Skip to Main Content
 
 
 
Web Content Viewer

Claim Submission Articles

Web Content Viewer
Web Content Viewer

2011 Healthcare Common Procedure Coding System Code Update—Revised

The following list identifies changes to level II HCPCS codes for 2011. Please refer to Change Request (CR) 7300, CR 7064 and CR 7121 on the CMS Web site for additional information.

Added Codes/Added Modifiers

New codes and modifiers are effective for dates of service on or after 1/1/2011.

Discontinued Codes/Deleted Modifiers

Codes or modifiers that are discontinued/deleted will continue to be valid for claims with dates of service on or before 12/31/2010, regardless of the date of claim submission. If there is a direct crosswalk for a discontinued/deleted code or modifier, it is listed in the table. The crosswalked codes are also “added” codes effective for dates of service on or after 1/1/2011.

Narrative Changes/Revised Modifiers

A description change for an existing code or modifier is effective for dates of service on or after 1/1/2011.

The appearance of a code in this list does not necessarily indicate coverage.

Ankle-Foot/Knee-Ankle-Foot Orthoses

Added Code

Code Narrative
L4631 ANKLE FOOT ORTHOSIS, WALKING BOOT TYPE, VARUS/VALGUS CORRECTION, ROCKER BOTTOM, ANTERIOR TIBIAL SHELL, SOFT INTERFACE, CUSTOM ARCH SUPPORT, PLASTIC OR OTHER MATERIAL, INCLUDES STRAPS AND CLOSURES, CUSTOM FABRICATED

Enteral Nutrition

Narrative Changes

Code Old Narrative New Narrative
B4034 ENTERAL FEEDING SUPPLY KIT; SYRINGE FED, PER DAY ENTERAL FEEDING SUPPLY KIT; SYRINGE FED, PER DAY, INCLUDES BUT NOT LIMITED TO FEEDING/FLUSHING SYRINGE, ADMINISTRATION SET TUBING, DRESSINGS, TAPE
B4035 ENTERAL FEEDING SUPPLY KIT; PUMP FED, PER DAY ENTERAL FEEDING SUPPLY KIT; PUMP FED, PER DAY, INCLUDES BUT NOT LIMITED TO FEEDING/FLUSHING SYRINGE, ADMINISTRATION SET TUBING, DRESSINGS, TAPE
B4036 ENTERAL FEEDING SUPPLY KIT; GRAVITY FED, PER DAY ENTERAL FEEDING SUPPLY KIT; GRAVITY FED, PER DAY, INCLUDES BUT NOT LIMITED TO FEEDING/FLUSHING SYRINGE, ADMINISTRATION SET TUBING, DRESSINGS, TAPE

External Infusion Pumps

Added Code

Code Narrative
J1559 INJECTION, IMMUNE GLOBULIN (HIZENTRA), 100 MG

Discontinued Code

Code Narrative Crosswalk to Code
J9110 INJECTION, CYTARABINE, 500 MG J9100
J9375 VINCRISTINE SULFATE, 2 MG J9370
J9380 VINCRISTINE SULFATE, 5 MG J9370

Home Dialysis Supplies and Equipment

Invalid for Submission to DME MAC

Code Narrative
A4651 CALIBRATED MICROCAPILLARY TUBE, EACH
A4652 MICROCAPILLARY TUBE SEALANT
A4653 PERITONEAL DIALYSIS CATHETER ANCHORING DEVICE, BELT, EACH
A4671 DISPOSABLE CYCLER SET USED WITH CYCLER DIALYSIS MACHINE, EACH
A4672 DRAINAGE EXTENSION LINE, STERILE, FOR DIALYSIS, EACH
A4673 EXTENSION LINE WITH EASY LOCK CONNECTORS, USED WITH DIALYSIS
A4674 CHEMICALS/ANTISEPTICS SOLUTION USED TO CLEAN/STERILIZE DIALYSIS EQUIPMENT, PER 8 OZ
A4680 ACTIVATED CARBON FILTER FOR HEMODIALYSIS, EACH
A4690 DIALYZER (ARTIFICIAL KIDNEYS), ALL TYPES, ALL SIZES, FOR HEMODIALYSIS, EACH
A4706 BICARBONATE CONCENTRATE, SOLUTION, FOR HEMODIALYSIS, PER GALLON
A4707 BICARBONATE CONCENTRATE, POWDER, FOR HEMODIALYSIS, PER PACKET
A4708 ACETATE CONCENTRATE SOLUTION, FOR HEMODIALYSIS, PER GALLON
A4709 ACID CONCENTRATE, SOLUTION, FOR HEMODIALYSIS, PER GALLON
A4714 TREATED WATER (DEIONIZED, DISTILLED, OR REVERSE OSMOSIS) FOR PERITONEAL DIALYSIS, PER GALLON
A4719 "Y SET" TUBING FOR PERITONEAL DIALYSIS
A4720 DIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID VOLUME GREATER THAN 249CC, BUT LESS THAN OR EQUAL TO 999CC, FOR PERITONEAL DIALYSIS
A4721 DIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID VOLUME GREATER THAN 999CC BUT LESS THAN OR EQUAL TO 1999CC, FOR PERITONEAL DIALYSIS
A4722 DIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID VOLUME GREATER THAN 1999CC BUT LESS THAN OR EQUAL TO 2999CC, FOR PERITONEAL DIALYSIS
A4723 DIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID VOLUME GREATER THAN 2999CC BUT LESS THAN OR EQUAL TO 3999CC, FOR PERITONEAL DIALYSIS
A4724 DIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID VOLUME GREATER THAN 3999CC BUT LESS THAN OR EQUAL TO 4999CC, FOR PERITONEAL DIALYSIS
A4725 DIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID VOLUME GREATER THAN 4999CC BUT LESS THAN OR EQUAL TO 5999CC, FOR PERITONEAL DIALYSIS
A4726 DIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID VOLUME GREATER THAN 5999CC, FOR PERITONEAL DIALYSIS
A4728 DIALYSATE SOLUTION, NON-DEXTROSE CONTAINING, 500 ML
A4730 FISTULA CANNULATION SET FOR HEMODIALYSIS, EACH
A4736 TOPICAL ANESTHETIC, FOR DIALYSIS, PER GRAM
A4737 INJECTABLE ANESTHETIC, FOR DIALYSIS, PER 10 ML
A4740 SHUNT ACCESSORY, FOR HEMODIALYSIS, ANY TYPE, EACH
A4750 BLOOD TUBING, ARTERIAL OR VENOUS, FOR HEMODIALYSIS, EACH
A4755 BLOOD TUBING, ARTERIAL AND VENOUS COMBINED, FOR HEMODIALYSIS, EACH
A4760 DIALYSATE SOLUTION TEST KIT, FOR PERITONEAL DIALYSIS, ANY TYPE, EACH
A4765 DIALYSATE CONCENTRATE, POWDER, ADDITIVE FOR PERITONEAL DIALYSIS, PER PACKET
A4766 DIALYSATE CONCENTRATE, SOLUTION, ADDITIVE FOR PERITONEAL DIALYSIS, PER 10 ML
A4770 BLOOD COLLECTION TUBE, VACUUM, FOR DIALYSIS, PER 50
A4771 SERUM CLOTTING TIME TUBE, FOR DIALYSIS, PER 50
A4772 BLOOD GLUCOSE TEST STRIPS, FOR DIALYSIS, PER 50
A4773 OCCULT BLOOD TEST STRIPS, FOR DIALYSIS, PER 50
A4774 AMMONIA TEST STRIPS, FOR DIALYSIS, PER 50
A4802 PROTAMINE SULFATE, FOR HEMODIALYSIS, PER 50 MG
A4860 DISPOSABLE CATHETER TIPS FOR PERITONEAL DIALYSIS, PER 10
A4870 PLUMBING AND/OR ELECTRICAL WORK FOR HOME HEMODIALYSIS EQUIPMENT
A4890 CONTRACTS, REPAIR AND MAINTENANCE, FOR HEMODIALYSIS EQUIPMENT
A4911 DRAIN BAG/BOTTLE, FOR DIALYSIS, EACH
A4913 MISCELLANEOUS DIALYSIS SUPPLIES, NOT OTHERWISE SPECIFIED
A4918 VENOUS PRESSURE CLAMP, FOR HEMODIALYSIS, EACH
A4928 SURGICAL MASK, PER 20
A4929 TOURNIQUET FOR DIALYSIS, EACH
E1500 CENTRIFUGE, FOR DIALYSIS
E1510 KIDNEY, DIALYSATE DELIVERY SYST. KIDNEY MACHINE, PUMP RECIRCULAT- ING, AIR REMOVAL SYST, FLOWRATE METER, POWER OFF, HEATER AND TEMPERATURE CONTROL WITH ALARM, I.V.POLES, PRESSURE GAUGE, CONCENTRATE CONTAINER
E1520 HEPARIN INFUSION PUMP FOR HEMODIALYSIS
E1530 AIR BUBBLE DETECTOR FOR HEMODIALYSIS, EACH, REPLACEMENT
E1540 PRESSURE ALARM FOR HEMODIALYSIS, EACH, REPLACEMENT
E1550 BATH CONDUCTIVITY METER FOR HEMODIALYSIS, EACH
E1560 BLOOD LEAK DETECTOR FOR HEMODIALYSIS, EACH, REPLACEMENT
E1570 ADJUSTABLE CHAIR, FOR ESRD PATIENTS
E1575 TRANSDUCER PROTECTORS/FLUID BARRIERS, FOR HEMODIALYSIS, ANY SIZE, PER 10
E1580 UNIPUNCTURE CONTROL SYSTEM FOR HEMODIALYSIS
E1590 HEMODIALYSIS MACHINE
E1592 AUTOMATIC INTERMITTENT PERITIONEAL DIALYSIS SYSTEM
E1594 CYCLER DIALYSIS MACHINE FOR PERITONEAL DIALYSIS
E1600 DELIVERY AND/OR INSTALLATION CHARGES FOR HEMODIALYSIS EQUIPMENT
E1610 REVERSE OSMOSIS WATER PURIFICATION SYSTEM, FOR HEMODIALYSIS
E1615 DEIONIZER WATER PURIFICATION SYSTEM, FOR HEMODIALYSIS
E1620 BLOOD PUMP FOR HEMODIALYSIS, REPLACEMENT
E1625 WATER SOFTENING SYSTEM, FOR HEMODIALYSIS
E1630 RECIPROCATING PERITONEAL DIALYSIS SYSTEM
E1632 WEARABLE ARTIFICIAL KIDNEY, EACH
E1634 PERITONEAL DIALYSIS CLAMPS, EACH
E1635 COMPACT (PORTABLE) TRAVEL HEMODIALYZER SYSTEM
E1636 SORBENT CARTRIDGES, FOR HEMODIALYSIS, PER 10
E1637 HEMOSTATS, EACH
E1699 DIALYSIS EQUIPMENT, NOT OTHERWISE SPECIFIED

Intravenous Immune Globulin

Added Code

Code Narrative
J1599 INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E.G. LIQUID), NOT OTHERWISE SPECIFIED, 500 MG

Lower Limb Prostheses

Added Code

Code Narrative
L5961 ADDITION, ENDOSKELETAL SYSTEM, POLYCENTRIC HIP JOINT, PNEUMATIC OR HYDRAULIC CONTROL, ROTATION CONTROL, WITH OR WITHOUT FLEXION AND/OR EXTENSION CONTROL

Mechanical In-Exsufflation Devices

Added Code

Code Narrative
A7020 INTERFACE FOR COUGH STIMULATING DEVICE, INCLUDES ALL COMPONENTS, REPLACEMENT ONLY

Miscellaneous

Added Code

Code Narrative
A4566 SHOULDER SLING OR VEST DESIGN, ABDUCTION RESTRAINER, WITH OR WITHOUT SWATHE CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT (Note: Noncovered; No benefit category)
A9273 HOT WATER BOTTLE, ICE CAP OR COLLAR, HEAT AND/OR COLD WRAP, ANY TYPE (Note: Noncovered; No benefit category)
E1831 STATIC PROGRESSIVE STRETCH TOE DEVICE, EXTENSION AND/OR FLEXION, WITH OR WITHOUT RANGE OF MOTION ADJUSTMENT, INCLUDES ALL COMPONENTS AND ACCESSORIES
L3674 SHOULDER ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN), THORACIC COMPONENT AND SUPPORT BAR, WITH OR WITHOUT NONTORSION JOINT/TURNBUCKLE, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT

Narrative Changes

Code Old Narrative New Narrative
L3671 SHOULDER ORTHOSIS, SHOULDER CAP DESIGN, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT SHOULDER ORTHOSIS, SHOULDER JOINT DESIGN, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT
L3677 SHOULDER ORTHOSIS, HARD PLASTIC, SHOULDER STABILIZER, PRE-FABRICATED, INCLUDES FITTING AND ADJUSTMENT SHOULDER ORTHOSIS, SHOULDER JOINT DESIGN, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

Discontinued Code

Code Narrative Crosswalk to Code
E0220 HOT WATER BOTTLE A9273
E0230 ICE CAP OR COLLAR A9273
E0238 NON-ELECTRIC HEAT PAD, MOIST A9273
L3672 SHOULDER ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN), THORACIC COMPONENT AND SUPPORT BAR, WITHOUT JOINTS, MAY INLCUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT L3674
L3673 SHOULDER ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN), THORACIC COMPONENT AND SUPPORT BAR, INCLUDES NONTORSION JOINT/TURNBUCKLE, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT L3674

Nebulizers

Added Code

Code Narrative
J7686 TREPROSTINIL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 1.74 MG

Narrative Changes

Code Old Narrative New Narrative
A7013 FILTER, DISPOSABLE, USED WITH AEROSOL COMPRESSOR FILTER, DISPOSABLE, USED WITH AEROSOL COMPRESSOR OR ULTRASONIC GENERATOR

Ostomy Supplies

Narrative Changes

Code Old Narrative New Narrative
A4399 OSTOMY IRRIGATION SUPPLY; CONE/CATHETER, INCLUDING BRUSH OSTOMY IRRIGATION SUPPLY; CONE/CATHETER, WITH OR WITHOUT BRUSH

Oxygen

Added Code

Code Narrative
E0446 TOPICAL OXYGEN DELIVERY SYSTEM, NOT OTHERWISE SPECIFIED, INCLUDES ALL SUPPLIES AND ACCESSORIES (Note: Denied as not medically necessary; National Coverage Determination 20.29[C])

