Level II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT codes, such as ambulance services and DMEPOS when used outside a physician’s office. Because Medicare and other insurers cover a variety of services, supplies, and equipment that are not identified by CPT codes, the HCPCS Level II codes were established for submitting claims for these items. The development and use of HCPCS Level II codes began in the 1980s. HCPCS Level II codes are also referred to as alphanumeric codes because they consist of a single alphabetical letter followed by four numeric digits, while CPT codes are identified using five numeric digits. Suppliers must use HCPCS Level II codes to identify items/services rendered to its Medicare beneficiaries when submitting claims to the DME MAC for payment.
National Government Services is the Jurisdiction B DME MAC. One role of the DME MAC is to create and maintain LCDs and PAs, together are referred to as medical policies, for certain DMEPOS items/services. Each LCD and PA contains information vital to the supplier community in determining whether the item/service meets medical necessity guidelines. In addition, the LCDs and PAs offer HCPCS coding information as well as coding guidelines in the LCD/PA-related articles. Suppliers should visit the National Government Services Web site to view the LCDs and PAs for specific HCPCS requirements. LCDs and PAs are found under the Medical Policy Center section of the National Government Services Web site.
Suppliers may also view a HCPCS code files under the HCPCS Code section of the National Government Services Web site.
Prior to utilizing the HCPCS file, suppliers should become familiar with the structure of HCPCS file, which provides an explanation of the HCPCS file table.
The HCPCS Jurisdiction List indicates whether a code should be billed to the DME MAC or the local Medicare carrier.
The following HCPCS codes will be denied as noncovered when they are submitted to the DME MAC. These items either do not meet the requirements for a benefit category processed by the DME MAC (technical denial) or are statutorily excluded for reasons other than lack of medical necessity. These items may be covered under other provisions of the law (e.g., as part of institutional care in a hospital or nursing facility, as an item incident to a physician’s service, etc.). However, in these circumstances, the claim would not be submitted to the DME MAC and/or would be submitted using a different code.
|A4210||Needle-free injection device, each|
|A4261||Cervical cap for contraceptive use|
|A4335||Disposable sheets and bags|
|A4490||Surgical stockings above knee length, each|
|A4495||Surgical stockings thigh length, each|
|A4500||Surgical stockings below knee length, each|
|A4510||Surgical stockings full length, each|
|A4554||Disposable underpads, all sizes, (e.g., chux’s)|
|A4575||Topical hyperbaric oxygen chamber, disposable|
|A4627||Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler|
|A4670||Automatic blood pressure monitor|
|A6000||Noncontact wound warming wound cover for use with the noncontact wound warming device and warming card|
|A9190||Personal comfort item|
|A9270||Noncovered item or service|
|E0191||Heel or elbow protector, each|
|E0220||Hot water bottle|
|E0230||Cap or collar|
|E0231||Non-contact wound warming device|
|E0232||Warming card for use with the noncontact wound warming device and noncontact wound warming wound cover|
|E0238||Nonelectric heat pad, moist|
|E0241||Bath tub wall rail, each|
|E0242||Bath tub rail, floor base|
|E0243||Toilet rail, each|
|E0244||Raised toilet seat|
|E0245||Tub stool or bench|
|E0246||Transfer tub rail attachment|
|E0270||Hospital bed, institutional type includes: oscillating, circulating and stryker frame with mattress|
|E0315||Bed accessories and boards or tables, any type|
|E0625||Patient lift, kartop, bathroom or toilet|
|E0700||Safety equipment (e.g., belt, harness or vest)|
|E0746||Biofeedback therapy for the treatment of urinary incontinence|
|E1300||Whirlpool, nonportable (overtub type)|
|J1055||Injection, medroxyprogesterone acetate for contraceptive use, 150 mg|
|J3520||Edetate disodium, per 150 mg|
|J3535||Drug administered through a metered dose inhaler|
|J3570||Laetrile, amygdalin, vitamin b17|
|J7300||Intrauterine copper contraceptive|
|J8499||Prescription drug, oral, nonchemotherapeutic, NOS|
|L3215||Orthopedic footwear, ladies shoes, oxford|
|L3216||Orthopedic footwear, ladies shoes, depth inlay|
|L3217||Orthopedic footwear, ladies shoes, hightop, depth inlay|
|L3219||Orthopedic footwear, mens shoes, oxford|
|L3221||Orthopedic footwear, mens shoes, depth inlay|
|L3222||Orthopedic footwear, mens shoes, hightop, depth inlay|
|Q0144||Azithromycin dihydrate, oral, capsules/powder, 1 gram|
|V2600||Hand held low vision aids and other nonspectacle mounted aids|
|V2610||Single lens spectacle mounted low vision aids|
|V2615||Telescopic and other compound lens system, including distance vision telescopic, near vision telescopes, and compound microscopic lens system|
|V2760||Scratch resistant coating, per lens|
|V5010||Assessment for hearing aid|
|V5011||Fitting/orientation/checking of hearing aid|
|V5014||Repair/modification of a hearing aid|
|V5336||Repair/modification of augmentative communicative system or device (excludes adaptive hearing aid)|
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In some instances, insurers instruct providers that a HCPCS code must be accompanied by a code modifier to provide additional information regarding the service or item identified by the HCPCS code. Modifiers are used when the information provided by a HCPCS code descriptor needs to be supplemented to identify specific circumstances that may apply to an item or service. Following is a list of HCPCS modifiers.
