Glossary

The quality standards review a DMEPOS supplier must pass to bill Medicare and to bid. Site visits are moving to an annual cycle.

RelatedPTANSmall supplier

A continuous glucose monitor whose readings must be confirmed with a fingerstick before an insulin or treatment decision. Billed under its own supply and device codes.

RelatedNon-adjunctive CGMCGM

A fee schedule amount that has been updated with competitive bidding pricing information, as applied outside the bidding areas themselves.

RelatedFee schedule

The item is furnished with a urological, ostomy or tracheostomy supply — ties the accessory to its covered base benefit.

RelatedKX modifier

A bond a bidder must obtain from an authorized surety for each bidding area it bids in, so that only capitalized suppliers bid.

RelatedCompetitive bidding area (CBA)

Manual pricing for codes with no promulgated fee-schedule amount: the supplier attaches cost documentation (an invoice or catalog page) to the claim.

RelatedFee schedule

CMS projects beneficiary demand for each category, then selects enough of the lowest bidders whose declared capacity together meets that demand.

Related75th percentile rule

Short for competitive bidding area.

RelatedCompetitive bidding area (CBA)

Short for the DMEPOS Competitive Bidding Program.

RelatedCompetitive Bidding Program (CBP)

A wearable sensor that reports glucose readings continuously. Round 2028 bids the non-adjunctive supply allowance as a lead item.

RelatedAdjunctive CGMNon-adjunctive CGM

A geographic area in which competitive bidding contracts and single payment amounts apply. Remote item delivery categories are bid nationally instead.

RelatedCBARemote item delivery (RID)

The CMS program that sets Medicare DMEPOS payment by supplier bids and contracts rather than the fee schedule. Round 2028 is its next round.

RelatedCBPCompetitive bidding area (CBA)Remote item delivery (RID)

A built in outward curve in a skin barrier that presses the skin around a flush or retracted stoma so the stoma protrudes into the pouch and leaks are prevented.

RelatedSkin barrier

A curved catheter tip used when a straight tip cannot pass, as with strictures or an enlarged prostate. Both catheter lead items are coudé tip codes.

RelatedHydrophilic coating

A prefabricated brace that a trained professional must substantially modify, for example by heat bending, to fit one patient. Custom fitted braces stay outside competitive bidding.

RelatedOff-the-shelf (OTS) orthotic

The regional contractors that process Medicare claims for durable medical equipment and supplies, and that publish the coverage rules those claims are judged against. Two companies hold the four jurisdictions: Noridian in JA and JD, CGS in JB and JC.

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies — the CMS benefit category urological supplies are billed under; catheters ride the Prosthetics benefit.

RelatedHCPCS Level IICompetitive Bidding Program (CBP)Medicare DMEPOS fee schedule

The billing unit for placing an indwelling catheter — CMS covers one insertion tray per episode, regardless of clinical complications.

RelatedInsertion kit

A skin barrier formulation designed to stay sealed longer than a standard wear barrier, resisting breakdown from output.

RelatedSkin barrier

A urine collection device worn outside the body rather than inserted, such as a condom style male catheter or a female pouch or meatal cup.

RelatedMeatal cup

No physician order on file for the item — an automatic denial flag.

RelatedSWO

The reusable rigid plate of an older ostomy system to which a pouch attaches. Faceplate pouch codes sit apart from barrier based systems.

RelatedSkin barrierTwo-piece system

A payer's list of maximum allowable reimbursement per HCPCS code, often geographically adjusted — the baseline every margin calculation starts from.

RelatedMedicare DMEPOS fee schedule

An Advance Beneficiary Notice is on file: the item is expected to be denied as not reasonable and necessary, and liability shifts to the beneficiary.

RelatedGZ modifierGY modifier

Rows in a machine-readable file that price a code for a provider who does not bill it. A file can carry a rate for a provider who has never supplied the item, so a row existing is not evidence that the code is billed or paid there. Also called zombie rates.

The item is statutorily excluded from the benefit — billed to obtain the denial a secondary payer needs.

RelatedGA modifier

The item is expected to be denied and NO Advance Beneficiary Notice is on file — the supplier absorbs the denial.

RelatedGA modifier

The alphanumeric coding system for medical products and supplies. Continence care uses A-codes for medical/surgical supplies and T-codes for state Medicaid programs.

RelatedPDACUPN

A catheter coating that becomes slippery when wet, usually from a sterile water sachet, reducing friction and urethral trauma on insertion. It defines the hydrophilic catheter category.

