a supplier can bill (211 and 212).
Sections billing teams use most
Section numbers and headings are CMS's; the notes are ours. Each section number opens the official chapter 20 PDF at the page where that section starts.
| Section | CMS heading | Why it matters |
|---|---|---|
| 10 | Where to Bill DMEPOS and PEN Items and Services | Where to bill DMEPOS and nutrition items: DME MAC or A/B MAC. |
| 30.5 | Capped Rental Items | Capped rental items, the rental cap and the transfer of title after 13 continuous rental months. |
| 30.6 | Oxygen and Oxygen Equipment | Payment for oxygen and oxygen equipment. |
| 50 | Payment for Replacement of Equipment | Replacement of equipment that is lost, stolen, irreparably damaged or past its useful lifetime. |
| 100 | General Documentation Requirements | General documentation requirements, including written orders before delivery. |
| 181 | Lymphedema Compression Treatment Benefit | The lymphedema compression treatment benefit and its payment policy. |
| 211 | SNF Consolidated Billing and DME Provided by DMEPOS Suppliers | How SNF consolidated billing affects DME furnished by outside suppliers. |
How chapter 20 shows up on claims and denials
DMEPOS claims are often denied for jurisdiction or category errors before medical review. A claim sent to the wrong contractor returns reason code 109, which tells the supplier to bill the correct payer or contractor. Modifiers that conflict with the payment category, such as a rental modifier on an item that is only purchased, return reason code 4, and a frequency or quantity above the policy limit is reduced or denied.
Medical necessity denials, reason code 50, usually trace back to the order and the medical record rather than the claim. The written order, proof of delivery and the treating practitioner's notes must support the local coverage determination for the item, and the supplier keeps them in case of review. Items furnished during a covered SNF stay or home health period of care may belong to the facility or agency under consolidated billing.
Codes you are likely to see on the remittance when a claim runs into this chapter's rules. The code pages explain each code's meaning, root causes and the usual fix.
| Code | Type | When it appears |
|---|---|---|
| 109 | Claim adjustment reason code | Claim sent to the wrong contractor; bill the DME MAC or A/B MAC that has jurisdiction. |
| 50 | Claim adjustment reason code | Item not reasonable and necessary under the coverage policy. |
| 4 | Claim adjustment reason code | Rental, purchase or other modifier inconsistent with the item. |
| 16 | Claim adjustment reason code | Claim missing required information such as the ordering practitioner. |
Current revision and recent transmittals
The chapter PDF posted on cms.gov is current through Rev. 12557, issued March 28, 2024, effective January 1, 2024, implemented April 29, 2024 (change request 13528). That revision changed section 181.1 (Payment Policy for Lymphedema Compression Treatment Items).
The newest rows of the transmittal history printed at the end of the chapter (59 revisions in all). Rows whose subject could not be read reliably from the PDF table are left out; the PDF has the complete list.
| Revision | Issued | Subject | CR |
|---|---|---|---|
| R11429CP | May 23, 2022 | Revisions to National Coverage Determination (NCD) 240.2 (Home Use of Oxygen) and 240.2.2 (Home Oxygen Use for Cluster Headache) | 12607 |
| R11414CP | May 12, 2022 | Claims Processing Manual Update - Pub. 100.04 for Elimination of Certificates of Medical Necessity (CMNs) and Durable Medical Equipment Forms (DIFs) | 12734 |
| R10840CP | June 11, 2021 | Updates to the Internet Only Publication 100-04, Chapter 1, Section 10.1 and Chapter 20, Section 10 | 12310 |
| R10236CP | July 31, 2020 | Update to the IOM Publication (Pub) 100-04, Medicare Claims Processing Manual, Chapters 1, 6, 8, 17, 20, 22, 24, and 31 Referencing the Active Universal Resource Locators (URLs) for the Washington Publishing Company (WPC) and the ASC X12 Organizations, and Updates to the | 11857 |
| R4202CP | January 18, 2019 | Update to Pub. 100-04 Chapters 8, 20, and 24 to Provide Language-Only Changes for the New Medicare Card Project | 10964 |
| R4112CP | November 1, 2018 | Temporary Transitional Payment for Home Infusion Therapy Services for CYs 2019 and | 10836 |
Sections ordered by the date in the revision note printed under each heading.