The fourth column (01) of the HCPCS modifier chart indicates the Medicare coverage status for the modifier. The codes and descriptions for these alpha characters include:
|Medicare Coverage Status Code||Description|
|D||Special coverage instructions apply|
|I||Not payable by Medicare (no grace period)|
|G||Not payable by Medicare (90-day grace period)|
|M||Noncovered by Medicare|
|S||Noncovered by Medicare statute|
Note: Modifiers marked with an asterisk (*) have additional information located in the section that follows the chart below.
|HCPCS Modifier||Action Code||Long Description||01||Code Add Date||Action Effective Date||Term Date|
|A1||Dressing for one wound||C||20020701||20020701|
|A2||Dressing for two wounds||C||20020701||20020701|
|A3||Dressing for three wounds||C||20020701||20020701|
|A4||Dressing for four wounds||C||20020701||20020701|
|A5||Dressing for five wounds||C||20020701||20020701|
|A6||Dressing for six wounds||C||20020701||20020701|
|A7||Dressing for seven wounds||C||20020701||20020701|
|A8||Dressing for eight wounds||C||20020701||20020701|
|A9||Dressing for nine or more wounds||C||20020701||20020701|
|AU||Item furnished in conjunction with a urological, ostomy, or tracheostomy supply||C||20030101||20030101|
|AV||Item furnished in conjunction with a prosthetic device, prosthetic, or orthotic||C||20030101||20030101|
|AW||Item furnished in conjunction with a surgical dressing||C||20030101||20030101|
|AX||Item furnished in conjunction with dialysis services||C||20030101||20030101|
|AY||Item or service furnished to an ESRD patient that is not for the treatment of ESRD.||20100420|
|BA||Item furnished in conjunction with parenteral enteral nutrition (PEN) services||C||20030101||20030101|
|BO||Orally administered nutrition, not by feeding tube||C||20030101||20030101|
|BP*||The beneficiary has been informed of the purchase and rental options and has elected to purchase the item||C||19920101||19970101|
|BR*||The beneficiary has been informed of the purchase and rental options and has elected to rent the item||C||19920101||19970101|
|BU*||The beneficiary has been informed of the purchase and rental options and after 30 days has not informed the supplier of his/her decision||C||19920101||19970101|
|CC||Procedure code change (use CC when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)||C||19900101||19970101|
|CS||Item or service related, in whole or in part, to an illness, injury, or condition that was caused by or exacerbated by the effects, direct or indirect, of the 2010 oil spill in the gulf of Mexico, including but not limited to subsequent clean-up activities||20100420|
|EA||ESA, anemia, chemo-induced||010108|
|EB||ESA, anemia, radio-induced||010108|
|EC||ESA, anemia, nonchemo/radio||010108|
|EJ||Subsequent claims for a defined course of therapy, e.g., Epotein Alfa (EPO), sodium hyaluronate, infliximab||D||19910101||20000101|
|EM||Emergency reserve supply (for end‑stage renal disease [ESRD] benefit only)||D||19910101||19970101|
|EY||No physician or other licensed health care provider order for this item or service||C||20030101||20030101|
|FB||C||Item provided without cost to provider, supplier, or practitioner, or credit received for replaced device (examples, but not limited to covered under warranty, replaced due to defect, free samples)||I||20060101||20070101|
|GA*||Waiver of liability statement issued as required by payer policy, individual case||C||19950101||20110101|
|GB||Claim being resubmitted for payment because it is no longer covered under a global payment demonstration||C||20020101||20020101|
|GK*||Actual item/service ordered by physician, item associated with GA or GZ modifier||C||20020101||20020101|
|GL*||Medically unnecessary upgrade provided instead of standard item, no charge, no advance beneficiary notice (ABN)||C||20020101||20020101|
|GS||C||Dosage of EPO or Darbepoietin Alfa has been reduced and maintained in response to hematocrit or hemoglobulin level||D||20060101||20070101|
|GU||Waiver of liability statement issued as required by payer policy, routine notice||20110101|
|GW*||Service not related to the hospice patient’s terminal condition||20020101||20020101|
|GY||Item or service statutorily excluded or does not meet the definition of any Medicare benefit||S||20020101||20020101|
|GZ*||Item or service expected to be denied as not reasonable and necessary||M||20020101||20020101|
|J4*||DMEPOS Item Subject to DMEPOS Competitive Bidding Program that is furnished by a Hospital upon Discharge||20100101||20100101|
|K0||Lower extremity prosthesis functional level 0—does not have the ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance their quality of life or mobility||C||19930101||20030101|
|K1||Lower extremity prosthesis functional level 1—has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. Typical of the limited and unlimited household ambulator.||C||19930101||19970101|
|K2||Lower extremity prosthesis functional level 2—has the ability or potential for ambulation with the ability to traverse low level environmental barriers such as curbs, stairs, or uneven surfaces. Typical of the limited community ambulatory.||C||19930101||19970101|
|K3||Lower extremity prosthesis functional level 3—has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to transverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion.||C||19930101||19970101|
|K4||Lower extremity prosthesis functional level 4—has the ability or potential for prosthetic ambulation that exceeds the basic ambulation skills, exhibiting high impact, stress, or energy levels, typical of the prosthetic demands of the child, active adult.||C||19930101||19970101|
|KA||Add on option/accessory for wheelchair||C||19940101||19970101|
|KB*||Beneficiary requested upgrade for ABN, more than four modifiers identified on claim||C||20030101||20030101|
|KC||Replacement of special power wheelchair interface||C||20050101||20050101|
|KD||Drug or biological infused through DME||C||20040101||20040101|
|KE*||DMEPOS Item Subject to DMEPOS Competitive Bidding Program for use with Non-Competitive Bid Base Equipment.||20090101||20090101|
|KF*||Item designated by FDA as Class III device||C||20040401||20040401|
|KG*||DMEPOS item subject to DMEPOS competitive bidding program number 1||20070107||20100101|