Surgical Dressings

Narrative Changes

Code Old Narrative New Narrative
A6011 COLLAGEN BASED WOUND FILLER, GEL/PASTE, STERILE, PER GRAM OF COLLAGEN COLLAGEN BASED WOUND FILLER, GEL/PASTE, PER GRAM OF COLLAGEN
A6248 HYDROGEL DRESSING, WOUND FILLER, GEL, STERILE, PER FLUID OUNCE HYDROGEL DRESSING, WOUND FILLER, GEL, PER FLUID OUNCE
A6260 WOUND CLEANSERS, STERILE, ANY TYPE, ANY SIZE WOUND CLEANSERS, ANY TYPE, ANY SIZE
A6261 WOUND FILLER, GEL/PASTE, STERILE, PER FLUID OUNCE, NOT OTHERWISE SPECIFIED WOUND FILLER, GEL/PASTE, PER FLUID OUNCE, NOT OTHERWISE SPECIFIED
A6262 WOUND FILLER, DRY FORM, STERILE, PER GRAM, NOT OTHERWISE SPECIFIED WOUND FILLER, DRY FORM, PER GRAM, NOT OTHERWISE SPECIFIED

Urological Supplies

Narrative Changes

Code Old Narrative New Narrative
A5112 URINARY LEG BAG; LATEX URINARY DRAINAGE BAG, LEG OR ABDOMEN, LATEX, WITH OR WITHOUT TUBE, WITH STRAPS, EACH

Wheelchair Seating

Added Code

Code Narrative
E2622 SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES, ANY DEPTH
E2623 SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22 INCHES OR GREATER, ANY DEPTH
E2624 SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES, ANY DEPTH
E2625 SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22 INCHES OR GREATER, ANY DEPTH

Discontinued Code

Code Narrative Crosswalk to Code
K0734 SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES, ANY DEPTH E2622
K0735 SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22 INCHES OR GREATER, ANY DEPTH E2623
K0736 SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES, ANY DEPTH E2624
K0737 SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22 INCHES OR GREATER, ANY DEPTH E2625

Modifiers

Added Code

Code Narrative
AY ITEM OR SERVICE FURNISHED TO AN ESRD PATIENT THAT IS NOT FOR THE TREATMENT OF ESRD
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 Note: This modifier was effective as of April 20, 2010.
GU WAIVER OF LIABILITY STATEMENT ISSUED AS REQUIRED BY PAYER POLICY, ROUTINE NOTICE
NB NEBULIZER SYSTEM, ANY TYPE, FDA-CLEARED FOR USE WITH SPECIFIC DRUG

Narrative Changes

Code Old Narrative New Narrative
GA WAIVER OF LIABILITY STATEMENT ON FILE WAIVER OF LIABILITY STATEMENT ISSUED AS REQUIRED BY PAYER POLICY, INDIVIDUAL CASE

HCPCS Code Update—2012

The following list identifies changes to level II Healthcare Common Procedure Coding System (HCPCS) codes for 2012.

Added Codes/Added Modifiers: New codes and modifiers are effective for dates of service on or after January 1, 2012.

Discontinued Codes/Deleted Modifiers: Codes or modifiers that are discontinued/deleted will continue to be valid for claims with dates of service on or before December 31, 2011, regardless of the date of claim submission. If there is a direct crosswalk for a discontinued/deleted code or modifier, it is listed in the table. The crosswalked codes are also “added” codes effective for dates of service on or after January 1, 2012.

There is no grace period that would allow submission of the discontinued code for dates of service in 2012.

Narrative Changes/Revised Modifiers: A description change for an existing code or modifier is effective for dates of service on or after January 1, 2012.

The appearance of a code in this list does not necessarily indicate coverage.

Ankle-Foot/Knee-Ankle-Foot Orthosis

Narrative Changes

Code Old Narrative New Narrative
L2005 Knee ankle foot orthosis, any material, single or double upright, stance control, automatic lock and swing phase release, mechanical activation, includes ankle joint, any type, custom fabricated Knee ankle foot orthosis, any material, single or double upright, stance control, automatic lock and swing phase release, any type activation, includes ankle joint, any type, custom fabricated

Immunosuppressive Drugs

Added Codes

Code Narrative
J8561 Everolimus, oral, 0.25 MG

Intravenous Immune globulin

Added Codes

Code Narrative
J1557 Injection, immune globulin, (gammaplex), intravenous, non-lyophilized (e.g. liquid), 500 MG

Narrative Changes

Code Old Narrative New Narrative
J1561 Injection, immune globulin, (gamunex), intravenous, non-lyophilized (e.g. liquid), 500 MG Injection, immune globulin, (gamunex/gamunex-c/gammaked), non-lyophilized (e.g. liquid), 500 MG

Lower Limb Prostheses

Added Codes

Code Narrative
L5312 Knee disarticulation (or through knee), molded socket, single axis knee, pylon, sach foot, endoskeletal system

Discontinued Code

Code Narrative Crosswalk to Code
L5311 Knee disarticulation (or through knee), molded socket, external knee joints, shin, sach foot, endoskeletal system L5312

Miscellaneous

Added Codes

Code Narrative
A9272 Mechanical wound suction, disposable, includes dressing, all accessories and components, each
L6715 Terminal device, multiple articulating digit, includes motor(s), initial issue or replacement
L6880 Electric hand, switch or myolelectric controlled, independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s)

Narrative Changes

Code Old Narrative New Narrative
E0638 Standing frame system, one position (e.g. upright, supine or prone stander), any size including pediatric, with or without wheels Standing frame/table system, one position (e.g. upright, supine or prone stander), any size including pediatric, with or without wheels
E0641 Standing frame system, multi-position (e.g. Three-way stander), any size including pediatric, with or without wheels Standing frame/table system, multi-position (e.g. Three-way stander), any size including pediatric, with or without wheels
E0642 Standing frame system, mobile (dynamic stander), any size including pediatric Standing frame/table system, mobile (dynamic stander), any size including pediatric
E0691 Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; treatment area 2 square feet or less Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection; treatment area 2 square feet or less
L6000 Partial hand, robin-aids, thumb remaining (or equal) Partial hand, thumb remaining
L0610 Partial hand, robin-aids, little and/or ring finger remaining (or equal) Partial hand, little and/or ring finger remaining
L0620 Partial hand, robin-aids, no finger remaining (or equal) Partial hand, no finger remaining
L7368 Lithium ion battery charger Lithium ion battery charger, replacement only

Discontinued Code

Code Narrative Crosswalk to Code
L1500 Thoracic-hip-knee-ankle orthosis (THKAO), mobility frame (newington, parapodium types) None
L1510 THKAO, standing frame, with or without tray and accessories None
L1520 THKAO, swivel walker None
L4380 Pneumatic knee splint, prefabricated, includes fitting and adjustment None
L7266 Servo control, steeper or equal None
L7272 Analogue control, unb or equal None
L7274 Proportional control, 6-12 volt, liberty, utah or equal None
L7500 Repair of prosthetic device, hourly rate (excludes V5335 repair of oral or laryngeal prosthesis or artificial larynx) None

Oral Antiemetic Drugs

Added Codes

Code Narrative
Q0162 Ondansetron 1 mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen

Discontinued Code

Code Narrative Crosswalk to Code
Q0179 Ondansetron hydrochloride 8 mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen Q0162

Ostomy Supplies

Added Codes

Code Narrative
A5056 Ostomy pouch, drainable, with extended wear barrier attached, with filter, (1 piece), each
A5057 Ostomy pouch, drainable, with extended wear barrier attached, with built in convexity, with filter, (1 piece), each

Power Mobility Devices

Added Codes

Code Narrative
E2358 Power wheelchair accessory, group 34 non-sealed lead acid battery, each
E2359 Power wheelchair accessory, group 34 sealed lead acid battery, each (e.g. gel cell, absorbed glassmat)

Wheelchair Options/Accessories

Added Codes

Code Narrative
E0988 Manual wheelchair accessory, lever-activated, wheel drive, pair
E2626 Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable
E2627 Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable rancho type
E2628 Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, reclining
E2629 Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, friction arm support (friction dampening to proximal and distal joints)
E2630 Wheelchair accessory, shoulder elbow, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke type suspension support
E2631 Wheelchair accessory, addition to mobile arm support, elevating proximal arm
E2632 Wheelchair accessory, addition to mobile arm support, offset or lateral rocker arm with elastic balance control
E2633 Wheelchair accessory, addition to mobile arm support, supinator

Discontinued Codes

Code Narrative Crosswalk to Code
L3964 Shoulder elbow orthosis, mobile arm support attached to wheelchair, balanced, adjustable, prefabricated, includes fitting and adjustment E2626
L3965 Shoulder elbow orthosis, mobile arm support attached to wheelchair, balanced, adjustable rancho type, prefabricated, includes fitting and adjustment E2627
L3966 Shoulder elbow orthosis, mobile arm support attached to wheelchair, balanced, reclining, prefabricated, includes fitting and adjustment E2628
L3968 Shoulder elbow orthosis, mobile arm support attached to wheelchair, balanced, friction arm support (friction dampening to proximal and distal joints), prefabricated, includes fitting and adjustment E2629
L3969 Shoulder elbow orthosis, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke type suspension support, prefabricated, includes fitting and adjustment E2630
L3970 SEO, addition to mobile arm support, elevating proximal arm E2631
L3972 SEO, addition to mobile arm support, offset or lateral rocker arm with elastic balance control E2632
L3974 SEO, addition to mobile arm support, supinator E2633

Reference: Pricing, Data Analysis, and Coding Contractor

2013 HCPCS Code Update

The following list identifies changes to level II HCPCS codes for 2013.

Added Codes/Added Modifiers: New codes and modifiers are effective for dates of service on or after 1/1/2013.

Discontinued Codes/Deleted Modifiers: Codes or modifiers that are discontinued/deleted will continue to be valid for claims with dates of service on or before 12/31/2012, regardless of the date of claim submission. If there is a direct crosswalk for a discontinued/deleted code or modifier, it is listed in the table. The crosswalked codes are also “added” codes effective for dates of service on or after 1/1/2013.

There is no grace period that would allow submission of the discontinued code for dates of service in 2013.

Narrative Changes/Revised Modifiers: A description change for an existing code or modifier is effective for dates of service on or after 1/1/2013.

Note: The appearance of a code in this list does not necessarily indicate coverage.

External Breast Prostheses

Narrative Changes

Code Old Narrative New Narrative
L8000 BREAST PROSTHESIS, MASTECTOMY BRA BREAST PROSTHESIS, MASTECTOMY BRA, WITHOUT INTEGRATED BREAST PROSTHESIS FORM, ANY SIZE, ANY TYPE
L8001 BREAST PROSTHESIS, MASTECTOMY BRA, WITH INTEGRATED BREAST PROSTHESIS FORM, UNILATERAL BREAST PROSTHESIS, MASTECTOMY BRA, WITH INTEGRATED BREAST PROSTHESIS FORM, UNILATERAL, ANY SIZE, ANY TYPE
L8002 BREAST PROSTHESIS, MASTECTOMY BRA, WITH INTEGRATED BREAST PROSTHESIS FORM,BILATERAL BREAST PROSTHESIS, MASTECTOMY BRA, WITH INTEGRATED BREAST PROSTHESIS FORM, BILATERAL, ANY SIZE, ANY TYPE

Hospital Beds and Accessories

Narrative Changes

Code Old Narrative New Narrative
E0300 PEDIATRIC CRIB, HOSPITAL GRADE, FULLY ENCLOSED PEDIATRIC CRIB, HOSPITAL GRADE, FULLY ENCLOSED, WITH OR WITHOUT TOP ENCLOSURE

Immunosuppressive Drugs

Discontinued Code

Code Narrative Crosswalk to Code
J8561 EVEROLIMUS, ORAL, 0. 25 MG J7527

Added Code

Code Narrative
J7527 EVEROLIMUS, ORAL, 0. 25 MG

Impotence Aid

Added Code

Code Narrative
L7902 TENSION RING, FOR VACUUM ERECTION DEVICE, ANY TYPE, REPLACEMENT ONLY, EACH

Intravenous Immune Globulin

Narrative Changes

Code Old Narrative New Narrative
J1561 INJECTION, IMMUNE GLOBULIN, (GAMUNEX/GAMUNEX-C/GAMMAKED), NON-LYOPHILIZED LIQUID), 500 MG INJECTION, IMMUNE GLOBULIN, (GAMUNEX-C/GAMMAKED), NON-LYOPHILIZED (E. G. LIQUID), 500 MG
J1569 INJECTION, IMMUNE GLOBULIN, (GAMMAGARD LIQUID), INTRAVENOUS, NON-LYOPHILIZED, (E.G. LIQUID), 500 MG INJECTION, IMMUNE GLOBULIN, (GAMMAGARD LIQUID), NON-LYOPHILIZED, (E. G. LIQUID), 500 MG

Lower Limb Prostheses

Added Code

Code Narrative
L5859 ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, POWERED AND PROGRAMMABLE FLEXION/EXTENSION ASSIST CONTROL, INCLUDES ANY TYPE MOTOR(S)

Narrative Changes

Code Old Narrative New Narrative
L5972 ALL LOWER EXTREMITY PROSTHESES, FLEXIBLE KEEL FOOT (SAFE, STEN, BOCK DYNAMIC OREQUAL) ALL LOWER EXTREMITY PROSTHESES, FOOT, FLEXIBLE KEEL

Ostomy Supplies

Added Code

Code Narrative
A4435 OSTOMY POUCH, DRAINABLE, HIGH OUTPUT, WITH EXTENDED WEAR BARRIER (ONE-PIECE SYSTEM), WITH OR WITHOUT FILTER, EACH

Oxygen and Oxygen Equipment

Discontinued Code

Code Narrative Crosswalk to Code
K0741 PORTABLE GASEOUS OXYGEN SYSTEM, RENTAL, INCLUDES PORTABLE CONTAINER, REGULATOR, FLOWMETER, HUMIDIFIER, CANNULA OR MASK, AND TUBING, FOR CLUSTER HEADACHES NONE
K0742 PORTABLE OXYGEN CONTENTS, GASEOUS, 1 MONTH'S SUPPLY = 1 UNIT, FOR CLUSTER HEADACHES, FOR INITIAL MONTHS SUPPLY OR TO REPLACE USED CONTENTS NONE

