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TODAY’S PRESENTATION Once you are connected to the webinar,
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Acronyms
ABN: Advance Beneficiary Notice of Noncoverage
CBIC: Competitive Bid Implementation Contractor
DMEPOS: Durable Medical Equipment, Prosthetics, Orthotics & Supplies
IRP: Inexpensive or Routinely Purchased
LCD: Local Coverage Determination
PDAC: Pricing, Data Analysis and Coding
5
Agenda
◦ Payment Category Modifiers
◦ Oxygen Modifiers
◦ Parenteral, Enteral, and External Infusion Pump Modifiers
◦ KX and Related Modifiers
◦ Supply Specific Modifiers
◦ Miscellaneous Modifiers
◦ Repair and Replacement Modifiers
◦ Competitive Bid Modifiers
◦ Advanced Beneficiary Notice of Noncoverage (ABN) Modifiers
What is a Modifier?
◦ Modifiers are defined as:
Two digit codes that indicate services or procedures have been altered by some specific
circumstance. Modifiers do not change the definition of the reported procedure codes
Modifiers can be pricing, informational, or both
◦ A list of DMEPOS modifiers is available on the PDAD Website at:
https://www.dmepdac.com/dmecsapp/do/search
Leave the field blank and click “Go” in the modifier search engine for a full listing
Modifiers - Did you Know?
◦ Modifiers are consistently the number one reason for front end
claim rejections and return/reject claims
◦ There is a limit of four (4) modifiers per claim line; additional
modifiers can be accommodated by appending one of the
overflow modifiers (KB or 99)
◦ Pricing modifiers will be listed on the fee schedule next to the
HCPCS code
Order of Modifiers
◦ Pricing modifiers (NU, RR, or UE), where applicable, should be in the first modifier
position
◦ When billing 2 units of a capped rental item, modifiers RT and LT must be in
positions two and three
◦ Overflow modifiers, 99 or KB, must be in the 4th modifier position when utilized
◦ Other modifiers can be in any position and the DME MAC will
re-organize for appropriate processing
Payment Categories
Most DMEPOS fall into the following categories:
◦ Capped Rental
◦ Inexpensive or Routinely Purchased DME
◦ Frequent and Substantial Servicing DME
◦ Oxygen and Oxygen Equipment
◦ Prosthetics and Orthotics
◦ Customized DMEPOS
How to Determine the
Payment Category?
Look up the HCPCS on the DMECS Website or view on the DME MAC Fee Schedule:
http://www.dmepdac.com
Capped Rental Modifiers
◦ Paid on rental basis only
RR - Rented Item
◦ Identify the rental month being billed:
KH - First rental month
KI - Second and third rental month
KJ - Fourth through thirteenth month
◦ CPAP Example:
E0601RRKHKX - Month 1
E0601RRKIKX - Month 2 and 3
E0601RRKJKX - Month 4 - 13
Capped Rental Modifiers
◦ Exception: Certain motorized wheelchairs (K0835 – K0891) may be purchased in the
first month.
When purchased, use:
NU - New purchased item or UE - Used purchase
BP - Beneficiary purchase
Example: K0835NUKHBPKX or K0835UEKHBPKX
When rented, use:
RR - Rental Item
BR - Beneficiary Rental
Example: K0835RRKHBRKX
◦ K0813-K0831 and K0898 cannot be purchased in the first month
Frequently and
Substantially Serviced (FSS)
These are items that require frequent and substantial servicing in order to
avoid risk to the health of the beneficiary
◦ Must be rented, never purchased
◦ RR modifier - Rented Item
◦ Will be paid on a monthly rental basis for as long as the equipment is medically
necessary
◦ Ventilator Example: E0466RR
Inexpensive or Other Routinely
Purchased (IRP) DME
◦ May be purchased or rented
RR - Rented item or
NU - New purchased item or
UE - Used purchased item
◦ Crutches example:
E0110RR
E0110NU
E0110UE
Oxygen and Oxygen Equipment
◦ Portable and Stationary units are paid as rental up to 36 months
RR - Rental
Example: E1390RR
◦ Prescribed liter flow rate must be identified for high
or low liter flow and will affect payment rate:
QE - Less than 1 liter per minute (LPM) prescribed
QF - Greater than 4 LPM prescribed with portable system
QG - Greater than 4 LPM prescribed
Example: E1390RRQE, E1390RRQF, E1390RRQG
Oxygen and Oxygen Equipment
◦ Oxygen conserving devices must be identified for informational purposes only and
will not affect payment rate:
QH - Oxygen conserving device used with oxygen delivery system
◦ Contents
No modifiers on content codes (E0441-E0444)
Oxygen and Oxygen Equipment
◦ Maintenance & Service
Medicare can pay for a general MS fee starting six (6) months after the end of the 36-month
rental period for concentrators and transfilling equipment
Only applies to equipment falling under HCPCS codes E1390, E1391, E1392, and K0738
Supplier must physically make an in-home visit to inspect the equipment and provide any
necessary maintenance and service
Example: E1390MS
Parenteral and Enteral Nutrition Pumps
◦ HCPCS: B9002, B9004, B9006
Can be rented or purchased
Modifiers:
NU, UE, RR
KH, KI, KJ
BP, BR
First billing month examples: B9002NUKHBP, B9002RRKHBR, B9002UEKHBP
If rented, will rent for a maximum of 15 months
Ownership remains with the supplier after 15 months and maintenance and service can be
billed when performed
MS billable once every six months for enteral pumps
MS billable once every three months for parenteral pumps
Example: B9002MS
Enteral Nutrition - Oral Administration
◦ Enteral nutrition products that are administered orally and related supplies are
noncovered
◦ When enteral nutrients (B4149-B4162) are administered by mouth:
Bill the appropriate procedure code, and
Append the BO modifier
Example: B4150BO
IV Poles (HCPCS: E0776)
◦ IV Pole with
Enteral Nutrition
Billed as a continuous rental or
purchase and must be billed
with the “BA” modifier and a
KG if provided in a competitive
bid area
E0776NUBAKG
(competitive bid area only)
E0776UEBAKG
(competitive bid area only)
E0776RRBAKG
(competitive bid area only)
IV Pole with Parenteral Nutrition
• Billed as a continuous rental or
purchase and must be billed with
the “BA” modifier
– E0776NUBA
– E0776UEBA
– E0776RRBA
IV Pole with External Infusion Pump
• Billed as a purchase or rents to
purchase price and billed without
“BA” modifier
– E0776NU
– E0776UE
– E0776RR
External Infusion
◦ JB - Administered subcutaneously
◦ Route of Administration is subcutaneous, and
◦ Billing for immune globulin J1559, J1561, J1562, and
◦ Infusion pump E0779
Example:
E0779RRKHJB
J1559JB
J1561JB
J1562JB
KX Modifier
◦ Requirements specified in the medical policy have been met
◦ Coverage criteria and documentation requirements must be met
◦ Documentation is essential in supporting the item is reasonable
and necessary
◦ Review each specific LCD to confirm the documentation requirements and which
codes require use of the KX
JA: https://med.noridianmedicare.com/web/jadme/policies/lcd/active
JB: http://www.cgsmedicare.com/jb/coverage/lcdinfo.html
JC: http://www.cgsmedicare.com/jc/coverage/lcdinfo.html
JD: https://med.noridianmedicare.com/web/jddme/policies/lcd/active
LCDs with a KX Modifier Requirement◦ Ankle-Foot/Knee-Ankle-Foot Orthosis
◦ Automatic External Defibrillators
◦ Cervical Traction Devices
◦ Commodes
◦ External Infusion Pumps
◦ Glucose Monitors
◦ High Frequency Chest Wall Oscillation Devices
◦ Hospital Beds
◦ Immunosuppressive Drugs
◦ Knee Orthoses
◦ Manual Wheelchair Bases
◦ Nebulizers
◦ Negative Pressure Wound Therapy Devices
◦ Oral Antiemetic Drugs
◦ Oral Appliances for Obstructive Sleep Apnea
Orthopedic Footwear
Patient Lifts
Positive Airway Pressure Devices
Power Mobility Devices
Pressure Reducing Support Surfaces
Refractive Lenses
Respiratory Assist Devices
Speech Generating Devices
Therapeutic Shoes for Persons with Diabetes
Transcutaneous Electrical Nerve Stimulators
Urological Supplies
Walkers
Wheelchair Options and Accessories
Wheelchair Seating
KX Modifier
◦ GA, GY, and GZ modifiers have been added to LCDs to indicate that the relevant KX
modifier requirements have not been met
Glucose Monitor LCD is the only exception
◦ Claims without KX, GA, GZ, or GY modifiers will be rejected and must be
resubmitted with the appropriate modifier
◦ A KX, GA, GZ, or GY modifier cannot be added/removed/updated through claim
reopenings
KX Modifier Examples
◦ CPAP Device
Criteria met per PAP LCD
E0601RRKHKX
Criteria not met per PAP LCD - ABN on file
E0601RRKHGA
Criteria not met per PAP LCD - No ABN on file
E0601RRKHGZ
◦ Intermittent Urinary Catheter
Criteria met per Urological Supplies LCD and Policy Article
A4353KX
Criteria not met per Urological Supplies Policy Article