|KH*||DMEPOS item, initial claim, purchase, or first month rental||C||19940101||19970101|
|KI*||DMEPOS item, second or third month rental||C||19940101||19970101|
|KJ*||DMEPOS item, parenteral enteral nutrition (PEN) pump or capped rental, months four to fifteen||C||19940101||19970101|
|KK*||DMEPOS item subject to DMEPOS competitive bidding program number 2||20070107||20100101|
|KL||DMEPOS item, delivered via mail||C||20070701||20070701|
|KM||Replacement of facial prosthesis including new impression/moulage||C||19960101||20010101|
|KN||Replacement of facial prosthesis using previous master model||C||19960101||20010101|
|KO||Single drug unit dose formulation||C||19970401||19970401|
|KP||First drug of a multiple drug unit dose formulation||C||19970401||19970401|
|KQ||Second or subsequent drug of a multiple drug unit dose formulation||C||19970401||19970401|
|KR*||Rental item, billing for partial month||C||20020101||20020101|
|KS||Glucose monitor supply for diabetic beneficiary not treated with insulin||D||19981001||19981001|
|KT*||Beneficiary resides in a competitive bidding area and travels outside that competitive bidding area and receives a competitive bid item||20040108||20100101|
|KU*||DMEPOS item subject to DMEPOS competitive bidding program number 3||20070107||20100101|
|KV*||DMEPOS item subject to competitive bidding program that is furnished as part of a professional service||20100108||20100101|
|KW*||DMEPOS item subject to DMEPOS competitive bidding program number 4||20100108||20100101|
|KX||Specific required documentation on file||C||20020701||20020701|
|KY*||DMEPOS item subject to DMEPOS competitive bidding program number 5||20010108||20100101|
|LL||Lease/rental (use the LL modifier when DME equipment rental is to be applied against the purchase price)||C||19840101||19970101|
|LR||Laboratory round trip||C||19870101||19970101|
|LS||FDA-monitored intraocular lens implant||D||19910101||19970101|
|LT||Left side (used to identify procedures performed on the left side of the body)||C||19840101||19970101|
|M2||A||Medicare secondary payer (MSP)||C||20070101||20070101|
|MS*||Six-month maintenance and servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warranty||C||19890101||19970101|
|NB||Nebulizer system, any type, FDA-cleared for use with specific drug|
|NR||New when rented (use the NR modifier when DME which was new at the time of rental is subsequently purchased)||C||19840101||19970101|
|PL||Progressive addition lenses||C||19890101||19970101|
|QA||FDA investigational device exemption||C||19960101||19961001|
|QE||Prescribed amount of oxygen is less than 1 liter per minute (lpm)||C||19890101||19970101|
|QF||Prescribed amount of oxygen exceeds 4 liters per minute (lpm) and portable oxygen is prescribed||C||19890101||19970101|
|QG||Prescribed amount of oxygen is greater than 4 liters per minute(lpm)||C||19890101||19970101|
|QH||Oxygen conserving device is being used with an oxygen delivery system||C||19890101||19970101|
|QJ||Services/items provided to a prisoner or patient in state or local custody, however the state or local government, as applicable, meets the requirements in 42 CFR 411.4 (b)||D||20030101||20030101|
|QO||Investigational clinical service provided in a clinical research study that is in an approved clinical research study||D||20080101||20080101|
|Q1||Routine clinical service provided in a clinical research study that is in an approved clinical research study||D||20080101||20080101|
|RA*||Replacement of a DME item||C||20090101||20090101|
|RB*||Replacement of a part of DME furnished as part of a repair||C||20090101||20090101|
|RP||Replacement and repair—RP may be used to indicate replacement of DME, orthotic and prosthetic devices which have been in use for sometime. The claim shows the code for the part, followed by the RP modifier and the charge for the part.||C||19840101||19970101||20081231|
|RR*||Rental (use the RR modifier when DME is to be rented)||C||19840101||19970101|
|RT||Right side (used to identify procedures performed on the right side of the body)||C||19840101||19970101|
|UE*||Used durable medical equipment||C||19840101||19970101|
HCPCS Level II Modifiers fall within one of two categories:
In cases where more than one modifier is required on a claim line, the pricing modifier should be appended to the HCPCS code first, followed by the secondary pricing modifiers then any informational modifiers. Appending a modifier to a submitted HCPCS code does not warrant automatic payment for the DMEPOS item billed.
Omitting a modifier or placement of an incorrect or invalid modifier will result in your claim being rejected with ANSI-16 (Claim/service lacks information which is needed for adjudication).
Primary Pricing Modifiers go in the first position following the HCPCS code.
To determine if a pricing modifier is needed, you must know the payment category of the item being billed. Review the section in this chapter titled “Determining the Payment Category” to learn how to determine the payment category.
Pricing Modifiers are used to define the appropriate fee schedule allowance for an item or service billed to the Medicare Program. A primary pricing modifier will indicate if the item or service being billed is new, rented or used. Appending the appropriate modifier to the claim will dictate the reimbursement.
|NU||New DME – Allows reimbursement at the full fee schedule for the purchased item.|
|RR||Rented DME – Allows reimbursement on a monthly basis according to the rental rate.|
|UE||Used DME – Reimbursement will be made at a reduced rate.|
Competitive bidding pricing modifiers are considered secondary and will follow the NU, RR, and UE pricing modifiers when applicable.
Section 302 of the MMA of 2003 established requirements for the Medicare Program to implement a new Medicare Competitive Bidding Program for certain items of DMEPOS. Under these new instructions, competitive bid payment amounts were established to replace the Medicare DMEPOS fee schedule amounts for the selected items in selected areas.
Some of the Competitive Bidding Pricing Modifiers are described below and they also can be found on the CBIC Web site , in MLN Matters Article SE1035 and and in MLN Matters Article 8181.