Pneumatic Compression Devices

Added Code

Code Narrative
E0670 SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, INTEGRATED, 2 FULL LEGS AND TRUNK

Surgical Dressings

Narrative Changes

Code Old Narrative New Narrative
A6021 COLLAGEN DRESSING, STERILE, PAD SIZE 16 SQ. IN. OR LESS, EACH COLLAGEN DRESSING, STERILE, SIZE 16 SQ. IN. OR LESS, EACH
A6022 COLLAGEN DRESSING, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., EACH COLLAGEN DRESSING, STERILE, SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN. , EACH
A6023 COLLAGEN DRESSING, STERILE, PAD SIZE MORE THAN 48 SQ. IN., EACH COLLAGEN DRESSING, STERILE, SIZE MORE THAN 48 SQ. IN. , EACH

Wheelchair Options/Accessories

Added Code

Code Narrative
E2378 POWER WHEELCHAIR COMPONENT, ACTUATOR, REPLACEMENT ONLY

Narrative Changes

Code Old Narrative New Narrative
E1020 RESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCHAIR RESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCHAIR, ANY TYPE
E2368 POWER WHEELCHAIR COMPONENT, MOTOR, REPLACEMENT ONLY POWER WHEELCHAIR COMPONENT, DRIVE WHEEL MOTOR, REPLACEMENT ONLY
E2369 POWER WHEELCHAIR COMPONENT, GEAR BOX, REPLACEMENT ONLY POWER WHEELCHAIR COMPONENT, DRIVE WHEEL GEAR BOX, REPLACEMENT ONLY
E2370 POWER WHEELCHAIR COMPONENT, MOTOR AND GEAR BOX COMBINATION, REPLACEMENT ONLY POWER WHEELCHAIR COMPONENT, INTEGRATED DRIVE WHEEL MOTOR AND GEAR BOX COMBINATION, REPLACEMENT ONLY

2016 HCPCS Code Update

Joint DME MAC Publication

The following tables identify changes to Level II HCPCS codes for 2016. The tables contain only the 2016 HCPCS codes that are applicable to items that fall within Medicare DME MAC jurisdiction. There may be other HCPCS code changes for items under the jurisdiction of other Medicare contractors. Consult with those contractors for information regarding HCPCS codes that fall within their areas of responsibility.

All HCPCS code changes are effective for claims with dates of service on or after 1/1/2016.

Code Change Categories

Added Codes/Added Modifiers: These are new codes and modifiers.

Discontinued Codes/Deleted Modifiers: These are codes and modifiers that are discontinued /deleted. These codes and modifiers continue to be valid for Medicare claims with dates of service on or before 12/31/2015.

If there is a direct crosswalk for a discontinued/deleted code or modifier, the crosswalk code is listed in the table. The crosswalked codes are effective for claims with dates of service on or after 1/1/2016.

There is no grace period that allows for submission of a discontinued code/modifier for claims with dates of service in 2016.

Narrative Changes/Revised Modifiers: These are changes in the narrative descriptor for an existing code or modifier.

For products not listed on the DMECS Product Classification Lists, suppliers should evaluate whether a revised narrative changes their coding choices.

For questions about correct coding, contact the PDAC Contact Center at 877-735-1326 during the hours of 8:30 a.m. to 4:00 p.m. CT, Monday through Friday, or e-mail the PDAC by completing the DME PDAC Contact Form located on the PDAC website.

Code Tables

The appearance of a code in the tables below does not necessarily indicate coverage. Refer to the applicable Local Coverage Determination for information regarding Medicare reimbursement requirements.

Ankle-Foot/Knee-Ankle-Foot Orthosis

Narrative Changes

Code Old Narrative New Narrative
L1902 Ankle foot orthosis, ankle gauntlet, prefabricated, off-the-shelf Ankle orthosis, ankle gauntlet or similiar, with or without joints, prefabricated, off-the-shelf
L1904 Ankle orthosis, ankle gauntlet, custom-fabricated Ankle orthosis, ankle gauntlet or similiar, with or without joints, custom fabricated

Bowel Management

Added Code

Code Narrative
A4337 Incontinence supply, rectal insert, any type, each

External Infusion Pumps

Added Code

Code Narrative
J7340 Carbidopa 5 mg/levodopa 20 MG enteral suspension
J9039 Injection, blinatumomab, 1 microgram
J1575 Injection, immune globulin/hyaluronidase, (hyqvia), 100 MG immuneglobulin

Immunosuppressive Drugs

Added Code

Code Narrative
J7503 Tacrolimus, extended release, (envarsus xr), oral, 0.25 MG
J7512 Prednisone, immediate release or delayed release, oral, 1 MG

Narrative Changes

Code Old Narrative New Narrative

J7508

Tacrolimus, extended release, oral, 0.1 MG

Tacrolimus, extended release, (astagraf XL), oral, 0.1 MG

Discontinued Code

Code Narrative Crosswalk to Code
J7506 Prednisone, oral, per 5 MG J7512

Miscellaneous

Added Code

Code Narrative
J7999 Compounded drug, not otherwise classified

Discontinued Code

Code Narrative Crosswalk to Code
Q9977 Compounded drug, not otherwise classified J7999 

Nebulizers

Discontinued Code

Code Narrative Crosswalk to Code
A7011 Corrugated tubing, non-disposable, used with large volume nebulizer, 10 feet None

Oral Antiemetic Drugs

Added Code

Code Narrative
J8655 Netupitant 300 MG and palonosetron 0.5 MG

Discontinued Code

Code Narrative Crosswalk to Code
Q9978 Netupitant 300 mg and palonosetron 0.5 MG J8655

Parenteral Nutrition

Narrative Changes

Code Old Narrative New Narrative
B5000 Parenteral nutrition solution:  compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, renal - amirosyn RF, nephramine, renamine - premix Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, renal-aminosyn-RF, nephramine, renamine-premix
B5100 Parenteral nutrition solution: compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, hepatic - freamine HBC, hepatamine - premix Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, hepatic, hepatamine-premix
B5200 Parenteral nutrition solution:  compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, stress - branch chain amino acids - premix Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, stress-branch chain amino acids-freamine-HBC-premix

Ventilators

Added Code

Code Narrative
E0465 Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube)
E0466 Home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell)

Discontinued Code

Code Narrative Crosswalk to Code
E0450 Volume control ventilator, without pressure support mode, may include pressure control mode, used with invasive interface (e.g., tracheostomy tube) E0465
E0460 Negative pressure ventilator; portable or stationary E0466
E0461 Volume control ventilator, without pressure support mode, may include pressure control mode, used with noninvasive interface (e.g., mask) E0466
E0463 Pressure support ventilator with volume control mode, may include pressure control mode, used with invasive interface (e.g., tracheostomy tube) E0465
E0464 Pressure support ventilator with volume control mode, may include pressure control mode, used with non-invasive interface (e.g., mask) E0466

Wheelchair Options/Accessories

Added Code

Code Narrative
E1012 Wheelchair accessory, addition to power seating system, center mount power elevating leg rest/platform, complete system, any type, each

Narrative Changes

Code Old Narrative New Narrative
K0017 Detachable, adjustable height armrest, base, each Detachable, adjustable height armrest, base, replacement only, each
K0018 Detachable, adjustable height armrest, upper portion, each Detachable, adjustable height armrest, upper portion, replacement only, each

Related Content

Posted 12/3/2015

Appropriate Modifiers for Incomplete or Lack of Orders

Suppliers may dispense most of DMEPOS items based on a dispensing order from the treating physician. However, some DMEPOS items require a WOPD from the treating physician prior to dispensing the DMEPOS item. Dispensing an item without a valid dispensing order or WOPD will impact the billing to Medicare for reimbursement.

Modifier EY is required to be appended on a claim when a supplier does not have a valid dispensing order or a valid DWO/WOPD. Reporting this modifier indicates to Medicare that suppliers did not have a valid order. The EY modifier does not assign financial liability.

Suppliers will need to properly execute an ABN in order to hold the beneficiary liable for items that will deny as “not medically necessary” when a DWO/WOPD is not received prior to dispensing or does not contain all required components. Properly executing an ABN requires the ABN to be completed, signed and dated by the beneficiary or their designee prior to dispensing the DMEPOS item. If this is completed, modifier GA should be appended on the claim. If an ABN is not properly executed, modifier GZ should be appended on the claim.

In instances where items are “noncovered” or “statutorily excluded/statutory requirement”, an ABN is not required to hold the beneficiary financially liable for the items. As a courtesy to the beneficiary, the supplier may choose to issue the ABN as a voluntary notice. However, when an ABN is issued as a voluntary notice, modifier GA should not be included on the claim line. Modifier GY would be appropriate to use in this situation.

WOPDs

For the following items, there is a statutory requirement for a WOPD:

  • Items subject to Section 6407 of the Affordable Care Act
    • Requires the NPI, a date stamp or equivalent, along with other required components of WOPD
  • NPWT
  • Power mobility devices
  • Wheelchair options and accessories (for power wheelchairs only)
  • Pressure reducing support surfaces (Group I, II, III)
  • Seat lift mechanisms
  • TENS
  • Wheelchair seating

Therefore, for the items listed above, the supplier must have received a WOPD prior to dispensing the item. If the supplier did not receive a WOPD or the WOPD does not contain all required components, the supplier must append modifier EY to the claim to identify a WOPD was not received prior to dispensing. Since this is a statutory requirement, modifier GY would also be appended.

Dispensing/DWOs

For all other items, if the supplier does not have a valid dispensing order prior to dispensing the item, the supplier must append modifier EY on the claim. Since this is a statutory requirement, modifier GY would also be appended.

A statutory requirement for a DWO prior to claim submission exists for the following items:

  • Oral anticancer drugs
  • Oral antiemetic drugs (replacement for intravenous antiemetics)
  • Therapeutic shoes for diabetics

Therefore, the supplier must have a DWO prior to submitting the claim to Medicare for the items list above. If the supplier does not have a DWO prior to claim submission, the supplier must append modifier EY on the claim. Since this is a statutory requirement, modifier GY would also be appended.

For all other items not listed above, suppliers are able to dispense with a dispensing order, however, they are required to obtain a valid DWO prior to claim submission. If the supplier bills for an item without obtaining a valid DWO, the item will be denied as not reasonable and necessary. The supplier must append modifier EY to the claim along with modifier GA or modifier GZ to identify a valid DWO was not received. Suppliers may only report modifier GA if the ABN was properly executed at the time the DMEPOS item was dispensed. If the ABN was not properly executed, suppliers must report modifier GZ. 

Separate claims are required for noncovered/statutorily excluded/statutory requirement items and not medically necessary/reimbursable items.

Refer to Chapter 8 for dispensing orders, DWOs, and WOPDs and Chapter 10 for completion of ABNs of the JB Supplier Manual.

Related Content

Billing Clarification: KX and GA Modifier on Same Claim Line

National Government Services, the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC), has received numerous questions related to the use of the KX and GA modifiers on the same claim line.

Last fall the DME MACs began updating local coverage determinations (LCDs) that include instructions for use of the KX modifier to incorporate additional instructions for the use of the GA, GZ, or GY modifiers. The DME MACs implemented system edits that will reject a claim line if the supplier does not indicate the beneficiary either meets or does not meet the requirements that are specified in each medical policy. The contractors use the presence of a GA, GZ, or GY modifier as an indication that coverage criteria are not met.

In most cases suppliers must append the KX modifier to a Healthcare Common Procedure Coding System (HCPCS) code only if all of the coverage criteria outlined in the Indications and Limitations Coverage section of the applicable LCD have been met. However, the KX modifier has a different definition depending on the LCD. For example, instructions within the LCD for Glucose Monitors indicate the KX modifier must be appended to the HCPCS code for the blood glucose monitor and each related supply on every claim submitted only if the patient is being treated with insulin injections.

The GA modifier indicates the supplier believes the provided item is expected to be denied as not reasonable and necessary and that an Advance Beneficiary Notice of Noncoverage (ABN) has been properly executed. Therefore, in most cases it would not be appropriate to append the GA and KX modifiers on the same claim line as they are contradictory.

Examples of when it would be appropriate to append both the GA and KX on the same claim line include but are not limited to the following:

  • Over utilization of blood glucose testing supplies for an insulin dependent diabetic patient
  • Over utilization of urological supplies for a patient who has permanent urinary incontinence or urinary retention

Same and Similar

Medicare does not pay separately for backup equipment or items that are deemed to be same or similar to equipment that is already in use as they are considered not reasonable and necessary.

If the supplier has evidence to believe that Medicare will not pay for an item because the patient already has or has had same/similar equipment which has not met the reasonable useful lifetime expectancy, an ABN should be executed to inform the Medicare beneficiary of the expected denial and his/her financial liability for the item.

It would not be appropriate to execute an ABN simply because you are unable to determine, or you believe the beneficiary may have had or has same/similar equipment. This would be considered a generic ABN. Such generic ABNs are not considered to be acceptable, as the ABN must clearly specify the service and a genuine reason that denial by Medicare is expected.

Scenario One

Joe Smith, a Medicare beneficiary arrives at ABC Supplier’s store with a prescription from his doctor for a manual wheelchair. ABC Supplier checks the interactive voice response (IVR) system prior to dispensing a manual wheelchair to Joe Smith and determines that Medicare previously paid another supplier 13 rental payments for a manual wheelchair, less than five years ago. Therefore, ABC Supplier advises Joe Smith that Medicare is likely to deny this manual wheelchair as not reasonable and necessary because it is considered same/similar equipment. Joe Smith indicates that he wants the new wheelchair and is willing to be held financially responsible. Therefore, ABC Supplier properly executes an ABN. In this scenario, it would be appropriate for ABC Supplier to submit a claim for the manual wheelchair with both the KX and GA modifier appended to the manual wheelchair HCPCS code and receive a patient responsibility denial from Medicare.