RelatedCoudé tipInsertion kit

A sterile package of insertion supplies, typically gloves, an underpad and a collection bag, bundled with or sold beside a catheter.

RelatedSterile intermittent catheterizationHydrophilic coating

The compression a rigid spinal brace applies to the abdomen, which offloads the intervertebral discs. Many back brace code descriptors name it.

RelatedSagittal-coronal controlTLSOLSO

The supplier's attestation that the LCD's medical-necessity requirements are met and documented — required on most urological supply claims.

RelatedPolicy ArticleGA modifier

Local Coverage Determination — a Medicare Administrative Contractor's binding coverage decision for its jurisdiction. LCD L33803 (Urological Supplies) governs continence-care coverage.

RelatedMACPolicy Article

The one code in a Round 2028 product category that suppliers actually bid on. Its single payment amount anchors the price of every other code in the category.

RelatedNon-lead itemRelative ratioSingle payment amount (SPA)

A back brace supporting the lower back and sacrum. The back brace category's lead item is a rigid LSO.

RelatedTLSOSagittal-coronal control

Medicare Administrative Contractor — the regional contractor that processes Medicare claims and issues the LCDs governing coverage in its jurisdiction.

RelatedLCD

A female external collection device that seals over the urethral opening. A niche item in the urological category.

RelatedExternal catheter

CMS's published allowable per code — the dashed reference line on the charts. Negotiated commercial rates are benchmarked against it.

RelatedFee scheduleDMEPOSp50 (median)

A rate file a payer publishes under the Transparency in Coverage rule. The in-network-rates file is the one that carries prices; an allowed-amounts file and a provider-reference file sit beside it. They are compressed JSON, and one payer month is commonly large enough that no ordinary desktop tool will open it.

How the filed rate is expressed: 'negotiated' is a dollar amount; 'percentage' is a percent of a reference schedule. A chart never mixes the two.

RelatedFee scheduleMedicare DMEPOS fee schedule

A continuous glucose monitor cleared for treatment decisions without a confirming fingerstick. It replaces the standard blood glucose monitor and its test strips in billing.

RelatedAdjunctive CGMCGM

A contract supplier must offer Medicare beneficiaries the same brands and models it offers other customers, and must furnish a specific prescribed item or help find a supplier that can.

RelatedCompetitive Bidding Program (CBP)

Any code in a category other than the lead item. Suppliers do not bid on it; its payment is the lead item's single payment amount scaled by a fixed relative ratio.

RelatedLead itemRelative ratio

How many rate rows back this figure — more occurrences mean the percentile rests on more filed provider-payer rates.

Relatedp50 (median)Negotiated type

A prefabricated brace that needs only minimal self adjustment by the patient or caregiver to fit. Only OTS braces are inside competitive bidding.

RelatedOTSCustom-fitted orthotic

An ostomy pouch with the skin barrier attached, changed as a unit.

RelatedTwo-piece systemSkin barrier

Short for off-the-shelf: a prefabricated brace fitted with minimal self adjustment.

RelatedOff-the-shelf (OTS) orthotic

The 25th percentile: a quarter of the negotiated rates on file sit at or below this value. The low end of the typical range.

Relatedp50 (median)p75Occurrences (n)

The median negotiated rate: half the rates on file are below, half above. The single most representative number for a payer's pricing.

Relatedp25p75Rate spread

The 75th percentile: three quarters of the negotiated rates on file sit at or below this value. The high end of the typical range.

Relatedp25p50 (median)

The CMS Pricing, Data Analysis and Coding contractor that assigns products to HCPCS codes — it maintains the hydrophilic catheter crosswalk.

RelatedPDAC coding verificationUPNHCPCS Level II

The formal review in which the PDAC contractor confirms a product meets a HCPCS code's criteria. Without it the supplier carries the coding and audit risk itself.

RelatedPDACHCPCS Level II

The qualifying condition for the Prosthetics benefit: a bladder/sphincter impairment of long and indefinite duration (in practice, three months or more).

RelatedSterile intermittent catheterization

The LCD's companion document carrying the coding guidelines, modifier requirements and utilization parameters that make the coverage decision operational.

RelatedLCDKX modifier

Payer approval required before dispensing. Rare for routine catheter supplies under Medicare; routine for above-quantity absorbent products under Medicaid.

RelatedPrior authorization exemptionUsual Maximum Quantity

A proposed benefit for suppliers with a high historical claim approval rate: they skip pre payment prior authorization and are reviewed after payment instead.