| Section | Heading | Revision |
|---|---|---|
| 181.1 | Payment Policy for Lymphedema Compression Treatment Items | Rev. 12557, March 28, 2024; effective January 1, 2024 |
| 181 | Lymphedema Compression Treatment Benefit | Rev. 12741, January 24, 2024; effective January 1, 2024 |
| 213 | Billing for Home IVIG Items and Services | Rev. 12437, December 28, 2023; effective January 1, 2024 |
| 01 | Foreword | Rev. 12423, December 20, 2023; effective January 1, 2024 |
| 140.1.1 | Billing of Insulin Furnished through DME | Rev. 12013, May 2, 2023; effective July 1, 2023 |
| 30.6 | Oxygen and Oxygen Equipment | Rev. 11429, May 23, 2022; effective September 27, 2021 |
| 10 | Where to Bill DMEPOS and PEN Items and Services | Rev. 11414, May 12, 2022; effective June 13, 2022 |
| 30 | General Payment Rules | Rev. 11414, May 12, 2022; effective June 13, 2022 |
Section index
Every section in the chapter's table of contents, grouped under its top-level heading, with the PDF page where it starts. Open a heading to see its subsections.
01 Foreword · p. 6
10 Where to Bill DMEPOS and PEN Items and Services · p. 7 · 9 subsections
- Open section 10 in the PDF
- 10.1 Definitions · p. 9
- 10.1.1 Durable Medical Equipment (DME) · p. 9
- 10.1.2 Prosthetic Devices - Coverage Definition · p. 10
- 10.1.3 Prosthetics and Orthotics (Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes) - Coverage Definition · p. 10
- 10.1.4 Payment Definition Variances · p. 11
- 10.1.4.1 Prosthetic Devices · p. 11
- 10.1.4.2 Prosthetic and Orthotic Devices (P&O) · p. 11
- 10.2 Coverage Table for DME Claims · p. 11
- 10.3 Beneficiaries Previously Enrolled in Managed Care Who Return to Traditional Fee for Service (FFS) · p. 13
20 Calculation and Update of Payment Rates · p. 15 · 6 subsections
- Open section 20 in the PDF
- 20.1 Update Frequency · p. 15
- 20.2 Locality · p. 16
- 20.3 Elimination of "Kit" Codes and Pricing of Replacement Codes · p. 16
- 20.4 Contents of Fee Schedule File · p. 16
- 20.5 Online Pricing Files for DMEPOS · p. 17
- 20.6 Phase-in For Competitive Bid Rates in Areas Not in a Competitive Bid Area · p. 17
30 General Payment Rules · p. 18 · 29 subsections
- Open section 30 in the PDF
- 30.1 Inexpensive or Other Routinely Purchased DME · p. 20
- 30.1.1 Used Equipment · p. 20
- 30.1.1.2 Used Rental Equipment · p. 21
- 30.1.2 Transcutaneous Electrical Nerve Stimulator (TENS) · p. 21
- 30.2 Items Requiring Frequent and Substantial Servicing · p. 21
- 30.2.1 Daily Payment for Continuous Passive Motion (CPM) Devices · p. 21
- 30.3 Certain Customized Items · p. 22
- 30.4 Other Prosthetic and Orthotic Devices · p. 23
- 30.5 Capped Rental Items · p. 24
- 30.5.1 Capped Rental Fee Variation by Month of Rental · p. 24
- 30.5.2 Purchase Option for Capped Rental Items · p. 24
- 30.5.3 Additional Purchase Option for Electric Wheelchairs · p. 25
- 30.5.3.1 Exhibits · p. 25
- 30.5.4 Payments for Capped Rental Items During a Period of Continuous Use · p. 27
- 30.5.5 Payment for Power-Operated Vehicles that May Be Appropriately Used as Wheelchair · p. 28
- 30.6 Oxygen and Oxygen Equipment · p. 29
- 30.6.1 Adjustments to Monthly Oxygen Fee · p. 30
- 30.6.2 Purchased Oxygen Equipment · p. 30
- 30.6.3 Contents Only Fee · p. 30
- 30.6.4 DMEPOS Clinical Trials and Demonstrations
- 30.7 Payment for Parenteral and Enteral Nutrition (PEN) Items and Services · p. 31
- 30.7.1 Payment for Parenteral and Enteral Pumps · p. 31
- 30.7.2 Payment for PEN Supply Kits · p. 32
- 30.8 Payment for Home Dialysis Supplies and Equipment · p. 32
- 30.8.1 DME MAC and A/B MAC (A) Determination of ESRD MethodSelection · p. 33
- 30.8.2 Installation and Delivery Charges for ESRD Equipment · p. 34
- 30.8.3 Elimination of Method II Home Dialysis · p. 34
- 30.9 Payment of DMEPOS Items Based on Modifiers · p. 35
- 30.9.1 Processing of Expatriate Beneficiary DMEPOS Claims for Purchased Items Submitted with the EX Modifier · p. 38
40 Payment for Maintenance and Service of Equipment · p. 39 · 3 subsections
- Open section 40 in the PDF
- 40.1 General · p. 39
- 40.2 Maintenance and Service of Capped Rental Items · p. 40
- 40.3 Maintenance and Service of PEN Pumps · p. 40
50 Payment for Replacement of Equipment · p. 41 · 5 subsections
- Open section 50 in the PDF
- 50.1 Payment for Replacement of Capped Rental Items · p. 42
- 50.2 A/B MAC (A) or (HHH) Format for Durable Medical Equipment, Prosthetic, Orthotic and Supply Fee Schedule