Scenario Two

Jane Smith, a Medicare beneficiary arrives at ABC Supplier’s store with a prescription from her doctor for a manual wheelchair. ABC Supplier checks the IVR prior to dispensing the manual wheelchair to Jane Smith and the IVR does not indicate any same/similar equipment on file. ABC Supplier asks Jane during the intake process if she has ever had a wheelchair before. Jane indicates that several years ago she broke her leg and used a wheelchair but she doesn’t remember when or if Medicare paid for it. She also doesn’t know what happened to the wheelchair. Therefore, ABC Supplier advises Ms. Smith that Medicare may deny the wheelchair. Therefore, because the supplier is unsure they execute an ABN just in case. In this scenario, it would not be appropriate for ABC Supplier to submit a claim for the manual wheelchair with both the KX and GA modifier appended to the HCPCS code and receive a patient responsibility denial.

Resources

To obtain more information regarding the proper use of the KX, GA, GZ, or GY modifiers, suppliers should refer to the revised LCDs located on the Coverage > Medical Policy Center section of the National Government Services Web site.

For additional information regarding how to properly complete and execute an ABN, suppliers should refer to the Jurisdiction B DME MAC Supplier Manual, Chapter 10.

Suppliers can obtain additional education on ABNs by completing the Advance Beneficiary Notice computer-based training (CBT) course available through Medicare University on the National Government Services Web site.

Billing for Tape Codes (A4450 and A4452) and Modifiers (AU, AV and AW)

Policy specific informational modifiers can be located in the local medical policies. When submitting claims that require policy specific informational modifiers, suppliers must be mindful of the coverage criteria that may be tied to the policy specific modifiers.

By submitting these types of modifiers suppliers are indicating to the durable medical equipment Medicare administrative contractor DME MAC criteria regarding the code at issue have been met. Suppliers are encouraged to review the local medical policies in their entirety to ensure that all documentation requirements are met prior to submitting a claim to the Medicare program for payment.

Tape codes identified as A4450 and A4452 are routinely denied as a noncovered supply when the tape is not used in conjunction with another covered benefit. For items such as surgical dressings, ostomy, tracheostomy or urological supplies, or prosthetic or orthotic devices, Medicare will make a separate payment for tape when it is furnished in conjunction with any of these services.

Suppliers are reminded that the following modifiers must be appended to tape codes A4450 and A4452 when the tape is being furnished with one of the corresponding items:

  • AU -  Items furnished in conjunction with a ostomy, tracheostomy or urological supply
  • AV -  Items furnished in conjunction with a prosthetic device, prosthetic or orthotics
  • AW - Items furnished in conjunction with a surgical dressing

Failure to append the appropriate AU, AV, or AW modifier to Healthcare Common Procedure Coding System (HCPCS) codes A4450 or A4452 will result in the denial of claim. Payment for tape is based on the presence of aforementioned modifiers.

For additional information regarding payment and coverage of tape, please review the local medical policies located in the Medical Policy Center.

For additional information regarding the Medicare fee schedule allowance for tape, please visit the Pricing, Data Analysis, and Coding Contractor’s (PDAC) Website

Billing for Temporary Replacement for Patient Owned Equipment Being Repaired

Due to recent supplier inquires, National Government Services, the Jurisdiction B DME MAC would like to remind suppliers about the proper billing of temporary replacement equipment.

The description for HCPCS code K0462 is temporary replacement for patient owned equipment being repaired, any type. Medicare covers temporary replacement equipment when repair of medically necessary patient owned equipment takes longer than one day.

Medicare does not allow a separate payment for repairs to capped rental items during a rental period or repairs to DMEPOS items covered under a manufacturer or supplier warranty. Furthermore, routine periodic servicing, such as testing, cleaning, regulating, and checking of the beneficiary’s equipment, is not covered. It is reasonable to expect that beneficiaries will perform this maintenance. Therefore, if while repairing the beneficiary owned equipment routine periodic servicing is also performed and that is the reason for the repair taking longer than one day, temporary loaner equipment is not justified and will be denied.

There are multiple reasons why repair of patient owned equipment may take longer than one day. Some of those reasons include ordering parts to repair the equipment that the supplier does not have in stock. However, it is expected that suppliers who are in the business of repairing patient owned equipment would have frequently replaced parts (i.e., batteries, battery chargers, tires, nuts, bolts, etc.) in stock. Repairs might also take longer than one day if the equipment needs to be sent out to the manufacturer to make the repairs, or if multiple repairs need to be made which take longer than one day to complete.

Temporary loaner equipment (K0462) does not require any modifiers but must be submitted on the same claim as the claim for repairs (labor and parts) and the claim must contain the following information:

  • The HCPCS code of the equipment being repaired, 
  • The HCPCS code of the equipment being provided as a temporary replacement
  • A detailed description of what was repaired
  • A narrative explanation as to why the repair took longer than one day

This information should be reported in Item 19 of the CMS-1500 paper claim for or the note (NTE) segment of the electronic claim for electronic submitters.

There is a limit of 80 character spaces in the line note, so suppliers should abbreviate when possible. View the Suggested Abbreviation List for Submitting Narrative Information article for more details.

Suggested Abbreviation List for Submitting Narrative Information

Example: Medicare beneficiary’s power mobility device (K0823) required repairs. The motor, joystick and batteries needed to be replaced. The supplier had the batteries in stock but did not have the motor or joystick. They were ordered from the manufacturer resulting in the repair taking longer than one day.

NTE segment or Item 19:  K0823K0823110109RPLBATTERIESJOYSTICK&MOTOR RPR>THAN1DAYPARTSORDEREDFROMMFG

Generally, the repairs listed in the chart below should not take more than one day and the payment of temporary loaner equipment (K0462) would not be justified unless there are extenuating circumstances.

Type of Equipment Part Being Repaired/Replaced Allowed Units of Service (UOS)
Power Wheelchair Batteries (includes cleaning and testing) 2
Power Wheelchair Charger 2
Power or Manual Wheelchair Wheel/Tire (all types, per wheel) 1
Power or Manual Wheelchair Armrest or armpad 1
Manual Wheelchair Anti-tipping device 1
Hospital Bed Pendant 2
Hospital Bed Headboard/footboard 2

Claim Completion Requirements for Facility Location (Item 32)

When a supplier submits a claim for DMEPOS provided in a location other than the beneficiary’s home (POS 12), the supplier must enter in Item 32, Facility Location, the name and address of the location where the order was accepted.

For example, if a beneficiary received a shipment of supplies while in an inpatient Part B SNF stay, the supplier would indicate the name and address of the SNF in Item 32 as follows:

ABC SNF
123 Somewhere Street
Anywhere, OH 41111

Reminder: New Facility Location Requirement

When the beneficiary has a representative payee or date of death on file, the supplier must enter the state and five-digit ZIP code in which the beneficiary resides. This information must be entered in Item 32, Facility Name, for all CMS 1500 claims submitted to the DME MAC. When claims are submitted electronically using ANSI 837 4010A1, the information is reported in loop 2310D.

For all NCPDP claims, when the POS is other than 12, the facility location is required in Item 32 or its electronic equivalent.

When a beneficiary has a representative payee or date of death on file, and the above information is not reported in the Facility Location, the claim will be returned/rejected for correction.

Claims Processing Change for Modifiers GA, GZ, and GY

Many medical policies (i.e., local coverage determination [LCD] and related policy article) require the presence of a KX, GA, GZ, or GY modifier to indicate whether the coverage criteria outlined within that policy are or are not met and whether an Advance Beneficiary Notice of Noncoverage (ABN) has or has not been properly executed. Following are the modifiers and their definitions:

  • KX - Requirements specified in the medical policy have been met
  • 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)
  • GY -Item or service statutorily excluded or does not meet the definition of any Medicare benefit

When the medical policy requires the use of these modifiers for a specific item(s), the claim line(s) will be rejected if the supplier does not include the appropriate modifier on the claim line according to the guidelines specified in the LCD. If a claim line is rejected, the supplier may resubmit the claim line with the appropriate modifier.

Suppliers are reminded that the GA, GZ, and/or GY may not be reported on the same claim line. Additionally, it is inappropriate to report both the GY and KX on the same claim line. Suppliers must select the appropriate modifier according to the guidelines outlined within the medical policy. Effective with claims received on or after May 1, 2011, claim lines containing more than one of these modifiers, GA, GZ, GY, will be rejected. When a claim line is rejected, the supplier may resubmit the claim line with the appropriate modifier.

The following are examples of inappropriate modifier combinations:

  • E0570NUKXGY
  • E0636NUGAGY
  • E0250RRGAGZ

Guidance on the Use of the KX, GA, GZ, and GY Modifiers

Modifier KX

The KX modifier serves as an attestation by the supplier that the requirements for its use that are defined in the particular LCD are true for that specific beneficiary. As the description of the KX modifier indicates, requirements for its use vary from policy to policy.

Suppliers append the KX modifier, only when all the requirements for its use have been met, as specified in the medical policy. Adding the KX modifier without ascertaining that all the requirements specified in the policy have been met could be viewed as filing a false claim and potential abuse of the Medicare Program. Penalties for violating the Federal False Claims Act can be up to three times the value of the False Claim, plus from $5,500 to $11,000 in fines, per claim. 

It is imperative that suppliers review the documentation requirements section of each LCD in order to fully understand the criteria that must be met for the proper use of the KX modifier. Obtaining physician records, test reports, and other documents is the best means of assuring that all of the information needed to support use of the KX modifier is present in the event of an audit.

Modifier GA

When an item or service that is provided to a Medicare beneficiary does not meet the coverage criteria outlined in the medical policy, it is the responsibility of the supplier to notify the beneficiary in writing through the use of the ABN before the item or service is delivered or purchased. When the supplier issues a properly executed ABN and obtains the beneficiary’s consent, the supplier must submit the claim to Medicare appending modifier GA to each Healthcare Common Procedural Coding System (HCPCS) code that is expected to be denied. Modifier GA indicates the supplier has a waiver of liability statement on file. Modifier GA must not be appended to the claim line if the supplier did not properly execute an ABN.

Modifier GZ

When an item or service that is provided to a Medicare beneficiary does not meet the coverage criteria outlined in the medical policy, the supplier must notify the beneficiary in writing through the use of the ABN before the item or service is delivered or purchased. If the supplier did not properly execute an ABN to notify the beneficiary of the expected denial, the supplier must append the GZ modifier to the claim line.

Modifier GY

The GY modifier indicates that an item or service is statutorily excluded or does not meet the definition of any Medicare benefit. Some LCDs require the use of modifier GY to indicate when an item or service may be excluded from coverage in a specific situation. Suppliers are instructed to code the claim with the appropriate HCPCS code indicated in the medical policy and append the GY modifier. Some examples of statutory exclusions where the GY modifier is required per policy include:

  • Dressings used in noncovered situations, such as, wound cleaning  
  • A wheelchair that is for use for mobility outside the home

Suppliers must review the applicable medical policy for the item or service being provided to determine when it is appropriate to append modifier GY.

Suppliers may access local coverage determinations and their related policy articles on the National Government Services Web site.

Correct Coding – MyoPro® (Myomo, Inc.) Assist Device

Joint DME MAC/PDAC Publication

The DME MACs have evaluated the MyoPro® upper extremity assist device and determined that it falls within the DME benefit category. Claims for MyoPro® should be submitted using the DME miscellaneous code E1399.

Suppliers are reminded that when submitting claims for items coded E1399, the supplier must include the following information:

  • Manufacturer name
  • Model name or number
  • Pricing information
  • Explanation of medical necessity

This information must be entered in the narrative field of an electronic claim (NTE 2300 or NTE 2400 of an electronic claim) or Item 19 of a paper claim.

This item is classified under the capped-rental payment methodology as it does not meet the requirements to be categorized as an inexpensive or routinely purchased item.

For questions about correct coding, contact the PDAC Contact Center at 877-735-1326 during the hours of 8:30 a.m. to 4:00 p.m. CT, Monday through Friday, or email the PDAC by completing the DME PDAC Contact Form.

Correct Coding – Buzzy®

Joint DME MAC Publication

The Buzzy® (MMJ Labs) is a palm-sized vibrating bee with a removable ice pack and center slot for an optional tourniquet. Per the manufacturer, when placed proximal to a painful procedure, the combination of cold and vibration block transmission of sharp pain. The device also buzzes like a bee, which provides an auditory distraction. The Buzzy Deluxe Kit includes: neoprene Cold-to-Go Tote, Buzzy® and Bee Stractors™ (distraction device), a velcro strap, two AAA batteries, a set of Blue Gel Wings and two White Ice Wings for longer procedures. Frozen inserts are also included to keep the bag and the frozen wings cold. Buzzy’s housing is composed of durable GE Lexan polycarbonate material and may be cleaned with germicidal disposable wipes.

Claims for the Buzzy® billed to the DME MAC must be coded with HCPCS code A9270 (Noncovered item or service) and will be denied as statutorily noncovered (no benefit).

For questions about correct coding, contact the PDAC Contact Center at 877-735-1326 during the hours of 8:30 a.m. to 4 p.m. CT, Monday through Friday, or email the PDAC by completing the DME PDAC Contact Form located on the PDAC website.

Posted 11/5/2015

Correct Coding – Face Down Positioning Devices

Joint DME MAC Publication

This article was originally published in 2003 and is being republished as a reminder to suppliers on the correct coding and coverage of these devices.

Following vitrectomy and certain other eye surgery procedures, patients are instructed to position themselves with their face down through most of the day. There are certain devices that facilitate this positioning. Examples (not all-inclusive) are a face cushion that is attached to a frame that can rest on a table or be positioned on a bed, or a cushion pad that is attached to a chair-like device.

The CMS has confirmed that these devices are statutorily noncovered because they do not fall within a Medicare benefit category. These types of devices are considered “precautionary devices” and also can be used for purposes other than the treatment of an illness or injury. The denial is a coverage denial, not a medical necessity denial.

For dates of service prior to 1/1/2004, the face cushion and frame should be coded A9270 (Noncovered item or service). For dates of service on or after 1/1/2004, code E0190 (Positioning cushion/pillow/wedge, any shape or size) must be used. For all dates of service, the chair-like device should be coded as A9270.

For questions about correct coding, contact the PDAC Contact Center at 877-735-1326 during the hours of 8:30 a.m. to 4:00 p.m. central time, Monday through Friday, or email the PDAC by completing the DME PDAC Contact Form located on the PDAC website.