A4353GY
Non-End Stage Renal Disease (ESRD)
Related Supplies (AY)
AY - Item or service furnished to an ESRD patient that is not
for the treatment of ESRD
◦ A4215
◦ A4216
◦ A4217
◦ A4218
◦ A4244
◦ A4245
◦ A4246
◦ A4247
◦ A4248
A4450
A4452
A4657
A4660
A4663
A4670
A4927
A4928
A4930
A4931
A6215
A6250
A6260
A6402
E0210
E1639
Surgical Dressings (AW)
◦ AW - Item furnished in conjunction with a surgical dressing
◦ AW required for the following HCPCS when provided under the Surgical Dressing
LCD requirements:
A4450 - Tape, non-waterproof, per 18 square inches (requires A1-A9)
A4452 - Tape, waterproof, per 18 square inches (requires A1-A9)
A6531 - Gradient compression stocking, below knee, 30-40 MMHG,
each (requires RT and/or LT)
A6532 - Gradient compression stocking, below knee, 40-50 MMHG,
each (requires RT and/or LT)
A6545 - Gradient compression wrap, non-elastic, below knee,
30-50 MM HG, each (requires RT and/or LT)
Surgical Dressings (A1-A9)
◦ Indicates that a particular item is being used as a primary or secondary dressing on a
surgical or debrided wound and indicates the number of wounds the dressing is used
on
◦ Modifier number must correspond to the number of wounds on which the dressing is
being used, not the total number of wounds treated
◦ Not used with codes A6531, A6532, and A6545
◦ If A9 is billed, the claim must include the number of wounds
Glucose Supplies (KS or KX)
◦ KS - Glucose monitor supply for diabetic beneficiary not treated
by insulin
Patient is not being treated with insulin injections
Must be added to the code for the monitor and each related supply
Example: E0607NUKS, A4253NUKS, A4259KS
◦ KX - Specific required documentation on file
Effective 08/01/2013 - KX is defined as “Requirements specified in the
medical policy have been met”
Patient is being treated with insulin injections
Must be added to the code for the monitor and each related supply
Example: E0607NUKX, A4253NUKX, A4259KX
Glucose Supplies (KL)
◦ Suppliers must use the KL modifier on all claims for diabetic supply codes (A4233,
A4234, A4235, A4236, A4253, A4256, A4258, and A4259) that are furnished via mail
order to beneficiaries
Example: A4253NUKSKL or A4253NUKXKL
◦ The KL modifier is not used with diabetic supply codes that are not delivered to the
beneficiary’s residence; however, are obtained from local supplier storefronts
◦ Must be a contract supplier
RT and LT Modifiers
◦ LT - Left side
◦ RT - Right side
◦ RT and LT are required for specified items in the following LCDs:
AFO/KAFO
External Breast Prosthesis
Eye Prosthesis
Facial Prosthesis
Knee Orthoses
Lower Limb Prosthesis
◦ Refer to the appropriate LCD for specific billing details
• Orthopedic Footwear
• Refractive Lenses
• Surgical Dressings
• Therapeutic Shoes for Persons
with Diabetes
• Wheelchair Options/Accessories
Nebulizer Drugs
Unit dose formulation modifiers
◦ KO: Single drug unit dose formulation
◦ KP: First drug of multiple drug unit dose formulation
◦ KQ: Second or subsequent drug of multiple drug unit dose formulation
Unit dose codes billed without appropriate modifier deny as invalid code
◦ Exception: J7620 (Albuterol/Ipratroprium) does not require KO, KP, or KQ
JW Modifier• Effective for claims with DOS on or after 1/1/17
• JW modifier- drug amount discarded/not administered to any patient
• For the DME MACs, the JW modifier only applies to the following LCDs:
◦ External Infusion Pumps
◦ Intravenous Immune Globulin (IVIG)
◦ Nebulizers
• Claims for drugs billed to Medicare must use drug dosage formulations
and/or unit dose sizes that minimize wastage
41
JW Modifier
Scenario 1: HCPCS code Unit of Service (UOS) is less than the drug
quantity contained in the single use vial or single dose package:
◦ The quantity administered is billed on one claim line without the JW
modifier
◦ The quantity discarded is billed on a separate claim line with the JW
modifier
◦ Both claim lines would be processed for payment
Scenario 2: HCPCS code UOS is equal to or greater than the total of
the actual dose and the amount discarded
◦ Use of the JW modifier is not permitted.
◦ If the quantity of drug administered is less that a full UOS, the billed
UOS is rounded to the appropriate UOS.