Modifier J4 is used by hospitals that are providing walkers (Round 1 Rebid, Round 2) and folding manual wheelchairs (Round 2) to their patients upon discharge. Medicare hospitals have the option to furnish competitively bid walkers or folding manual wheelchairs to their own patients without submitting a bid or being awarded a competitive bid contract if the following requirements are met:
Separate payment is not made for walkers or folding manual wheelchairs furnished by a hospital for use in the hospital, as payment for these items is included in the Part A payment for inpatient hospital services.
Modifier KV is used by physicians and other practitioners in a CBA that are providing walkers (Round 1 Rebid, Round 2) and folding manual wheelchairs (Round 2) to their own patients as part of a professional service.
Physicians and treating practitioners who are not contract suppliers and who furnish walkers or folding manual wheelchairs to beneficiaries residing in a CBA must submit the informational KV modifier for the claim to be paid under Medicare.
The KL modifier must be used by all Medicare-enrolled suppliers to indicate that diabetic testing supplies were delivered to the beneficiary’s residence by mail order and not obtained from a local supplier storefront.
The mail-order diabetic testing supplies product category includes items such as lancets, test strips, and batteries that are provided through mail-order only.
Prior to July 1, 2013, the term “mail-order” referred to items ordered remotely (i.e., by phone, e-mail, Internet, or mail) and delivered to a beneficiary’s residence by common carriers (e.g., U.S., Postal Service, Federal Express, United Parcel Service, or other shipping or courier service companies) and does not include items obtained by beneficiaries from local storefronts. However, the competitive bidding program regulations were changed in 2010 to require a new definition of “mail-order.”
For all competitions after the Round 1 Rebid, a mail-order item is defined as any item shipped or delivered to the beneficiary’s place of residence, regardless of the method of delivery. A nonmail order item is one that a beneficiary or caregiver picks up in person at a local pharmacy or supplier storefront rather than having the item delivered to the beneficiary’s residence.
The National Mail-Order Program, which went into effect July 1, 2013, includes all 50 U.S. states, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, and American Samoa.
Only contract suppliers will be reimbursed by Medicare for providing diabetic testing supplies ordered remotely and delivered to beneficiaries’ homes on or after July 1, 2013. The only items excluded from the mail-order definition and mail-order competition would be those that a beneficiary or caregiver picks up in person at a local pharmacy or other local supplier storefront.
Note: Suppliers that furnish mail-order diabetic supplies that fail to use the HCPCS modifier KL on the claim may be subject to significant penalties.
Modifier KT is used by suppliers when providing nonmail-order DMEPOS competitive bidding items that are furnished to beneficiaries who have traveled outside of the CBA in which they reside. If a beneficiary who lives in a CBA travels to an area that is not a CBA and obtains an item included in the competitive bidding program, the non contract supplier must affix this modifier to the claim. Similarly, if a beneficiary who lives in a CBA travels to a different CBA and obtains an item included in the competitive bidding program from a contract supplier for that CBA, the contract supplier must use the KT modifier.
Note: Suppliers should not use the KT for mail-order diabetic supplies for traveling beneficiaries. Claims for mail-order competitive bidding diabetic supplies submitted with the KT modifier will be denied. Contract suppliers must submit mail-order diabetic supply claims for traveling beneficiaries using the beneficiary’s permanent home address.
For information on the use of these competitive bidding modifiers, please refer to the CMS’ Special Edition article SE1035.
As mandated by the Medicare Improvements for Patients and Providers ACT (MIPPA) of 2008, items selected for Round 1 competitive bidding in 2008 received a -9.5 percent update for 2009. This reduction to the fee schedule file applies to those items selected for Round 1 competitive bidding that are furnished on or after July 1, 2009, in any geographical area, i.e., noncompetitive bid areas as well as competitive bid areas.
Some of the items that were bid under Round 1 were accessory codes that could be used with both a competitively bid base and a noncompetitively bid base. The 9.5 percent payment reduction is applicable to accessories used with a competitively bid base, but does not apply to accessories used with noncompetitively bid base items. Therefore, in order to implement the covered item update required by MIPPA, the KE modifier was added to the DMEPOS fee schedule file in 2009 to identify Round I competitively bid accessory codes that could be used with both competitively bid and noncompetitively bid base equipment. DMEPOS suppliers were instructed to use the KE modifier on all claims to identify when a Round I bid accessory item is used with a noncompetitively bid base item (an item that was not competitively bid prior to July 2008).
A list of the HCPCS codes that were selected for competitive bidding in 2008 and are subject to the 9.5 percent payment reduction for 2009 is located in CR6270, Attachment A and identified in the charts below. Proper use of modifier KE will ensure appropriate payment amounts for those items and situations listed. Failure to use modifier KE as appropriate will result in a 9.5 percent reduction in payment for these items.
Important information for beneficiaries residing in CBAs on or after January 1, 2011:
Note that for beneficiaries living in competitive bid areas on or after January 1, 2011, the start of the Round 1 Rebid, suppliers were instructed not to use the KE modifier to identify competitively bid accessories that could be used with both a competitively bid base and a noncompetitively bid base. Instead, suppliers were instructed to use either the KG or the KK (whichever was appropriate) as indicated on the single payment amount public use charts found on the CBIC Web site. Refer to the section below for details regarding modifiers KK, KG, and their use.
Important information for beneficiaries residing in Round 2 (or subsequent Round) CBAs:
Also, note that the “KY” modifier should be used when billing for Round 2 (or subsequent Round) competitively bid wheelchair accessories used with certain noncompetitively bid wheelchair base units for beneficiaries residing in Round 2 (or subsequent Round) CBAs. Refer to the section below for details regarding the KY modifier and its use.
Note: Suppliers should not use the KE modifier on any claims for items that were included under Round 1 of competitive bidding such as an accessory for a standard or complex rehabilitative power wheelchair.