- 50.3 Payment for Replacement of Parenteral and Enteral Pumps · p. 42
- 50.4 Payment for Replacement of Oxygen Equipment in Bankruptcy Situations · p. 42
- 50.5 Payment of a Part of a DMEPOS Item · p. 43
60 Payment for Delivery and Service Charges for Durable Medical Equipment · p. 44
80 Penalty Charges for Late Payment Not Included in Reasonable Charges or Fee Schedule Amounts · p. 45
90 Payment for Additional Expenses for Deluxe Features · p. 45
100 General Documentation Requirements · p. 46 · 13 subsections
- Open section 100 in the PDF
- 100.1 Written Order Prior to Delivery · p. 47
- 100.1.1 Written Order Prior to Delivery - HHAs · p. 47
- 100.2 Certificates of Medical Necessity (CMN) · p. 47
- 100.2.1 Completion of Certificate of Medical Necessity Forms · p. 48
- 100.2.2 Evidence of Medical Necessity for Parenteral and Enteral Nutrition (PEN) Therapy · p. 50
- 100.2.2.1 Scheduling and Documenting Certifications and Recertifications of Medical Necessity for PEN · p. 51
- 100.2.2.2 Completion of the Elements of PEN CMN · p. 51
- 100.2.2.3 DME MAC Review of Initial PEN Certifications · p. 55
- 100.2.3.1 Scheduling and Documenting Recertifications of Medical Necessity for Oxygen · p. 56
- 100.2.3.2 HHA Recertification for Home Oxygen Therapy · p. 57
- 100.2.3.3 A/B MAC (A) or (HHH) Review of Oxygen Certifications · p. 58
- 100.3 Limitations on DME MAC Collection of Information · p. 58
- 100.4 Reporting the Ordering/Referring NPI on Claims for DMEPOS Items Dispensed Without a Physician's Order · p. 59
110 General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies · p. 60 · 11 subsections
- Open section 110 in the PDF
- 110.1 Billing/Claim Formats · p. 60
- 110.1.1 Requirements for Implementing the NCPDP Standard · p. 61
- 110.1.2 Certificate of Medical Necessity (CMN) · p. 61
- 110.1.3 NCPDP Companion Document · p. 61
- 110.2 Application of DMEPOS Fee Schedule · p. 61
- 110.3 Pre-Discharge Delivery of DMEPOS for Fitting and Training · p. 63
- 110.3.1 Conditions That Must Be Met · p. 63
- 110.3.2 Date of Service for Pre-Discharge Delivery of DMEPOS · p. 64
- 110.3.3 Facility Responsibilities During the Transition Period · p. 65
- 110.4 Frequency of Claims for Repetitive Services (All Providers and Suppliers) · p. 65
- 110.5 DME MACs Only - Appeals of Duplicate Claims · p. 66
120 DME MACs - Billing Procedures Related To Advanced Beneficiary Notice (ABN) Upgrades · p. 67 · 1 subsections
- Open section 120 in the PDF
- 120.1 Providing Upgrades of DMEPOS Without Any Extra Charge · p. 70
130 Billing for Durable Medical Equipment (DME) and Orthotic/Prosthetic Devices · p. 71 · 10 subsections
- Open section 130 in the PDF
- 130.1 Provider Billing for Prosthetic and Orthotic Devices · p. 71
- 130.2 Billing for Inexpensive or Other Routinely Purchased DME · p. 73
- 130.3 Billing for Items Requiring Frequent and Substantial Servicing · p. 73
- 130.4 Billing for Certain Customized Items · p. 74
- 130.5 Billing for Capped Rental Items (Other Items of DME) · p. 74
- 130.6 Billing for Oxygen and Oxygen Equipment · p. 74
- 130.6.1 Oxygen Equipment and Contents Billing Chart · p. 79
- 130.7 Billing for Maintenance and Servicing (Providers and Suppliers) · p. 85
- 130.8 Installment Payments · p. 86
- 130.9 Showing Whether Rented or Purchased · p. 86
140 Billing for Supplies · p. 87 · 4 subsections
- Open section 140 in the PDF
- 140.1 Billing for Supplies and Drugs Related to the Effective Use of DME · p. 88
- 140.1.1 Billing of Insulin Furnished through DME · p. 88
- 140.2 Billing for HHA Medical Supplies · p. 89
- 140.3 Billing DME MAC for Home Dialysis Supplies and Equipment · p. 89
150 Institutional Provider Reporting of Service Units for DME and Supplies · p. 90
160 Billing for Total Parenteral Nutrition and Enteral Nutrition · p. 90 · 2 subsections
- Open section 160 in the PDF
- 160.1 Billing for Total Parenteral Nutrition and Enteral Nutrition Furnished to Part B Inpatients · p. 90
- 160.2 Special Considerations for SNF Billing for TPN and EN Under Part B · p. 91
170 Billing for Splints and Casts · p. 92
180 Billing for Home Infusion Therapy Services · p. 92
181 Lymphedema Compression Treatment Benefit · p. 97 · 1 subsections
- Open section 181 in the PDF
- 181.1 Payment Policy for Lymphedema Compression Treatment Items · p. 97
190 A/B MAC (A), (B), (HHH), or DME MAC Application of Fee Schedule and Determination of Payments and Patient Liability for DME Claims · p. 98