42
Special Power Wheelchair Interface
◦ KC - Replacement of special power wheelchair interface
Used for the following situations:
Integrated joystick and controller is being replaced by another drive control
interface due to patient’s condition
Interface (e.g., joystick, head control, sip and puff) and the controller electronics
are being replaced due to irreparable damage, such as:
E2321-E2322, E2325, E2327-E2330, or E2373
KC modifier would never be used at initial use of wheelchair, only for replacement
RB Modifier is not necessary since KC specifically indicates replacement
Class III Devices
◦ KF - Item designated by FDA as Class III device
Must be submitted for HCPCS, when the specific device has been classified by the FDA as a
Class III device
• E0617
• E0747
• E0748
• E0760
• E0764
• E0766
• E0766
• K0606
• K0607
• K0608
• K0609
• K0861
EY Modifier
◦ EY - No physician or other licensed health care provider order
for this item or service
◦ Items submitted without order will deny as not reasonable
and necessary
Exception for items which require a Written Order Prior to Delivery,
which will deny as not meeting the benefit category
PR - Patient Responsibility
◦ ABN is recommended to protect supplier from liability
GY Modifier
◦ GY - Item or service statutorily excluded or does not meet
the definition of any Medicare benefit
◦ Examples:
Hearing aids
Personal comfort items
Wheelchairs exclusively for use outside the home
Statutorily non-covered items
GW Modifier
◦ GW - Item or service not related to the hospice patient’s
terminal condition
Used specifically for beneficiaries enrolled in a Medicare Advantage Plan while receiving
hospice care and whom are receiving items unrelated to their hospice diagnosis
Any items related to the patient’s terminal condition are included in the hospice payment rate
and are not payable by the DME MAC
Overflow Modifiers
◦ KB - Beneficiary requested upgrade for ABN, more than 4 modifiers identified on
claim
Replace the fourth modifier with the KB modifier and place the remaining ABN modifiers in
Item 19 of a paper claim or the NTE 2400 field of an electronic claim
◦ 99 - Modifier overflow
Used for non-upgrade claims with more than 4 modifiers
Replace the fourth modifier with the 99 modifier and place the
remaining modifiers in Item 19 of a paper claim or the NTE 2400
field of an electronic claim
Repair and Replacement Modifiers
◦ RA - Replacement of a DME, Orthotic or Prosthetic item
Replacement of DME, Orthotic or Prosthetic item due to loss, stolen, irreparable damage or
reached it’s useful lifetime
◦ RB - Replacement of a part of a DME, Orthotic or Prosthetic item furnished as part of
a repair
Competitive Bid Modifiers
◦ KE Modifier - Bid under round one of DMEPOS Competitive Bidding Program for use
with a non-competitive bid base equipment
The KE modifier must be used to identify an accessory code that can be dually billed with
either a competitive or non-competitive bid base item and is not subject to the fee schedule
reduction under MIPAA
KE modifier use was suspended for dates of service on or after July 1, 2016
◦ KY Modifier - For wheelchair accessories, modifier “KY” is used to identify a
competitively bid wheelchair accessories that should be paid at fee schedule when
billed for use with a base unit that was not bid, even when provided to a beneficiary
that resides in a CBA and without regard to the contract status of the supplier
KU Modifier
◦ KU Modifier – Wheelchair accessory and seat and back cushions used with a Group
3 Complex Rehab wheelchair base (K0848 – K0864)
Effective for Dates of Service: January 1, 2016 – June 30, 2017
◦ List of accessories to which the KU modifier applies is located in
CR 9520:
https://www.cms.gov/Regulations-and-
Guidance/Guidance/Transmittals/Downloads/R3535CP.pdf
Competitive Bid Modifiers
◦ KT Modifier - Beneficiary resides in a CBA and travels outside that CBA and receives
a competitive bidding item
◦ KV Modifier - DMEPOS item subject to DMEPOS Competitive Bidding Program that
is furnished as part of a professional service
◦ J4 Modifier - DMEPOS item subject to DMEPOS Competitive Bidding Program that
is furnished by a hospital upon discharge
KG Modifier
◦ KG Modifier – Used to identify when the same supply or accessory is furnished in
multiple competitive bidding product categories or when the same code can be used
to describe both competitively and non-competitively bid items
◦ Suppliers should only apply modifier KG to competitive bid HCPCS codes according