When billing a Column I accessory code for use with a base code in Column II, do not use modifier KE. When billing a Column I accessory code for use with a base code in Column III, use modifier KE.
|Column I: Accessory||Column II: Power Mobility Device Base (no Modifier KE)||Column III: Wheelchair Base (Modifier KE)|
|E0950, E0951, E0952, E0955, E0956, E0957, E0960, E0973, E0978, E0981, E0982, E0990, E0995, E1016, E1020, E1028, E2208, E2209, E2210, E2361, E2363, E2365, E2366, E2367, E2368, E2369, E2370, E2371, E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2394, E2395, E2396, E2601, E2602, E2603, E2604, E2605, E2606, E2607, E2608, E2611, E2612, E2613, E2614, E2615, E2616, E2619, E2620, E2621, K0015, K0017, K0018, K0019, K0020, K0037, K0038, K0039, K0040, K0041, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052, K0053, K0098, K0195, K0733, K0734, K0735, K0736, K0737||K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864||K0001, K0002, K0003, K0004, K0005, K0006, K0009, K0830, K0831, K0898, E1050, E1060, E1070, E1083, E1084, E1085, E1086, E1087, E1088, E1089, E1090, E1092, E1093, E1100, E1110, E1130, E1140, E1150, E1160, E1161, E1170, E1171, E1172, E1180, E1190, E1195, E1200, E1220, E1221, E1222, E1223, E1224, E1225, E1226, E1227, E1228, E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, E1239, E1240, E1250, E1260, E1270, E1280, E1285, E1290, E1295|
When billing a Column I accessory code used with a base code in Column II, do not use modifier KE. When billing a Column I accessory code used with a base code in Column III, use modifier KE.
|Column I: Accessory||Column II: Complex Rehab Base (no Modifier KE)||Column III: Wheelchair Base (Modifier KE)|
|E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1010, E1029, E1030, E2310, E2311, E2321, E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329, E2330, E2351, E2373 KC*, E2374, E2375, E2376, E2377||K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864||K0001, K0002, K0003, K0004, K0005, K0006, K0009, K0830, K0831, K0898, E1050, E1060, E1070, E1083, E1084, E1085, E1086, E1087, E1088, E1089, E1090, E1092, E1093, E1100, E1110, E1130, E1140, E1150, E1160, E1161, E1170, E1171, E1172, E1180, E1190, E1195, E1200, E1220, E1221, E1222, E1223, E1224, E1225, E1226, E1227, E1228, E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, E1239, E1240, E1250, E1260, E1270, E1280, E1285, E1290, E1295|
* When billing E2373 KC for use with a Column III wheelchair, use modifier KE in place of the KC pricing modifier.
When billing an IV pole for use with an enteral code in Column II, do not use the KE modifier; continue to use modifier BA. When billing the IV pole for use with a parenteral code in Column III, use modifier KE in place of modifier BA.
|Column I: IV Pole||Column II: Billed with Enteral Nutrition (no KE—only Modifier BA||Column III: Billed with Parenteral Nutrition
|E0776 BA||B4149, B4150, B4152, B4153, B4154, B4155||B4164, B4168, B4176, B4178, B4180, B4185, B4189, B4193, B4197, B4199, B4216, B4220, B4222, B4224, B5000, B5100, B5200|
When billing A7000 for use with a negative pressure wound therapy pump in Column II, do not use the KE modifier. When billing A7000 for use with a respiratory or gastric suction pump code in Column III, use modifier KE.
|Column I: Canister||Column II: Billed with NPWT (No KE Modifier)||Column III: Billed with Suction Pumps (KE Modifier)|
When billing replacement handgrips and tips for use with a walker code in Column II, do not use modifier KE. When billing replacement handgrips and tips for use with a cane or crutch code in Column III, use modifier KE.
|Column I: Handgrips and Tips||Column II: Billed with Walkers (no KE—only Modifier BA)||Column III: Billed with Canes or Crutches (Modifier KE)|
|A4636, A4637||E0130, E0135, E0140, E0141, E0143, E0144, E0147, E0148, E0149||E0100, E0105, E0110, E1111, E1112, E0114, E0116, E0117, E0118|
|L0430||Spinal Orthosis, anterior-posterior-lateral control, with interface material, custom fitted (DeWall Posture Protector only).|
The KG, KK, KU and KW modifiers are modifiers that identify when the same supply or accessory HCPCS code is furnished in multiple competitive bidding product categories or when the same code can be used to describe both competitively and noncompetitively bid items.
Note: Modifiers KK and KG are currently in effect, however, the KU and KW modifiers are reserved for use in future rounds of the competitive bid program.
All suppliers that submit claims for beneficiaries that live in a CBA, including contract, noncontract, and grandfathered suppliers, should submit claims for competitive bid items using the these competitive bidding modifiers. Noncontract suppliers that furnish competitively bid supply or accessory items to traveling beneficiaries who live in a CBA must use the appropriate KG or KK modifier with the supply or accessory HCPCS code when submitting their claim. Also, grandfathered suppliers that furnish competitively bid accessories or supplies used in conjunction with a grandfathered item must include the appropriate KG or KK modifier when submitting claims for accessory or supply codes.