Revised on 12/17/2015

Correct Coding – JW Modifier Use – Revised – Effective for Claims with Dates of Service On or After 1/1/2017

Joint DME MAC Publication

Revised 6/16/2016 to reflect change in Effective Date
Revised 5/19/2016
Posted 9/16/2010

The CMS recently issued updated guidance on the billing of drug wastage to require use of the JW modifier (drug amount discarded/not administered to any patient). For the DME MACs, the JW modifier only applies to the following LCDs:

These LCDs will be updated to include the JW modifier requirements. Required use of the JW modifier is effective for claims with DOS on or after 1/1/2017.

The CMS Internet-Only Manual Publication 100-04, Medicare Claims Processing Manual, Chapter 17, Section 40 contains information on the use of the JW modifier for discarded drugs and biologicals. The Medicare Program provides payment for the amount of a single use vial or other single use package of drug or biological discarded, in addition to the dose administered, up to the amount of the drug or biological. There are two scenarios that can occur:

Scenario 1

When the HCPCS code UOS is less than the drug quantity contained in the single use vial or single dose package, the following applies:

  • The quantity administered is billed on one claim line without the JW modifier, and
  • The quantity discarded is billed on a separate claim line with the JW modifier.

In this scenario, the JW modifier must be billed on a separate line to provide payment for the amount of discarded drug or biological. For example:

  • A single use vial is labeled to contain 100 mg of a drug.
  • The drug’s HCPCS code UOS is 1 UOS = 1 mg.
  • 95 mg of the 100 mg in the vial are administered to the beneficiary.
  • 5 mg remaining in the vial are discarded.
  • The 95 mg dose is billed on one claim line as 95 UOS.
  • The discarded 5 mg is billed as 5 UOS on a separate claim line with the JW modifier.
  • Both claim line items would be processed for payment.

Scenario 2

When the 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. For example:

  • A single use vial is labeled to contain 100 mg of a drug.
  • The drug’s HCPCS code UOS is 1 UOS = 100 mg.
  • 70 mg of the 100 mg in the vial are administered to the beneficiary.
  • 30 mg remaining in the vial are discarded.
  • The 70 mg dose is billed correctly by rounding up to one UOS (representing the entire 100 mg vial) on a single line item.
  • The single line item of 1 UOS would be processed for payment of the combined total 100 mg of administered and discarded drug.
  • The discarded 30 mg must not be billed as another 1 UOS on a separate line item with the JW modifier. Billing an additional 1 UOS for the discarded drug with the JW modifier is incorrect billing and will result in an overpayment.

Multi-use vials are not subject to payment for discarded amounts of drug or biological.

Claims for drugs billed to Medicare must use drug dosage formulations and/or unit dose sizes that minimize wastage. Providers and suppliers are expected to use drugs or biologicals most efficiently, in a clinically appropriate manner. Only when the most efficient combination of dosage forms are used and there is drug remaining may a supplier bill the discarded amount using the JW modifier on the claim line for the UOS not administered to the patient. Because of the HCPCS code descriptors and the associated UOS for DMEPOS items, the DME MACs expect rare use of the JW modifier on claims.

The JW modifier is used in conjunction with other modifiers listed in the applicable LCDs. For example, suppliers must add a JW modifier to codes for nebulizer drugs, in conjunction with the KX modifier, only if all of the criteria in the “Coverage Indications, Limitations and/or Medical Necessity” section of the nebulizer LCD have been met.

Correct Coding – P-stim® Device

Joint DME MAC Publication

Recently the DME MAC contractors have received inquiries about the P-stim® auricular stimulation device (Biegler GmbH). The P-stim® is a miniaturized electro-acupuncture device for use in the practice of acupuncture by qualified practitioners of acupuncture. It provides auriculo-point stimulation treatment over several days. This item is not reimbursable by Medicare. Claims submitted to the DME MACs for the P-stim® device must be coded A9270 (Noncovered item or service).

For questions about coding verification reviews and correct coding, contact the PDAC Contact Center at 877-735-1326 during the hours of 8:30 a.m. to 4:00 p.m. CT, Monday through Friday, or email the PDAC by completing the DME PDAC Contact Form located on the PDAC website.

Correct Coding – Powered Exoskeleton Products

DME MAC Joint Publication

Recently several products described as powered exoskeletons have been developed. These items are reported to support mobility for spinal cord injured beneficiaries who are unable to ambulate. These products are principally provided for supervised use in rehabilitation settings. Currently there are two FDA-approved products, Rewalk™ (Argo Technologies) and Indego® (Parker Hannifin Corp.). Other similar products are in development but are not yet on the market in the United States. These devices provide a powered lower limb exoskeleton enabling beneficiaries who are nonambulatory due to spinal cord injuries to ambulate with the assistance of a cane, crutches or a walker under direct supervision and thus participate in over-ground gait training.

Although these products resemble “orthoses”, for Medicare HCPCS coding purposes, brace-like products that exert a powered force across a joint are not coded as orthoses with HCPCS “L” codes but rather are coded using other HCPCS codes. Equipment used in institutional rehabilitation settings is statutorily excluded from reimbursement under the DME benefit. Claims submitted to the DME MACs for a powered exoskeleton must use HCPCS code:

  • A9270 – Noncovered item or service

This code describes the entire product provided at initial issue. A complete, functional product must be provided at initial issue. Use of other HCPCS codes to bill for the entire items or for separate components, options, accessories and/or supplies is considered incorrect coding.

For questions about correct coding, contact the PDAC contractor Contact Center at 877-735-1326 during the hours of 8:30 a.m.–4 p.m. central time, Monday through Friday, or email the PDAC.

Correct Coding – TOBI® Podhaler™

Joint DME MAC Publication

The TOBI® Podhaler™ (Novartis) is a disposable, hand-held medication dispenser used for the inhalation of tobramycin. This device is not a hand-held nebulizer with a pneumatic compressor and thus is not eligible for reimbursement under the Medicare durable medical equipment benefit. The TOBI® Podhaler™ is provided as a complete system that includes both the inhaler and tobramycin capsules. Claims for the TOBI® Podhaler™ billed to the DME MAC must be coded with HCPCS code A9270 (Noncovered item or service) and will be denied as statutorily noncovered (no benefit).

HCPCS code J7682 (Tobramycin, Inhalation Solution, FDA-Approved Final Product, Non-Compounded, Unit Dose Form, Administered Through DME, Per 300 Milligrams) must not be used to bill  separately for the tobramycin capsules provided for use in a TOBI® Podhaler™. Separate billing for the TOBI® Podhaler™ device and tobramycin capsules will be denied as unbundling.

For questions about correct coding, contact the PDAC Contact Center at 877-735-1326 during the hours of 8:30 a.m. to 4 p.m. CT, Monday through Friday, or email the PDAC by completing the DME PDAC Contact Form located on the PDAC website.

Correct Coding and Coverage - Peristeen® Transanal Irrigation System

Joint DME MAC Publication

The Peristeen® transanal irrigation  system is a device used to empty the lower bowel and to prevent chronic constipation and fecal incontinence or simply as a method of bowel management. The system consists of an enema bag, a rectal catheter with an inflatable balloon and a pump. Effective for claims with dates of service on or after 1/1/2015 the correct code to bill is:

A4459 – Manual pump enema system, includes balloon, catheter and all accessories, reusable, any type

There is no Medicare benefit for this device; therefore, claims for code A4459 will be denied as noncovered (no Medicare benefit).

Code A4459 is an all-inclusive code at initial issue. Separate billing of any of the individual components is not allowed. The code is established as a single code to include all parts including the disposable supplies at initial issue. For refills of disposable supplies such as rectal catheters, HCPCS code A9270 (Noncovered item or service) should be used.

For questions about correct coding, contact the Pricing Data Analysis and Contractor Contact Center at (877) 735-1326 during the hours of 8:30 a.m. to 4:00 p.m. CT, Monday through Friday, or email the PDAC by completing the DME PDAC Contact Form located on the PDAC website.

Related Content

Correct Coding – Diathermy and Biofeedback Devices

Joint DME MAC Publication

Recently HCPCS coding verification reviews have been received for both diathermy and biofeedback devices used as part of inpatient or outpatient facility therapy but that are subsequently given to the beneficiary for use in the home. These items do not meet the payment requirements to be reimbursed as DME.

Diathermy and biofeedback therapies are addressed separately by NCD; NCD 150.5 for “Diathermy Treatment” and NCD 30.1 for “Biofeedback Therapy”. Both of these services are coded using current procedural terminology (CPT) Codes. The equipment used in association with the provision of these services falls under the jurisdiction of the Medicare A/B MAC. All diathermy and biofeedback devices are considered not separately billable to the DME MACs under the DME Benefit.

The PDAC will assign the coding determination, “NO HCPCS CODE ASSIGNED” to diathermy and biofeedback devices submitted for review. A comment stating “NOT BILLABLE TO THE DME MACS” will be added to each diathermy and biofeedback device posted on the DMECS Product Classification List.

Devices not reviewed or not listed on DMECS must not be billed to the DME MAC. Claims submitted to the DME MACs for diathermy and biofeedback devices will be denied as wrong jurisdiction.

Manufacturers, distributors and suppliers should consult the Medicare A/B MAC contractor for correct billing of these devices.

For questions about coding verification reviews and correct coding, contact the PDAC Contact Center at 877-735-1326 during the hours of 8:30 a.m. to 4:00 p.m. CT, Monday through Friday, or e-mail the PDAC by completing the DME PDAC Contact Form located on the PDAC website.

Correct Coding: Modifiers AU, AV and AW

Joint DME MAC Publication

HCPCS modifiers have been established for use when items are furnished in conjunction with various supplies listed in multiple DME MAC LCDs and related PAs. These modifiers are effective for DOS on or after 1/1/2003 and claims submitted without the appropriate modifiers are currently denied as noncovered. Effective for dates of service on or after 8/1/2015, claims submitted without the appropriate modifier will be rejected as missing information. The modifier narratives are:

  • AU – Item furnished in conjunction with a urological, ostomy, or tracheostomy supply
  • AV – Item furnished in conjunction with a prosthetic device, prosthetic or orthotic
  • AW – Item furnished in conjunction with a surgical dressing

These modifiers identify items that are eligible for reimbursement under multiple benefit or payment categories. At this time, the only codes with which these modifiers may be used are:

  • A4217 – Sterile water/saline, 500 ml
  • A4450 – Tape, nonwaterproof, per 18 square inches
  • A4452 – Tape, waterproof, per 18 square inches
  • A5120 – Skin barrier, wipes or swabs, each
  • A6531 – Gradient compression stocking, below knee, 30-40 MMHG, each
  • A6532 – Gradient compression stocking, below knee, 40-50 MMHG, each
  • A6545 – Gradient compression stocking, wrap, nonelastic, below knee, 30-50 MMHG, each

For example, tape used with a facial prosthesis must be billed using the AV modifier. Tape used with an ostomy pouch must be billed with the AU modifier. Tape used with a surgical dressing must be billed using the AW modifier. The use of specific modifiers is addressed in each LCD and related PA in which these modifiers are applicable. Suppliers should consult the appropriate LCD and related PA for additional coverage, coding and documentation requirements.

These modifiers must not be used with any other HCPCS codes. Use of these modifiers with other codes will result in the return or rejection of the claim line(s) for incorrect modifier use. 

Claims for codes A4217, A4450, A4452, A5120, A6531, A6532 and A6545 submitted  without an AU, AV or AW modifier (as applicable) with dates of service on or after 8/1/2015 will rejected as missing information and must be resubmitted with the correct modifier applied.

Reference: Alpha Numeric Workgroup (ANWG) 02.45; PM AB-02-152

Related Content

Downcoding – Use of GK and GL Modifiers on Claims for Upgrades

GK and GL modifiers are used on claims for upgraded DMEPOS items. An upgrade is defined as an item that goes beyond what is medically necessary under Medicare’s coverage requirements. An item can be considered an upgrade even if the physician has signed an order for it.

Use of the GK and GL modifiers allows the DME MAC to automate the downcoding at the time of the initial determination. The advantage to suppliers is that they will not receive a total denial at the time of initial determination. Therefore the claim will not have to be sent through the appeals process in order to be paid comparable to the least costly alternative. Some examples (not all-inclusive) of situations in which this would be used are downcoding between different types of power wheelchairs, different types of hospital beds, different type of prosthetic components, or from a bi-level positive airway pressure device to a CPAP.

The GK and GL modifiers are used and the following instructions apply only when suppliers provide an upgrade – i.e., an item that goes beyond what is covered by Medicare.

The descriptions of the modifiers are:

  • GK Reasonable and necessary item/service associated with a GA or GZ modifier
  • GL Medically unnecessary upgrade provided instead of nonupgraded item, no charge, no ABN

If the beneficiary does not meet the coverage criteria specified in the medical policy for the item that is provided, but does meet the criteria for a different type device, the GK or GL modifier must be used. Suppliers decide which modifier to use depending on whether or not they want to collect the difference between the submitted charge for the upgraded item and the submitted charge for the item that meets coverage criteria from the beneficiary.

Supplier Collects Additional Charge for Upgrade – GK/GA Modifiers

If a supplier wants to collect the difference from the beneficiary, a properly completed ABN must be obtained. If an ABN is obtained, the supplier bills the HCPCS code for the item that is provided (but that does not meet coverage criteria) with a GA modifier on one claim line and the HCPCS code for the item that meets coverage criteria with a GK modifier on the next claim line.

(Note: The codes must be billed in this specific order on the claim.) In this situation, the claim line with the GA modifier will be denied as not medically necessary with a “patient responsibility” (PR) message and the claim line with the GK modifier will continue through the usual claims processing.

Supplier Provides Upgrade without Additional Charge – GL Modifier or GK/GZ Modifiers

If a supplier wants to provide the upgrade without any additional charge to the beneficiary, then no ABN is obtained. In this situation, there are two options for claim submission:

  1. If the physician has ordered the upgrade or if the upgrade is 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 item that is provided is not billed. The code with the GL modifier will continue through the usual claims processing.
  2. If the physician has not ordered the upgrade but it is provided at the request of the beneficiary, the supplier bills the HCPCS code for the item that is provided (but that does not meet coverage criteria) with a GZ modifier on one claim line and the HCPCS code for the item that meets coverage criteria with a GK modifier on the next claim line. (Note: The codes must be billed in this specific order on the claim.) In this situation, the claim line with the GZ modifier will be denied as not medically necessary with a “contractual obligation” (CO) message and the claim line with the GK modifier will continue through the usual claims processing.