to current policy instructions. HCPCS codes designated as valid for use with the KG
modifier are listed in the Single Payment Amount Files at:
http://dmecompetitivebid.com
Definitions of ABN Modifiers
◦ GA - Waiver of liability (expected to be denied as not reasonable and necessary,
ABN on file)
◦ GZ - Item or service not reasonable and necessary (expected to be denied as not
reasonable and necessary, no ABN on file)
◦ GK - Actual item or service ordered by physician, item associated with GA or GZ
modifier
◦ GL - Medically unnecessary upgrade provided instead of standard item no charge,
no ABN on file
GX Modifier
◦ GX - Notice of liability issued, voluntary under payer policy
◦ Used to report instances where a voluntary ABN was issued
for an item
◦ May be reported on the same line as certain other liability-related modifiers (i.e. GY
modifier)
Example: J3370GYGX
(Vancomycin not administered via external infusion pump)
DME Upgrades
ABN and Claims Modifiers
ABN
Required
Required
Modifier(s)DMAC Payment
Beneficiary Pays
for Upgrade
1) Physician orders upgrade:
a) Supplier provides upgrade free of charge
to beneficiaryNo GL
R&N item only
(GL line)No
b) Supplier bills beneficiary for upgrade Yes GA/GKR&N item only
(GL line)Yes
2) Patient requests upgrade:
a) Supplier providers upgrade free of charge
to beneficiaryNo
GZ/GK R&N item only
(GL line)No
b) Supplier bills beneficiary for upgrade YesGA/GK R&N item only
(GL line)Yes
3) Supplier providers upgrade for supplier convenience
a) Supplier provides upgrade free of charge
to beneficiaryNo GL
R&N item only
(GL line)No
JA and JD Modifier Resources
◦ Browse by Topic – Modifiers
◦ JA - https://med.noridianmedicare.com/web/jadme/topics/modifiers
◦ JD - https://med.noridianmedicare.com/web/jddme/topics/modifiers
◦ One stop includes
Modifier definitions
Modifier presentations
Modifier Q & A
DME on Demands for Modifiers (A1-A9, Au, AV, AW, GA, GZ, CX, EY, GY, KX, RT/LT and Upgrades)
◦ Policies
◦ JA – https://med.noridianmedicare.com/web/jadme/policies
◦ JD - https://med.noridianmedicare.com/web/jddme/policies
JB and JC Modifier Resources
◦ Modifier Finder Tool:
JB: http://www.cgsmedicare.com/medicare_dynamic/modifiers_jb/search.asp
JC: http://www.cgsmedicare.com/medicare_dynamic/modifiers_dme/search.asp
◦ KE & KY Modifier Tool: http://www.cgsmedicare.com/medicare_dynamic/dme/
ke_ky_modifier_tool.asp
◦ KX Table:
JB: http://www.cgsmedicare.com/jb/help/kx_table.html
JC: http://www.cgsmedicare.com/jc/pubs/news/2010/0510/cope12183.html
◦ Repair Modifier Tool: http://www.cgsmedicare.com/medicare_dynamic/dme/
repair_modifier_tool.asp
◦ LCDs and Policy Articles
JB: http://www.cgsmedicare.com/jb/coverage/lcdinfo.html
JC: http://www.cgsmedicare.com/jc/coverage/lcdinfo.html
Jurisdiction A
◦ https://med.noridianmedicare.com/web/jadme
◦ Contact Center 866-419-9458
Jurisdiction B
◦ https://www.cgsmedicare.com/jb/index.html
◦ Contact Center 866-590-6727
Jurisdiction C
◦ http://www.cgsmedicare.com/jc/index.html
◦ Contact Center 866-270-4909
Jurisdiction D
◦ https://med.noridianmedicare.com/web/jddme
◦ Contact Center 877-320-0390
© 2016 Copyright. 63
Contacts
Additional Resources
◦ Coding - PDAC
1.877.735.1326
http://www.dmepdac.com
◦ National Supplier Clearinghouse
1.866.238.9652
http://www.palmettogba.com/nsc
◦ CEDI
1.866.311.9184
http://www.ngsedi.com
How to Participate Today
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Disclaimer
The presentations herein were current at the time they were published or uploaded onto the Web.
Medicare policy changes frequently so links to the source documents have been provided within the
document for your reference. The presentations herein were prepared as tools to assist providers
and are not intended to grant rights or impose obligations. Although every reasonable effort has
been made to assure the accuracy of the information within these pages, the ultimate responsibility
for the correct submission of claims and response to any remittance advice lies with the provider of
services.
The Centers for Medicare & Medicaid Services (CMS) employees and agents, including CGS and its
staff, make no representation, warranty, or guarantee that this compilation of Medicare information is
error free and will bear no responsibility or liability for the results or consequences of the use of this
guide. This publication is a general summary that explains certain aspects of the Medicare Program,
but is not a legal document. Official Medicare Program provisions are contained in relevant laws,
regulations, and rulings.