The competitive bidding HCPCS codes and their corresponding competitive bidding modifiers (KG or KK) are denoted in the single payment amount public use charts found under the supplier page on the CBIC Web site. Suppliers should refer to the single payment amount charts to determine if the item requires the KK or KG modifier,
Below is a chart that illustrates the relationship between the competitive bid modifiers (KG, KK, KU, and KW) and the KE modifier using competitively bid accessory code E0950:
|Accessory Code E0950 used with a:||Base Code Competitive Bid Status||Claim for a Beneficiary who Permanently Lives in a CBA||Claim for a Beneficiary who Permanently Lives Outside a CBA*|
|Manual Wheelchair (K0001 thru K0009) or Miscellaneous Power Wheelchair (K0898)||Non- Bid||Bill with KE modifier||Bill with KE modifier|
|Standard Power Wheelchair (K0813 thru K0829)||Bid in Round 1 and the Round 1 Rebid||Bill with KG modifier||Bill without KE modifier|
|Complex Rehabilitative Group 2 Power Wheelchair (K0835 thru K0843)||Bid in Round 1 and the Round 1 Rebid||Bill with KK modifier||Bill without KE modifier|
|Complex Rehabilitative Group 3 Power Wheelchair (K0848 thru K0864)||Bid in Round 1||Bill without KE, KK or KG modifier||Bill without KEmodifier|
Modifier KY is effective for claims with dates of service on or after July 1, 2013. Suppliers use the “KY” modifier when billing for competitively bid (Round 2 or subsequent Round) wheelchair accessories used with certain noncompetitively bid wheelchair base units for beneficiaries residing in Round 2 (or subsequent Round) CBAs. The “KY” modifier is appended to accessory codes that are used with complex rehabilitative power wheelchair bases that are not Round 2 (or subsequent Round) competitive bid items, but were bid in Round 1 of the DMEPOS Competitive Bidding Program. Since Group 2 Power Wheelchairs K0835-K0843 and Group 3 Power Wheelchairs K0848-K0864 were not bid in Round 2, but were bid in Round 1, when a beneficiary resides in a Round 2 CBA the KY modifier must be appended to accessory codes used with those HCPCS.
See below for Round 2 accessory billing scenarios that are based on the types of wheelchair bases that the accessory is used with and the competitive bid status of the base unit.
|Accessory Code E0950 used with a:||Base Code Competitive Bid Status||Claim for a Beneficiary who Permanently Lives in a CBA||Payment Basis in CBA||Claim for a Beneficiary who Permanently Lives Outside a CBA||Payment Basis Outside CBA|
|Manual Wheelchair (K0001- K0004, K0006, K0007)||Bid in Round 2; (not bid in Round 1)||Bill without KE or KY modifier||Single Payment Amount (SPA)||Bill with KE modifier||Fee Schedule**|
|Standard Power Wheelchair (K0813 thru K0829)||Bid in Round 2 (bid in Round 1)||Bill without KE or KY modifier||SPA||Bill without KE modifier||Fee Schedule*|
|Complex Rehabilitative Group 2 Power Wheelchair (K0835 thru K0843) and Complex Rehabilitative Group 3 Power Wheelchair (K0848 thru K0864)||Not bid in Round 2 (bid in Round 1)||Bill with KY modifier||Fee Schedule*||Bill without KE modifier||Fee Schedule*|
|Manual Wheelchair (K0005, K0009) or Miscellaneous Power Wheelchair (K0898)||Not bid in Round 2 (not bid in Round 1)||Bill with KE modifier||Fee Schedule**||Bill with KE modifier||Fee Schedule**|
* Fee schedule amount includes the 9.5% reduction.
** Fee schedule amount includes the 5% covered item update increase
Capped rental modifiers are also considered secondary pricing modifiers and will follow all primary pricing modifiers (NU, RR, UE) applicable to the HCPCS code.
To determine if a capped rental modifier is needed, you must know the payment category of the item being billed. Review the section in this chapter titled “Determining the Payment Category“ to learn how to determine the payment category.
For monthly billing of capped rental items, you will be required to append pricing modifier RR (rental) to your claim along with the monthly modifiers KH, KI, KJ, KR, or MS as they relate to the months being billed.
|KH||DMEPOS item, initial claim, purchase or first month rental|
|KI||DMEPOS item, second and/or third month rental|
|KJ||DMEPOS item, PEN pump or capped rental items months four through thirteen/fifteen|
|KR||Rental item billing partial month|
|MS||Six months maintenance and servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warranty.|
The Medicare Program requires suppliers to give (beneficiaries entitled to certain items) the option of purchasing at the time they initially furnish an item. If the beneficiary elects to purchase items that qualify, Medicare will make payment on a lump sum purchase basis.
To notify the DME MAC of the beneficiary’s election to purchase or rent the item, the claims must be submitted with one of the following purchase option modifiers.
These purchase modifiers are only applicable for complex rehabilitative wheelchairs and PEN and EN pumps.
If a beneficiary opts to purchase the PEN pump at the time the pump was furnished, the supplier would bill the DME MAC with the pricing modifier (modifier NU or UE), modifier BP, and any additional modifiers that are required per the LCD.
If the beneficiary opts to rent the PEN pump at the time the pump was furnished, the supplier would bill the DME MAC with the pricing modifier (i.e., modifier RR), modifier BR, and any additional modifiers required per the LCD.
|BR||If the beneficiary decides to continue rental, Medicare will pay 15 months of rental payments.|
|BP||If the beneficiary decides to purchase the pump, Medicare will pay 13 months of rental payments.|
|BU||If the beneficiary is undecided (the supplier has not received notification from the beneficiary of their decision).|
If the beneficiary decides to purchase the pump after rental payments have been paid, the supplier would bill modifier BP in the month the beneficiary has requested to purchase the item.
Note: For additional details regarding payment for PEN, please reference the CMS Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 20, Section 30.7.1 (Payment for Parenteral and Enteral Pumps). (473 KB)
Effective for items provided on or after January 1, 2011, standard power wheelchairs (K0813 – K0831, K0898) must be furnished on a monthly rental basis like other capped rental DME. Therefore, for those items provided on or after January 1, 2011, it is no longer necessary to issue the Rent/Purchase option letter. Suppliers should not be appending the BP, BR, BU modifiers on claims for these items. However, for complex rehabilitative power-driven wheelchairs, Medicare will continue to permit payment to be made on a lump sum purchase method or a monthly rental method.