KX Modifier

If there is a requirement in a specific policy to use a KX modifier to indicate that an item meets coverage criteria, then it is used in addition to the GK or GL modifier. For example:

  • If a power wheelchair that does not meet coverage criteria specified in the policy is provided and an ABN is obtained, the supplier bills the HCPCS code for the PWC that is provided with a GA modifier and no KX modifier on one claim line and the HCPCS code for the power wheelchair (PWC) that meets coverage criteria with a GK modifier and a KX modifier on the next claim line.
  • If a supplier does not obtain an ABN and therefore provides an upgrade without any additional charge to the beneficiary, the supplier either (1) bills the HCPCS code for the item that meets coverage criteria with the GL modifier and a KX modifier or (2) bills the HCPCS code for the PWC that is provided with a GZ modifier and no KX modifier on one claim line and the HCPCS code for the PWC that meets coverage criteria with a GK modifier and a KX modifier on the next claim line. The specific situations in which the GZ/GK combination is used instead of the GL are discussed above.

Orders and the EY Modifier

In order to use the GK or GL modifier, the supplier must have a physician order for one of the items. An order for either the covered or upgraded item is acceptable.

If the GK or GL modifier is used as specified in these instructions, the EY should not be used – i.e., it is not used on the GA, GK, or GL claim line. This is an exception to the general instruction that an EY modifier is added to a code if there is no physician order for the item that is billed.

The supplier may not use the GK or GL modifiers if there is no physician order for either the upgraded item or the item that otherwise meets coverage criteria. In this situation, the HCPCS code for the item that is provided must be billed with an EY modifier and the claim line will be denied.

The supplier may not use the GK or GL modifiers if there is a physician order for the upgraded item but the supplier provides an item that meets coverage criteria. In this situation, the HCPCS code for the item that is provided is billed but the EY modifier should not be used. This is another exception to the general instruction that an EY modifier is added to a code if there is no physician order for the item that is billed.

Other Requirements/Instructions

In order to use the GK or GL modifiers, the upgraded item must be within the range of items that are medically appropriate for the beneficiary’s medical condition and the purpose of the physician’s order. For example, there could be an upgrade between two different types of wheelchairs but the upgrade modifiers would not be used if a walker met a patient’s mobility needs but the beneficiary chose to obtain a wheelchair.

When using the GK or GL modifier, the supplier must specify the manufacturer and model name/number of the item that is actually furnished – i.e., the upgraded item – and describe why this item is an upgrade. This information must be included in the narrative field of the electronic claim.

Codes with a GK or GL modifier will continue through the usual claims processing. Other edits may cause the GK/GL claim line to be paid at a less costly alternative or to be denied. However, if no other edits are involved, payment would be made for the code with the GK or GL modifier.

An upgrade may be from one HCPCS code to another code or it may be from one item to another item within a single HCPCS code. When an upgrade is within a single code, the upgraded item must include features that exceed the official code descriptor for that item.

Refer to the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 20, Sections 120 and 120.1 for additional billing information.

These instructions are effective for claims with dates of service on or after 4/1/2007.

DME Upgrades

ABN and Claims Modifiers

An upgrade is defined as an item that goes beyond what is medically necessary under Medicare coverage requirements.

Upgrade Scenario ABN Required Required Modifier(s) DMAC Payment Beneficiary Pays for Upgrade
1) Physician orders upgrade:

a) Supplier provides upgrade free of charge to beneficiary

b) Supplier bills beneficiary for upgrade



No





Yes



GL





GA/GK



R&N item only (GL line)




R&N item only (GK line)



No





Yes
Patient requests upgrade:

a) Supplier provides upgrade free of charge to beneficiary

b) Supplier bills beneficiary for upgrade




No





Yes




GZ/GK





GA/GK




R&N item only (GL line)




R&N item only (GK line)




No





Yes
Supplier provides upgrade for supplier convenience:

a) Supplier provides upgrade free of charge to beneficiary






No






GL






R&N item only (GL line)






No
  • GK or GL is added to HCPCS code for item that meets Medicare coverage requirements.
  • When GK is used, GA or GZ is added to HCPCS code for item that is provided.
  • R&N = Reasonable and necessary

For additional information, refer to CMS IOM Publication 100-04, Medicare Claims Processing Manual, Publication 100-04, Chapter 20, Sections 120 and 120.1

Related Content

General Billing Reminders for Durable Medical Equipment, Prosthetics, Orthotics and Supplies

Providers and suppliers of DMEPOS generally submit claims for repetitive services or items on a monthly basis unless medical policy allows billing at a different frequency, (e.g., suppliers may bill for a three-month supply of diabetic test strips).

You are reminded that monthly claims for repetitive services and items provided during periods of continuous use, such as capped rental equipment, oxygen, or nutrition pumps, are to be submitted in sequence according to the date of service. When there is a break in billing (e.g., interruption as the result of an extensive inpatient stay), you should continue sequential billing when the your services resume. The purpose of this requirement is to avoid Medicare Program operational expenses, enable accurate processing of claims, and simplify the review process.

(For details and billing instructions pertaining to interruptions during a period of continuous use, refer to the JB Supplier Manual, Chapter 15 on our website.)

Accessories that are normally purchased (e.g., batteries) along with the rental of a base item, may be submitted on one claim. You are encouraged to submit the base item on the first claim line and the purchased accessories on subsequent claim lines. When accessories are itemized first on the claim, this may result in incorrect claim processing.

Related Content

How to Determine the Date of Service on a Claim

National Government Services the Jurisdiction B DME MAC recently conducted a teleconference on refractive lenses. During this teleconference, several suppliers had questions in regards to what date of service should be indicated on the claim. In most cases, the date of service on the claim is the date the beneficiary receives the DMEPOS by picking the item(s) up or the date the DMEPOS is delivered to the beneficiary.

In instances where the supplies are delivered directly by the supplier, the date the beneficiary received the DMEPOS item shall be the date of service on the claim. If a supplier utilizes a shipping service or mail order, suppliers shall use the shipping date as the date of service on the claim.

In the specific case of glasses or contacts following cataract surgery, the patient typically visits an optician for refraction and subsequently orders glasses or contact lenses. The date of service for the glasses or contacts should be the date the glasses or contacts are dispensed to the patient. The date of service indicated on the claim would not be the date the glasses or contacts were ordered.

A supplier may deliver a DMEPOS item to a beneficiary’s home in anticipation of a discharge from a hospital or nursing facility. The supplier may arrange for actual delivery of the DMEPOS approximately two days prior to the beneficiary’s anticipated discharge to their home. The supplier shall bill the date of service on the claim as the date of discharge and should use the POS code 12 (Patient’s home).

For additional information regarding how to determine the date of service on a claim based on the delivery method, please refer to the Jurisdiction B DME MAC Supplier Manual, Chapter 8 under Proof of Delivery on the National Government Services website.

ICD-10 Implementation

ICD-10 incorporates greater and specific data from clinical detail and specificity than ICD-9, and offers better support for care management, analytics and quality measurement. ICD-10 will also improve the understanding of risk and severity. The modern classification system will provide much better data needed for measuring the quality, safety, and efficiency of care and improve clinical, financial, and administrative performance. Here are some examples of the benefits of ICD-10:

  • ICD-10 CM specificity and detail have significantly expanded more than 68,000 codes; ICD-10-PCS significantly expanded more than 87,000 codes
  • ICD-10 uses 4–7 digit alpha-numeric codes instead of the 4–5 digit numeric codes used in ICD-9.
  • ICD-10 provides new tabulation lists.
  • ICD-10 transfers conditions among the classifications. It may be necessary to search for conditions in various sections.
  • ICD-10 utilizes “includes notes” and two types of “excludes notes”.

Looking for ICD-10 LCDs?

All of the Jurisdiction B ICD-10 policies are available on the Medical Policy Center.

Dear Physician Letter: Implementation of ICD-10-CM/PCS

Send the Dear Physician Letter: Implementation of ICD-10-CM/PCS to your referral source as a reminder to provide ICD-10 diagnosis codes to the highest level of specificity as well as maintaining documentation within the patient’s medical record to support the ICD-10 diagnosis code billed.

Related Content

Centers for Medicare & Medicaid Services Resources

CMS has developed timeline resources, checklists, and provides various resources to help the health care industry transition to ICD-10 by the 10/1/2015, deadline.

MLN Matters Articles

MLN Matters Fact Sheets

ICD-10 Training & Resources

MACs will not provide ICD-10 training for coding purposes. The resources provided below are for convenience only. National Government Services is not responsible for the content updates, maintenance or fees associated with these external sites.

Image of the YouTube Banner to the CMS ICD-10 Playlist on YouTube.

Items Provided on a Recurring Basis and Request for Refill Requirements – Annual Reminder

Joint DME MAC Publication

Posted 1/28/2016

Requirements

For all DMEPOS items and supplies provided on a recurring basis, billing must be based on prospective, not retrospective use. For DMEPOS products that are supplied as refills to the original order, suppliers must contact the beneficiary prior to dispensing the refill and not automatically ship on a pre-determined basis, even if authorized by the beneficiary. This shall be done to ensure that the refilled item remains reasonable and necessary, existing supplies are approaching exhaustion, and to confirm any changes or modifications to the order. Contact with the beneficiary or designee regarding refills must take place no sooner than 14 calendar days prior to the delivery/shipping date. For delivery of refills, the supplier must deliver the DMEPOS product no sooner than 10 calendar days prior to the end of usage for the current product. This is regardless of which delivery method is utilized.

For all DMEPOS items that are provided on a recurring basis, suppliers are required to have contact with the beneficiary or caregiver/designee prior to dispensing a new supply of items. Suppliers must not deliver refills without a refill request from a beneficiary. Items delivered without a valid, documented refill request will be denied as not reasonable and necessary.

Suppliers must not dispense a quantity of supplies exceeding a beneficiary's expected utilization. Suppliers must stay attuned to changed or atypical utilization patterns on the part of their clients. Suppliers must verify with the ordering physicians that any changed or atypical utilization is warranted. Regardless of utilization, a supplier must not dispense more than a one- or three-month quantity at a time. See below for billing frequencies.

Documentation Requirements

A routine refill prescription is not needed. A new prescription is needed when:

  • There is a change of supplier
  • There is a change in the item(s), frequency of use, or amount prescribed
  • There is a change in the length of need or a previously established length of need expires
  • State law requires a prescription renewal

For items that the patient obtains in person at a retail store, the signed delivery slip or copy of itemized sales receipt is sufficient documentation of a request for refill.

For items that are delivered to the beneficiary, documentation of a request for refill must be either a written document received from the beneficiary or a contemporaneous written record of a phone conversation/contact between the supplier and beneficiary. The refill request must occur and be documented before shipment. A retrospective attestation statement by the supplier or beneficiary is not sufficient. The refill record must include:

  • Beneficiary’s name or authorized representative if different from the beneficiary
  • A description of each item that is being requested
  • Date of refill request
  • For consumable supplies i.e., those that are used up (e.g., ostomy or urological supplies, surgical dressings, etc.) – The Supplier should assess the quantity of each item that the beneficiary still has remaining, to document that the amount remaining will be nearly exhausted on or about the supply anniversary date.
  • For non-consumable supplies i.e., those more durable items that are not used up but may need periodic replacement (e.g., Positive Airway Pressure and Respiratory Assist Device supplies) – The supplier should assess whether the supplies remain functional, providing replacement (a refill) only when the supply item(s) is no longer able to function. Document the functional condition of the item(s) being refilled in sufficient detail to demonstrate the cause of the dysfunction that necessitates replacement (refill).

This information must be kept on file and be available upon request.

Billing Frequencies

For refills of surgical dressings, enteral and parenteral nutrients and supplies, immunosuppressive drugs, oral anti-cancer drugs, intravenous immune globulin, and oral antiemetic drugs, only a one-month quantity of supplies may be dispensed.

For all other refills that are provided on a recurring basis suppliers may dispense no more than a three-month supply at any one time.

Miscellaneous

These requirements are not limited to DMEPOS refills for items addressed in LCDs only. All DMEPOS items that are refilled on a recurring basis are subject to these requirements.

For additional information, refer to CMS Internet-Only Manual Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.8 and 5.2.9, and the applicable LCDs and the supplier manual.

Related Content

Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor Same or Similar Tips and Reference Chart

The Same or Similar Reference Chart was created by National Government Services for the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC) supplier community as a tool to assist in understanding same or similar denials and prevention tips have been provided as well!  

According to our most recent data analysis, the CO-151 denial continues to be one of the top claim submission errors that suppliers receive. The CO-151 states the following:

“Payment adjusted because the payer deems the information submitted does not support this many/frequency of services”

This American National Standards Institute (ANSI) code is used when the patient’s Medicare claim payment history includes claims for services that are the same (meaning same Healthcare Common Procedure Coding System (HCPCS) or similar (meaning it falls within a range of HCPCS) to what is being billed. In addition to ANSI code CO-151, the remittance advice will also include Remark Codes M3 and M25, which serve as additional clarification to the denial. The M3 and M25 remark codes state:

“Equipment is the same or similar to equipment already being used”

During the intake process, and prior to dispensing or delivering the item, suppliers should ask the beneficiary if they have purchased or are currently renting the same or similar equipment, from another supplier.

Additionally, suppliers should evaluate the patient’s Medicare claims payment history to determine if there is record of the beneficiary’s purchase or rental of same or similar equipment. If the patient’s Medicare claims payment history reveals that  same, or similar equipment, was previously purchased or rented, suppliers should then determine what happened to the equipment previously purchased or rented by the beneficiary (i.e., was the equipment lost, stolen, irreparably damaged, etc.)

There are several steps a supplier can take to avoid same/similar equipment denials:

  • Ask the beneficiary
  • Check your records
  • Utilize Connex: http://www.NGSConnex.com
  • Utilize the interactive voice response (IVR) System: 877-299-7900
  • Claim Status Inquiry (CSI)  
  • Contact Customer Care: 866-590-6727
  • Submit a Written Request:   

National Government Services, Inc.
P.O. Box 6036
Indianapolis, IN 46206-6036

Reasonable Useful Lifetime

The reasonable useful lifetime (RUL) of durable medical equipment prosthetics, orthotics, and supplies (DMEPOS) devices is five years unless Medicare Program instructions, or national or local policies, indicate otherwise. It is the supplier’s responsibility to be aware of the RUL provisions for the items they routinely bill. Medicare will not pay for a piece of equipment if the beneficiary already owns or rents the same or a similar piece of equipment and it has not reached its RUL (except in limited situations where the original equipment was lost, stolen, or irreparably damaged). If a supplier bills for an item the beneficiary already rents or owns, and the item has not reached its RUL, the claim will deny for ANSI code CO-151 (same/similar).