200 Automatic Mailing/Delivery of DMEPOS · p. 103
210 CWF Crossover Editing for DMEPOS Claims During an Inpatient Stay · p. 103
211 SNF Consolidated Billing and DME Provided by DMEPOS Suppliers · p. 106 · 2 subsections
- Open section 211 in the PDF
- 211.1 General Information · p. 106
- 211.2 Partial Month Stays For Capped Rental Equipment · p. 106
212 Home Health Consolidated Billing and Supplies Provided by DMEPOS Suppliers · p. 108
213 Billing for Home IVIG Items and Services · p. 109
220 Appeals · p. 110
230 DME MAC Systems · p. 110
300 New Systems Requirements · p. 111
Using this chapter in a denial or appeal
Start with the remittance. The claim adjustment reason code says what happened to the line, the remark code narrows it, and the group code says who is liable. Match that to the section of the chapter that sets the rule, then read the section in the official PDF rather than a summary: the wording that matters, such as a time limit, a modifier requirement or a documentation element, is usually a single sentence. Check the revision note under the section heading, because a rule that changed after the date of service may not apply to the claim, and an effective date earlier than the issue date can make a new rule reach back.
When the chapter supports the claim, cite it precisely in the redetermination request: the publication number, chapter, section and revision. When it does not, the fix is usually a corrected claim or better documentation rather than an appeal, and a coding or format rejection is corrected and resubmitted because it carries no appeal rights. Manual instructions bind the Medicare Administrative Contractor, so they settle most first-level disputes; at the hearing level, administrative law judges give them substantial deference without being bound by them. If the issue turns on whether a service is covered at all, read the matching Benefit Policy Manual chapter and any national coverage determination or local coverage determination as well, because coverage and billing rules are written in different places.
How QuickIntell works with Claims Processing Manual chapter 20
QuickRCM covers eligibility, claim readiness, denials, posting and A/R with configurable automation and human review, which is where the billing rules in this chapter are checked before a claim goes out. QuickCode supports qualified coder review of the coding and modifier questions the chapter answers.
Frequently asked questions: chapter 20
When does a capped rental item belong to the beneficiary?
Chapter 20 section 30.5 explains that the supplier continues rental payments until 13 continuous rental months have been paid, and on the first day after that the supplier must transfer title to the beneficiary.
Do DMEPOS claims still need a certificate of medical necessity?
No, not for dates of service on or after January 1, 2023. Chapter 20 records that certificates of medical necessity and DME information forms are no longer submitted, and claims sent with them attached are rejected.
Who processes DMEPOS claims?
Under chapter 20 section 10, suppliers generally bill the DME MAC that serves the beneficiary's state, while institutional providers such as hospitals and SNFs bill their A/B MAC for items they furnish.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-10. Verify against the primary file before billing or contracting decisions. The reference methodology explains how each figure is computed from these files.
- Medicare Claims Processing Manual, Chapter 20: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)Version Rev. 12557, issued 2024-03-28 · effective 2024-01-01 · file clm104c20.pdfSHA-256 2c63e4136e442711…
- Medicare Claims Processing Manual (Pub. 100-04)Version 39 chapter PDFs; newest revision Rev. 13836 (chapter 14), issued 2026-06-24 · effective 2026-09-27 · file 100-04-claims-processing-manual/*.pdf (39 chapters; SHA-256 of their sha256sum listing)SHA-256 f87bc3bcd9d1570d…
Disclaimer
This guide summarizes a CMS manual chapter in our own words for billing teams; section headings and transmittal subjects are quoted from the chapter PDF. The chapter itself is the authority, and it changes by transmittal. Not legal, clinical or billing advice.
Found a figure that does not match the CMS file? Report a data correction with the CMS file and the value you expected; the request reaches the editorial team through the contact form.