To determine the payment category of an item, review the Fee Schedule on the National Government Services Web site or the “Search DMECS for Codes and Fees” section of the Pricing, Data Analysis, and Coding (PDAC) contractor Web site.
The “CA” (Category) column on the National Government Services Fee Schedule will provide the payment category.
On the PDAC Web site, the payment category is found by following the steps below:
Once the payment category is determined, you will know if a pricing modifier is needed. The chart below provides each payment category and what pricing modifiers are needed (if any).
|Payment Category:||Pricing Modifiers Needed|
|Capped Rental||Primary and secondary pricing modifiers|
|Frequently Serviced||Always use RR modifier, no secondary pricing modifier|
|Inexpensive and Routinely Purchased||Primary pricing modifier only|
|Parenteral & Enteral||Primary and secondary pricing modifiers for pump only|
|Oxygen and Oxygen Equipment||Always use RR modifier, no secondary pricing modifier|
|Prosthetics & Orthotics||No pricing modifiers|
|Surgical Dressings||No pricing modifiers|
|Ostomy, Tracheostomy & Urologicals||No pricing modifiers|
|Supplies||No pricing modifiers|
|Therapeutic Shoes||No pricing modifiers|
|TENS||Primary pricing modifier for unit only|
Informational modifiers will follow all primary and secondary pricing modifiers applicable to the HCPCS code.
To determine if an informational modifier is needed, you must review the LCD and PA of the appropriate medical policy of the item being billed. The LCDs and PAs of all medical policies are located on the National Government Services Web site in the Medical Policy Center section. Be sure to review both, the actual LCD and PA of the item being billed.
Informational modifiers are used as a required means to communicate additional information about the beneficiary’s medical condition, documentation requirements and/or medical necessity of an item or service to the DME MAC.
In limited cases, informational modifiers are considered general and can be appended to any claim depending upon the beneficiary’s medical circumstance or condition. Informational modifiers may be policy specific and required when a specific DMEPOS item is provided and the coverage criteria for that item are met.
There are certain informational modifiers that are not outlined in the medical policy. These include the following:
We will provide details on each one of the modifiers mentioned above in the sections below.
An ABN is a written notice provided to the Medicare beneficiary when there is a reasonable expectation that Medicare will deny a claim due to Medical Necessity, unsolicited telephone contacts, the servicing supplier not having a provider transaction access number (PTAN), or the denial of an ADMC request.
It is the supplier’s responsibility to notify the beneficiary in writing before providing an item or service that is expected to be denied, so that the beneficiary understands they will be held responsible for payment. When an ABN is on file modifier GA must be appended to each HCPCS code it applies to. If the supplier opts to render the item or service to the beneficiary and not obtain an ABN, modifier GZ must be appended to each line item it applies to.
Any covered Medicare services not related to the treatment of the patient’s terminal condition for which hospice care was elected, and which is furnished during a hospice election period, may be billed by the supplier for nonhospice Medicare payment. These services are coded with modifier GW (Service not related to the hospice patient’s terminal condition) when submitted to the DME MAC. Claims will be processed in the normal manner for coverage and payment determinations. If warranted, the DME MAC may conduct prepayment development or postpayment review to validate that services billed with the GW modifier are not related to the patient's terminal condition.
Upgrades may be from one item to another within a single HCPCS code, or may be from one HCPCS code to another. The upgrade must be within the range of items or services that are medically appropriate for the beneficiary’s medical condition and the purpose of the physician’s order. In other words, if the physician orders a cane for the beneficiary, it cannot be upgraded to a wheelchair.
Use of an ABN to furnish an upgraded item or service does not change coverage or payment rules, statutory provisions or manual instructions for the item the beneficiary qualifies for.
Modifiers GK, GL and KB may be when an upgrade situation occurs.
Suppliers furnishing an upgrade and using an ABN must submit a claim and include information on the claim that identifies the upgrade feature. Suppliers must bill two line items for upgraded DMEPOS items where the beneficiary has requested an upgrade.
The first line item must be coded for the upgraded item the supplier actually provided. Remember that pricing modifiers should be appended to the HCPCS first, followed by any additional informational modifiers. If the supplier has obtained an ABN, modifier GA would be appended to the first line item.
The second line item must be coded for the item that is reasonable and necessary and modifier GK must be appended to this line item.If a suppliers opts to provide an upgrade without any additional charge to the beneficiary then an ABN is not required. In this situation, the claim must be coded using modifier GL.
If the physician has ordered the upgrade or if the upgrade is being provided without additional charge for supplier convenience, the supplier only bills the HCPCS code for the item that meets coverage criteria with a GL modifier. The HCPCS code for the upgraded item provided is not billed and the code with modifier GL will process in the Medicare system.
When the beneficiary requests an upgrade, an ABN has been properly executed, and more than four modifiers will be reported on the claim, the supplier must report modifier KB. When submitting a claim with the KB modifier, the supplier should first append the pricing modifier followed by the informational modifiers, ensuring that modifier KB is appended in the fourth modifier position. Any remaining modifier should be placed in Item 19 of the CMS 1500 for paper submitters or in the NTE segment for electronically submitted claims.
Medicare provisions will allow for the repair or replacement of medically required durable medical equipment. This includes equipment that may have been in place prior to the beneficiary being enrolled in the Medicare program.
For equipment being repaired, modifier RB must be used on the claim to indicate replacement parts of a DMEPOS item furnished as part of the service of repairing the DMEPOS item.
Replacement refers to the provision of an identical or nearly identical item. Beneficiary owned equipment or capped rental equipment may be replaced in cases of loss or irreparable damage. Irreparable damage refers to a specific accident or to a natural disaster.