Advance Beneficiary Notice of Noncoverage

DME suppliers are expected to be familiar with DME coverage policies and any additional pertinent information that may have an impact on medical necessity determinations. In order to be protected under the limitation of liability provision, a supplier must provide a proper Advance Beneficiary Notice of Noncoverage (ABN) for each item that they believe is likely to be denied as not medically necessary, same and similar denials are considered medical necessity denials.

If a beneficiary has had any piece of equipment from the same DMEPOS item category within the previous five years, a same or similar denial can be expected.

Same/Similar Reference Chart

Durable Medical Equipment Item Health Care Common Procedure Coding System (HCPCS) Code
MOBILITY DEVICES
Canes E0100, E0105
Crutches E0110, E0111, E0112, E0113, E0114, E0116, E0117, E0118
Walkers E0130, E0135, E0140, E0141, E0143, E0144, E0147, E0148, E0149
Manual Wheelchairs

Note: When checking for manual wheelchairs, National Government Service will provide same similar information for manual wheelchairs on file.
E1031, E1037, E1038, E1039, E1161, E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, E1239, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0009
Power Mobility Devices

Note: When checking for power mobility devices, National Government Service will provide same similar information for power mobility devices on file. 
E1035, E1036, E1230, K0010, K0011, K0012, K0014, K0800, K0801, K0802, K0806, K0807, K0808, K0812, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886, K0890, K0891, K0898, K0899
MOBILITY DEVICE ACCESSORIES
Wheelchair Seat Cushions E0176, E0177, E0178, E0179, E0962, E0963, E0964, E0965, E2601, E2602, E2603, E2604, E2605, E2606, E2607, E2608, E2609, E2610, E2618, K0650, K0651, K0652, K0653, K0654, K0655, K0656, K0657, K0658, K0659, K0734, K0735, K0736, K0737
Wheelchair Back Cushions E2611, E2612, E2613, E2614, E2615, E2616, E2617, E2620, E2621
PARENTERAL AND ENTERAL NUTRITION (PEN)
Enteral Formula B4149, B4150, B4151, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162
Enteral Pumps B9000, B9002
Parenteral Nutrition B4164, B4168, B4172, B4176, B4178, B4180, B4189, B4199, B5000, B5100, B5200, B4184, B4186
Parenteral Pumps B9004, B9006
INFUSION
Infusion Pumps E0779, E0780, E0781, E0784, E0791, K0284
RESPIRATORY
Nebulizers and Compressors E0565, E0570, E0571, E0572, E0574, E0575, , E0580, E0585
Humidifiers E0550, E0560, E0561, E0562, K0268, K0531
Respiratory Assist Devices E0450, E0454, E0460, E0461, E0470, E0471, E0472, E0601, K0532, K0533, K0534
Stationary Oxygen Equipment E0424, E0425, E0439, E0440, E1353, E1390, E1391, E1405, E1406
Oxygen Contents (Portable) E0443, E0444
Oxygen Contents (Stationary) E0441, E0442
GLUCOSE
Blood Glucose Monitors E0607, E2100, E2101
MISCELLANEOUS HOME HEALTH AIDS
Commodes E0163, E0164, E0165, E0166, E0168, E0169, E0170, E0171
Heat Lamps E0200, E0205
Patient Lifts E0625, E0630, E0635, E0639
Heat Pads E0210, E0215, E0217, E0220, E0221, E0225, E0236, E0237, E0238, E0239
Seat Lift Mechanisms E0627, E0628, E0629
Sitz Baths E0160, E0161, E0162
HOSPITAL BEDS AND ACCESSORIES
Hospital Beds E0194, E0250, E0251, E0255, E0256, E0260, E0261, E0265, E0266, E0290, E0291, E0292, E0293, E0294, E0295, E0296, E0297, E0300, E0301, E0302, E0303, E0304, E0328, E0329, E0462, K0549, K0550
Hospital Bed Side Rails/Safety Enclosures E0305, E0310, E0316
Traction Frames E0840, E0850, E0855, E0856, E0860, E0870, E0880, E0890, E0900, E0920, E0930, E0941, E0946, E0947, E0948, K0627, E0849
Trapeze Bars E0910, E0911, E0912, E0940
SUPPORT SURFACES
Group I & II Pressure Reducing Support Surfaces E0180, E0181, E0182, E0184, E0185, E0186, E0187, E0188, E0189, E0193, E0196, E0197, E0198, E0199, E0277, E0371, E0372, E0373
PNEUMATIC COMPRESSION DEVICES & APPLIANCES
Pneumatic Compressors E0650, E0651, E0652
Pneumatic Appliances-Arm A4600, E0655, E0665, E0668, E0672
Pneumatic Appliances-Leg A4600, E0660, E0666, E0667, E0669, E0671, E0673
STIMILATORS
Osteogenesis Stimulators E0747, E0748, E0760
Transcutaneous Electrical Nerve Stimulators (TENS) E0720, E0730
NEGATIVE PRESSURE WOUND THERAPY PUMPS
Wound Therapy E0231, E2402, K0538
SPEECH GENERATING DEVICES
Speech Generating Devices E2500, E2502, E2504, E2506, E2508, E2510, E2511, K0541, K0542, K0543, K0544, K0545, K0615, K0616, K0617

Note: Same and Similar information is not available for the following items through any system (i.e., IVR, CSI, or Connex). For this information you must call the Provider Contact Center (866-590-6727) and have the Medicare beneficiary on the line in order for the contact center representative to be able to release this information to you.

  • Diabetic supplies
  • External breast prosthesis
  • Eye prosthesis
  • Facial prosthesis
  • Knee orthosis
  • Lower limb prosthesis
  • Orthotic footwear
  • Refractive lenses
  • Spinal orthosis
  • Surgical dressings
  • Therapeutic shoes for persons with diabetes
  • Tracheostomy supplies
  • TENS supplies

More information regarding this topic is available on the National Government Services Web site.

Disclaimer

National Government Services, Inc. has produced this material as an informational reference for providers furnishing services in our contract jurisdiction. National Government Services employees, agents, and 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 material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the Medicare program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare Program requirements. Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice. Current Medicare regulations can be found on the Centers for Medicare & Medicaid Services (CMS) Web site

KX and GA Modifier on Same Claim Line in Same/Similar Situations

National Government Services, the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC) has received numerous questions related to the use of the KX and GA modifiers on the same claim line.

The DME MACs have updated the majority of the local coverage determinations (LCDs) that include the use of the KX modifier to incorporate instructions for the use of the GA, GZ, or GY modifiers. The DME MACs implemented system edits that will reject a claim line if the supplier does not indicate the beneficiary either meets or does not meet the requirements that are specified in each medical policy. The contractors use the presence of a GA, GZ, or GY modifier as an indication that coverage criteria are not met.

The KX modifier has a different definition depending on the LCD in question, for example if the patient is being treated with insulin injections, the KX modifier must be appended to the Health Care Common Procedure Coding System (HCPCS) code for the blood glucose monitor and each related supply on every claim submitted. However, in most cases suppliers must append the KX modifier to a HCPCS code only if all of the coverage criteria outlined in the Indications and Limitations of Coverage section of the applicable policy have been met.

The GA modifier indicates the supplier believes the item they are providing is expected to be denied as not reasonable and necessary and that an Advance Beneficiary Notice of Noncoverage (ABN) has been properly executed. Therefore, in most cases it would not be appropriate to append the GA and KX modifiers on the same claim line as suppliers are responsible for making a determination as to whether Medicare is expected to allow or deny payment and must append the modifier based upon that determination.

Examples of when it would be appropriate to append both the GA and KX on the same claim line and when it would not be appropriate to append both the GA and KX on the same claim line, include but are not limited to the following:

Same and Similar

Medicare does not pay separately for backup equipment or items that are deemed to be same or similar to equipment that is already in use as they are considered not reasonable and necessary.

If the supplier has evidence to believe that Medicare will not pay for an item because the patient already has or has had same/similar equipment, which has not met the reasonable useful lifetime expectancy an ABN should be executed to inform the Medicare beneficiary that Medicare will likely deny payment of the item.

A supplier should not execute an ABN unless the supplier has some genuine doubt regarding the likelihood of Medicare payment. Giving ABNs for all claims, items, or services is not an acceptable practice. This would be considered a generic ABN. Such generic ABNs are not considered to be acceptable, as the ABN must clearly specify the service and a genuine reason that denial by Medicare is expected. 

Scenario One 

Joe Smith, a Medicare beneficiary comes into ABC Supplier’s store with a prescription from his doctor for a manual wheelchair. ABC Supplier checks the IVR prior to dispensing a manual wheelchair to Joe Smith and determines that Medicare previously paid another supplier 13 rental payments for a manual wheelchair, less than five years ago. Therefore, ABC supplier advises Joe Smith that Medicare is likely to deny this manual wheelchair as not reasonable and necessary because it is considered same/similar equipment. Joe Smith indicates that he wants the manual wheelchair and is willing to be held financially responsible. Therefore, ABC supplier properly executes an ABN. In this scenario it would be appropriate for ABC Supplier to submit a claim for the manual wheelchair with both the KX and GA modifier appended to the manual wheelchair HCPCS code and receive a patient responsibility denial from Medicare.

Scenario Two

Jane Smith, a Medicare beneficiary comes into ABC Supplier’s store with a prescription from her doctor for a manual wheelchair. ABC Supplier checks the IVR prior to dispensing the manual wheelchair to Jane Smith and the IVR does not indicate any same/similar equipment on file. ABC Supplier asks Jane during the intake process if she has ever had a wheelchair before. Jane indicates that several years ago she broke her leg and used a wheelchair but she doesn’t remember when or if Medicare paid for it. She also doesn’t know what happened to the wheelchair. Therefore, ABC Supplier advises Ms. Smith that Medicare may deny the wheelchair because she previously had same/similar equipment. In this scenario it would be appropriate for ABC Supplier to execute an ABN and submit a claim for the manual wheelchair with the GA modifier and the KX modifier (if all of the coverage criteria outlined in the Indications and Limitations of Coverage section of the applicable policy have been met) appended to the HCPCS code for the manual wheelchair and receive a patient responsibility denial.

Scenario Three

Mary Jones, a Medicare beneficiary comes into ABC Supplier’s store with a prescription from her doctor for a walker. ABC Supplier checks the IVR prior to dispensing the walker to Mary Jones and the IVR does not indicate any same/similar equipment on file. ABC Supplier asks Mary during the intake process if she has ever had a walker before. Mary indicates that she has never had any durable medical equipment before. ABC Supplier decides that just in case they receive a same/similar denial they will execute an ABN so that they can hold Mary financially liable. In this scenario it would not be appropriate for ABC Supplier to execute an ABN because the supplier does not have a genuine reason to believe that Medicare is likely to deny payment. Therefore, it would not be appropriate for ABC Supplier to submit a claim for the walker with both the KX and GA modifiers appended.

Resources

To obtain more information regarding the proper use of the KX, GA, GZ, or GY modifiers suppliers should refer to the revised LCDs, located on the National Government Services Web site.

For additional information regarding how to properly complete and execute an ABN, suppliers should refer to the Jurisdiction B DME MAC Supplier Manual, Chapter 10. Suppliers can obtain additional education on ABNs by taking the computer based training course Advance Beneficiary Notice available through Medicare University on the National Government Services Web site.

 

Modifier Billing Reminders

Modifiers provide a means to enable the DME MACs to effectively respond to the parameters of the payment policy and LCD and PA requirements established by the Medicare program. In many instances, certain modifiers are required to make a HCPCS code valid before claim processing can be completed.

Missing or incorrect usage of modifiers is one of the most common reasons that claims are rejected by the DME MACs. Omitting a modifier or placement of an incorrect or invalid modifier may cause your claim to be denied or paid at the wrong amount. Modifiers can be used independently or in conjunction with each other on each claim line. In some cases, multiple modifiers may be required to ensure accurate claims processing; however, only four modifiers may be reported on a single claim line.

Pricing Modifiers

Modifier Definition
NU New DME
RR Rented DME
UE Used DME
KE Bid Under Round One of the DMEPOS Competitive Bidding Program for Use With Non-Competitive Bid Base Equipment
KG DMEPOS Item Subject to DMEPOS Competitive Bidding Program Number 1
KK DMEPOS Item Subject to DMEPOS Competitive Bidding Program Number 2
KU, KW, KY DMEPOS Item Subject to DMEPOS Competitive Bidding Program Number 3,4,5 (Reserved for future program use)

If the item requires a pricing modifier NU, RR, or UE along with a DMEPOS Competitive Bidding Program pricing modifier KE, KG, KK, KU, KW, or KY, the NU, RR or UE modifier should be placed in the first position following the HCPCS code and the KE modifier should be placed in the second position.

Capped Rental Modifiers

Modifier Definition
KH DMEPOS item, initial claim, purchase or first month rental
KI DMEPOS item, second or third month rental
KJ DMEPOS item, DMEPOS item, parenteral enteral nutrition (PEN) pump or capped rental, months four to thirteen for capped rental items and four to fifteen for PEN pumps
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
BR Beneficiary elected to continue rental
BP Beneficiary elected to purchase
BU Rental/purchase status not selected by beneficiary 30 days past notification of option

If the item also requires a 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.

Informational Modifiers

Modifier Definition
CR Catastrophe/disaster related
EY No physician or other licensed health care provider order for this item or service
GA Waiver of liability statement on file
GK Actual item/service ordered by physician, item associated with GA or GZ
GL Medically unnecessary upgrade provided instead of standard item, no charge, no ABN
GW Service not related to the hospice patient’s terminal condition
GY Item or service statutorily excluded or does not meet the definition of any Medicare benefit
GZ Item or service expected to be denied as not reasonable and necessary
KB Beneficiary requested upgrade, for ABN, more than four modifiers identified on claim
KX Specific documentation on file
LT Left side
RT Right side
RA Replacement of a DME, orthotic or prosthetic item
RB Replacement of a part of a DME, orthotic or prosthetic item furnished as part of a repair
KL DMEPOS item delivered via mail
KV DMEPOS item subject to DMEPOS Competitive Bidding Program that is furnished as part of a professional service
KT Beneficiary resides in a Competitive Bidding Area and travels outside that Competitive Bidding Area and receives a Competitive Bid item
J4 DMEPOS item subject to DMEPOS Competitive Bidding Program that is furnished by a hospital upon discharge

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.