RelatedPrior Authorization

The Medicare benefit category these codes fall under. It is not capped rental, so coverage continues once it has been established, and audits concentrate on the documentation held and on the monthly quantity ceilings rather than on a rental clock.

The Medicare billing number a supplier must hold and keep active to participate in competitive bidding.

RelatedAccreditation

The gap between the highest and lowest payer medians shown — a quick read on how far apart payers price the same code.

Relatedp50 (median)

Documented urinary tract infections meeting the LCD's frequency criteria — a key gateway to sterile-kit (A4353) coverage.

RelatedSterile intermittent catheterization

The fixed multiplier that ties a non-lead item's payment to the lead item's single payment amount. Derived from historical fee schedules, it does not change with the bid.

RelatedLead itemNon-lead item

The national competitive bidding track for supplies shipped to a beneficiary's home or picked up locally, such as CGM supplies, ostomy and urological items. No local bidding areas apply.

RelatedRIDCompetitive bidding area (CBA)

The CMS notice that opens a bidding round, with the bid window, instructions and category list.

RelatedCompetitive Bidding Program (CBP)

Short for remote item delivery, the national bidding track for shipped supplies.

RelatedRemote item delivery (RID)

A flexible or paneled belt supporting the pelvis and sacrum. The simplest entries in the back brace category.

RelatedLSO

A brace that limits both forward and backward (sagittal) and side to side (coronal) trunk motion. Sagittal control alone limits only the forward and backward plane.

RelatedIntracavitary pressureLSO

The most Medicare pays a contract supplier for a competitively bid item. Round 2028 sets it at the 75th percentile of winning bids for the lead item.

RelatedSPA75th percentile ruleLead item

The adhesive wafer or flange that seals an ostomy pouch system to the skin around the stoma and protects it from output. The ostomy category's lead item is a skin barrier.

RelatedConvexityExtended wearFaceplateStoma

A supplier under the program's annual revenue threshold. CMS aims for a share of contracts to go to small suppliers and may offer extra contracts to reach it.

RelatedAccreditation

Short for single payment amount: the contract price Medicare pays for a competitively bid item.

RelatedSingle payment amount (SPA)

The order document required before most DMEPOS items are billed. It replaced the detailed written order and the certificate of medical necessity.

RelatedSWO

One sterile single-use catheter per catheterization event — the coverage standard that replaced clean reuse in 2008 and drives per-month quantities.

RelatedPermanent urinary incontinence / retentionRecurrent UTIsInsertion kit

The surgically created opening on the abdomen through which bowel or urinary output passes in a colostomy, ileostomy or urostomy.

RelatedSkin barrier

The order a supplier must hold on file before it bills Medicare for an item. The January 1, 2026 code split required a new order only where the existing order named a HCPCS code, which meant A4351, A4352 or A4353. An order written with a general description such as hydrophilic catheter, or with a brand and model, needed no replacement, and the supplier simply bills the new code for dates of service on or after January 1, 2026.

Stated by Noridian Healthcare Solutions, jurisdictions JA and JD, July 17, 2025

Transanal irrigation — bowel-management therapy delivered via rectal catheter (A4453) with a manual (A4459) or electronic (A4479) system.

RelatedDMEPOS

The federal rule requiring health plans and insurers to publish machine-readable files of their negotiated in-network rates, refreshed every month. It is the rule the provenance line at the foot of every page on this site refers to.

A back brace that spans the thoracic, lumbar and sacral spine. The back brace category's flexible entries are TLSOs.

RelatedLSOIntracavitary pressure

The index file listing where a payer has put its machine-readable files for a given month. It is far smaller than the files it points at, and reading a payer month starts here, because nothing else states which files exist.

An ostomy system in which the skin barrier with a flange stays on the skin and the pouch snaps on and off separately.

RelatedOne-piece systemSkin barrier

Universal Product Number — the product-level identifier PDAC crosswalks to HCPCS codes when coding structures change.

RelatedPDACHCPCS Level II

The payer's hard per-period unit limit (e.g. 200 intermittent catheters per month). Exceeding it triggers automated denials without added medical-necessity documentation.

RelatedPrior AuthorizationKX modifier

How Round 2028 prices a lead item: the single payment amount is the bid at the 75th percentile of the winning bids, not the highest winning bid as in earlier rounds.

RelatedSingle payment amount (SPA)Capacity evaluation