For equipment being replaced due to loss or irreparable damagemodifier RA must be appended to the HCPCS.
According to the Centers for Medicare & Medicaid (CMS), Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Integrity Manual, Chapter 14, Section 20, FDA Approval Investigational Device Exemptions (IDE), (190 KB) the FDA assigns a special identifier number that corresponds to each device granted an investigational device exemption. Under the Food, Drug, and Cosmetic Act, devices are categorized into three classes:
Class I devices are the least regulated. These are devices that the FDA has determined need to be subject only to general controls, such as good manufacturing practice regulations.
Class II devices are those which, in addition to general controls, require special controls such as performance standards or postmarket surveillance, to assure safety and effectiveness.
Class III devices are those which cannot be classified into class I or class II because insufficient information exists to determine that either special or general controls, would provide reasonable assurance of safety and effectiveness. Class III devices require premarket approval.
The HCPCS codes for DME designated as class III devices by the FDA are identified on the DMEPOS fee schedule by the presence of modifier KF.
To determine if a device that is being billed is considered a class III, go to the FDA Web site.
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Modifier KB should be utilized by the supplier when the beneficiary has requested an upgrade, a properly executed Advance Beneficiary Notice of Noncoverage (ABN) is on file, and there will be more than four modifiers reported with the appropriate HCPCS code. The supplier should report modifier KB in the 4th modifier position (Item 24d on the CMS-1500 claim form) and any remaining modifiers should be placed in the abbr title="note">NTE segment for electronic claim submission or Item 19 on the CMS-1500 claim form.
Note: Even though the KB modifier definition states that an ABN is on file, suppliers are still required to append the GA modifier to hold the beneficiary liable for the charges.
Example: The supplier is submitting a claim with modifiers RR, KH, BR, LT, KX, and GA. The supplier should place modifiers RR, KH, BR, and KB on the claim line, and then report the additional modifiers LT, KX, and GA in the NTE segment for electronic claim submission, or Item 19 of the CMS-1500 claim form.
When submitting a claim which requires more than four modifiers, modifier 99 must be reported. Suppliers should place modifier 99 in the fourth position (Item 24d on the CMS-1500 claim form). Suppliers are required to place all modifiers in the NTE segment for electronic claim submission, or Item 19 on the CMS-1500 claim form.
Example: The supplier is submitting a claim with modifiers RR, KH, BR, LT, and KX. The supplier should place modifiers RR, KH, BR, and 99 on the claim line, then report all modifiers RR, KH, BR, LT, and KX in the NTE segment for electronic claim submission, or Item 19 of the CMS-1500 claim form.
If the item requires a primary pricing modifier along with a DMEPOS Competitive Bidding Program secondary pricing modifier KE, KG, KK, KU, KW, or KY, the primary pricing modifier should be placed in the first position following the HCPCS code and the KE modifier should be placed in the second position.
If the item also requires a secondary pricing modifier/capped rental modifier (KH, KI, KJ, KR, MS, BR, BP or BU), it would be placed in the third position followed by any subsequent informational modifiers.
If the item requires a KX modifier we suggest the KX modifier be placed on the claim line. However, if the claim line necessitates the use of more than four modifiers, the 99 modifier must be placed in the fourth two-digit position. Suppliers should then list all of the modifiers in Item 19 for hardcopy claims or in the NTE segment for electronic claims. The modifiers should be listed first before any other narrative information and should not include any spaces.
In situations where more than 4 modifiers are required, the beneficiary requests an upgrade, and suppliers have properly executed an ABN, suppliers must append the KB modifier. When submitting a claim with the KB modifier, the supplier should first place the pricing modifier(s), followed by informational modifiers, and then place the KB modifier in the fourth modifier position. Any remaining modifiers should be placed in Item 19 for paper submitted claims or in the NTE segment for electronically submitted claims.
Note: Electronic submitters should verify that the HCPCS and modifiers are transmitted electronically in upper case. Suppliers should contact their software vendor, billing service or clearinghouse if they are unsure whether the information is transmitted using upper case letters. If the HCPCS and/or the modifiers are transmitted in lower case, the electronic trading partner will receive the C172 edit on the electronic GenResponse Report they receive from CEDI.
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The PDAC Contractor is a national entity that provides services under contract for CMS. Noridian Administrative Services, LLC has been contracted by the CMS to serve as the PDAC.
The PDAC provides data analysis support to the four DME MACs, and guidance to manufacturers and suppliers on the proper use of the HCPCS, the means by which DMEPOS services are identified for Medicare billing. Additionally, the PDAC performs a variety of national pricing functions for DMEPOS services, assists CMS with the DMEPOS fee schedules, and analyzes DMEPOS fees to identify unreasonable or excessive reimbursement amounts.
Manufacturers and suppliers should contact the PDAC HCPCS Unit to obtain proper billing codes for DMEPOS items. In addition to coding assistance, manufacturers and suppliers may also obtain fee schedule prices.
A function of the PDAC is to help determine the appropriate HCPCS code to use when submitting claims to Medicare. A HCPCS code identifies the DMEPOS being billed.
P.O. Box 6757
Fargo, North Dakota 58108-6757
8:30 a.m.–4:00 p.m. central time
Additional information is available on the PDAC Web site.
The DMECS provides HCPCS coding assistance and national pricing information via searches for:
The DMECS is available through the PDAC (Noridian Administrative Services) and provides coding assistance to the public that is reflective of DME MAC policies and guidelines. DMECS is designed to assist the public with the coding of DMEPOS products for submission to the DME MAC.
DMECS currently has four interactive components that work together to provide HCPCS coding information. Once on the PDAC Web site, choose “Search DMECS for codes and fees” to obtain search capabilities for the following:
DMECS is available on the PDAC Web site.
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