  • Example: Supplier is submitting a claim with modifiers RR KG KH RA KX. The supplier should place modifiers RR, KG, KX, and 99 on the claim line, then place in Item 19 for paper submitted claims or in the NTE segment for electronically submitted claims all modifiers (RRKGKHRAKX).

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.

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.

  • Example: Supplier is submitting a claim with the RR, KH, KX, BR and GK/GL modifiers. The supplier should place modifiers RR, KH, KX, and KB on the claim line, then place in Item 19 for paper submitted claims or in the NTE segment for electronically submitted claims the remaining modifiers (BR, and GK/GL modifiers).

For additional information concerning HCPCS modifiers suppliers should refer to the Jurisdiction B DME MAC Supplier Manual, Chapter 14 which can be located on the National Government Services Web site.

Modifier JW for Discarded Drugs and Biologicals

The Centers for Medicare & Medicaid Services Internet-Only Manual Publication 100-04, Medicare Claims Processing Manual, Chapter 17, Section 40, (815 KB) contains instructions for the use of the JW modifier for discarded drugs and biologicals. The descriptor for the JW modifier reads:

JW – Drug amount discarded to administered to any patient

National Government Services, the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC), does not require use of the JW modifier for discarded drugs and biologicals.

Suppliers with additional questions should refer to Medicare Learning Network (MLN) Matters articles MM6711 and MM7095

Modifier Requirements Due To Lack of a Physician’s Order (Modifier EY)

We have recently received inquiries regarding the proper submission of modifiers EY, GY and GA when a denial is anticipated due to the lack of a prescription. To reduce errors related to this process, it is important to remember that all DMEPOS items require a prescription (physician’s order). Some DMEPOS items require a detailed WOPD, while others require a DWO prior to billing. The specific requirements for an order are specified in the Medical Policy (local coverage determination and/or policy article) for the specific item.

Please remember that if you submit a claim to Medicare and specified requirements for an order are not met, you must append modifier EY (“No physician or other licensed health care provider order for this item or service”) to the claim line. This informs the DME MAC that you do not have a physician’s order for the item. Additionally, items submitted with the EY modifier must be on a separate claim from those items not requiring an EY modifier.

When lack of an order is expected to result in a medical necessity denial (ANSI 50 –“These are non-covered services because this is not deemed a ‘medical necessity’ by the payer”), you must execute an ABN if you intend to protect your company from financial liability. If you have properly executed an ABN, you must append modifier GA (“Waiver of liability statement issued as required by payer policy, individual case”) to the claim line in addition to modifier EY.

However, when the lack of a physician’s order is expected to result in a statutory denial, an ABN is not required. If you correctly submit the claim with modifier EY appended to the claim line, the claim will process and deny with ANSI 96 (“Noncovered charge[s]”). Neither modifier GY (“Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit”) nor modifier GA is required when an item is expected to deny on the basis of a statutory denial (ANSI 96).

As a reminder, all items specified in Change Request 8304 which are subject to the Affordable Care Act 6407 require a WOPD. This is a statutory requirement. You must have received a complete WOPD that has been both signed and dated by the treating physician and meets the requirements for a DWO before dispensing the item. If you deliver the item prior to your receipt of a written order, it will be denied as statutorily noncovered. Therefore, when you do not have an order for these items, you must submit the claim with modifier EY. Again, neither modifier GY nor GA would be required.

We encourage you to refer to the LCD and related policy article for specific order and other documentation requirements for the items you provide.

Related Content

National Competitive Bidding Modifiers - Billing Reminder

National Government Services, the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC), has identified that suppliers are inappropriately omitting competitive bidding modifiers KG, KK, and KL from their claims. These modifiers are pricing modifiers used to generate accurate payments in accordance with the statute for the items and services the supplier is claiming to have furnished. The competitive bidding modifiers are:

KG—DMEPOS item subject to DMEPOS competitive bidding program number 1 (effective date 07/01/2007)
KK—DMEPOS item subject to DMEPOS competitive bidding program number 2 (effective date 07/01/2007)
KL—DMEPOS item delivered via mail (effective date 07/01/2007)

Modifiers KG and KK must be used to identify when the same supply or accessory is furnished in multiple competitive bidding product categories, such as the standard power wheelchair product category and the complex rehabilitative power wheelchair product category. For example, when suppliers submit claims for elevating footrests (Healthcare Common Procedure Coding System [HCPCS] code K0053) used with standard power wheelchairs, the KG modifier should be used. However, when claims are submitted for elevating footrests (K0053) used with complex rehabilitative power wheelchairs, the KK modifier must be used. Data analysis on wheelchair bases and accessories shows that the most common HCPCS codes for which the modifiers are omitted are:

Base Codes

K0822, K0823, K0825

Accessory Codes

E0951, E0973, E2361, E0955, E1028, E2365, E0971, E1226, K0195

In addition, the KG modifier should be used to distinguish when the same HCPCS code can be used with both competitively bid and noncompetitively bid items. For example, an IV pole (HCPCS code E0776) can be used in the enteral nutrients, equipment and supplies product category (competitively bid item) and with parental nutrients, equipment and supplies (non-competitively bid item). When suppliers submit claims for an IV pole used with the competitively bid item (enteral nutrients), the KG modifier should be affixed to the code on the claim.

All suppliers that submit claims for beneficiaries that live in a competitive bidding area (CBA), including contract, noncontract, and grandfathered suppliers, should submit claims for competitive bid items using the KG and KK 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 KL modifier should be used by all Medicare-enrolled suppliers to indicate that the diabetic testing supplies were delivered to the beneficiary’s residence by mail order and not obtained from a local supplier storefront.

It is imperative that all suppliers comply with the modifier usage requirements. Failure to use these modifiers correctly can result in claim denials, Medicare overpayments, and possible additional sanctions, including contract termination.

For additional information about the modifiers and their usage, please review the Medicare Learning Network (MLN) Matters article SE1035. The modifiers associated with particular competitive bidding codes are listed by product category on the single payment amount charts found on the competitive bidding implementation contractor (CBIC) Web site. From the home page, select Contract Suppliers and then choose Single Payment Amounts.

Ordering/Referring Physician Checklist for DMEPOS

Effective 1/6/2014, the CMS turned on the Phase 2 ordering/referring denial edits. This means that Medicare will deny DMEPOS claims if the physician is not:

  • Identified as the ordering/referring physician, 
  • Enrolled in PECOS, or 
  • A specialty type that may order/refer the service/item being billed.

Phase 1 – Claims with Dates of Service Prior to 1/6/2014

Claims with dates of service prior to 1/6/2014 billing providers/suppliers will continue to receive informational messages on their remittance advices to alert them that the that the identification of the ordering/referring provider is missing, incomplete, or invalid, or that the ordering/referring provider is not eligible to order or refer.

  • N544 – Although this was paid, you have billed with a referring/ordering provider that does not match our system record. Unless corrected, this will not be paid in the future.

Phase 2 – Claims with Dates of Service on or After 1/6/2014

A claim submitted with a date of service on or after 1/6/2014 will be denied with one of the following ANSI denials if the ordering/referring provider NPIs reported on the claim does not pass the edits.

Only physicians and certain types of nonphysician practitioners are eligible to order or refer items or services for Medicare beneficiaries. Claims that a billing provider or supplier submits in which the ordering/referring provider or supplier is not authorized by statute and regulation will be denied.

  • Chiropractors are not eligible to order and refer supplies or services for Medicare beneficiaries. All services ordered or referred by a chiropractor will be denied.
  • Optometrists may only order and refer DMEPOS items, laboratory and X-ray services.

Example: A DMEPOS claim is submitted and the ordering/referring physician name and NPI listed on the claim are for a chiropractor, the claim will be denied because a chiropractor is not eligible to order and refer DMEPOS items for Medicare beneficiaries.

If the referring/ordering provider name reported on the claim does not match what is stored in PECOS the claim will be denied with the following ANSI denial and remark codes:

  • CO-16 – Claim/service lacks information which is needed for adjudication
    • N264 – Missing/incomplete/invalid ordering provider name.
    • N575 – Mismatch between the submitted ordering/referring provider name and records

Example: A DMEPOS claim is submitted and the ordering/referring physician’s last name entered on the claim does not match what is in PECOS, (i.e., name spelled incorrectly, wrong name entered, etc.).This would cause the claim to fail the Phase 2 edits and the claim would be denied.

If the referring/ordering provider NPI reported on the claim is missing or does not match a provider record in PECOS the claim will be denied with the following ANSI denial and remark codes:

  • CO-16 – Claim/service lacks information which is needed for adjudication
    • N265 – Missing/incomplete/invalid ordering provider name.
    • N276 – Mismatch between the submitted ordering/referring provider name and records

Example: A DMEPOS claim is submitted and the ordering/referring physician’s NPI listed on the claim does not match what is in PECOS, (i.e., number transposed, wrong number entered, etc.). This would cause the claim to fail the Phase 2 edits and the claim would be denied.

Statutorily Noncovered Items – GY Modifier

Medicare will not pay for services excluded by statute, which often are services not recognized as part of a covered Medicare benefit. If a claim is submitted using the GY modifier and the claim is missing an ordering and referring provider or the provider is not authorized to order and refer, the claim will be denied with the following ANSI denial codes:

  • PR-96 – Noncovered charges
  • PR-204 – This service/equipment/drug is not covered under the patient’s current benefit plan

Steps to Prevent Unnecessary Denials

  1. Check the “Ordering Referring Report” – This file contains the NPI and names of physicians and nonphysician practitioners who have current enrollment records in PECOS and are of a type/specialty that is eligible to order and refer. CMS updates the report on a periodic basis, and each document includes a create date. This file is available on the CMS website.
  2. If the physician or nonphysician practitioner appears on the file, follow these tips for claim submission to avoid denials for invalid format of ordering physician and nonphysician practitioner names:
    • File a new claim – no need to file an appeal if you received a claim denial with one of the above CARC and RARC messages. 
      • Ensure you are correctly spelling the ordering/referring provider’s name. Use the name and NPI exactly as it appears on the “Ordering Referring Report” which comes directly from PECOS. The edits will compare the first four letters of the last name.
      • Do not use “nicknames” on the claim, as their use could cause the claim to fail the edits.
      • Do not enter a credential, (e.g., “Dr.”) in a name field.
      • Special characters, such as apostrophes (') or hyphens (–), appear in some names on the PECOS list and should be submitted on the claim as such. Spaces must also be present as depicted on the CMS PECOS list.
      • Make sure the last name is in the last name field and first name in the first name field.
        • On paper claims (CMS-1500), enter the ordering provider's first name first, and last name second (e.g., John Smith), in Item 17.
        • On electronic claims, ensure that you are not submitting the last name in the first name field and vice versa.
      • Ensure that the name and the NPI you enter for the ordering/referring provider belong to a physician or nonphysician practitioner and not to an organization, such as a group practice that employs the physician or nonphysician practitioner who generated the order or referral.
      • Make sure that the qualifier in the electronic claim 2420E NM102 loop is a one (person). Organizations (qualifier two) cannot order and refer.
  1. If the physician does not appear on CMS’ “Ordering Referring Report,” contact the ordering/referring physician to find out if they are in the process of enrolling with Medicare. The CMS “Ordering Referring Report” will include a create date; any applications processed after the create date will not appear on the report until it is next updated. Services ordered by a physician who is not enrolled in Medicare will be denied. Check the “Ordering Referring Report” weekly for newly enrolled providers.

Reminders

Billing providers should be aware that claims that are denied because they failed the ordering/referring provider edits would not expose the Medicare beneficiary to liability. Therefore, an ABN is not appropriate.

Chiropractors are not eligible to order or refer supplies or services for Medicare beneficiaries. All services ordered or referred by a chiropractor will be denied.

Opt-Out Physicians and Nonphysician Practitioners: A physician who has opted out of Medicare may order items or services for Medicare beneficiaries by submitting an opt-out affidavit to a Medicare contractor within the physician’s specific jurisdiction. Opt-out physicians who are able to order or refer Medicare services will appear on the “Ordering Referring Report.”

DVA, PHS, or the DOD/Tricare: These physicians and nonphysician practitioners will need to enroll in Medicare in order to continue to order or refer items or services for Medicare beneficiaries. DVA, PHS or DoD/Tricare physicians who are able to order or refer Medicare services will appear on the “Ordering Referring Report.”

Related Content

CMS MLN Matters article, SE1305 “Full Implementation of Edits on the Ordering/Referring Providers in Medicare Part B, DME, and Part A Home Health Agency (HHA) Claims (Change Requests 6417, 6421, 6696, and 6856

Part A Medical Review of Acute Care Hospital Inpatient Short Stay Claims

NGS Part A Medical Review, Appeals and Mobile Medical Review, in conjunction with NGS CMDs, is providing this information in response to requests for clarification of how medical necessity determinations of medical records are made for inpatient short stay claims.

Medical review of inpatient hospital claims is a complex review, and the CMS provide instruction and guidance regarding inpatient admission decisions.

CMS Internet-Only Manual (IOM) Publication 100-8, Medicare Program Integrity Manual, Chapter 6, Section 6.5.1 (248 KB) requires that review staff of Medicare contractors use a screening tool as part of their medical review process for inpatient hospital claims. CMS does not require that the contractor use specific criteria nor endorse any particular brand of screening guidelines. Contractors are not required to pay a claim even if screening criteria indicates inpatient admission is appropriate. Conversely, contractors are not required to automatically deny a claim that does not meet the admission guidelines of a screening tool. In all cases, in addition to a screening tool, the reviewer shall apply his/her own clinical judgment to make a medical review determination based on the documentation in the medical record.

CMS considers the use of screening criteria as only one tool that should be utilized by contractors to assist them in making an inpatient hospital claim determination.

CMS responded to concerns of some hospitals about utilizing screening criteria to analyze medical documentation and make a medical necessity determination on inpatient hospital claims; several screening tools that Medicare contractors in specific jurisdictions may use (including InterQual, Milliman, and other proprietary systems). To provide clarification, CMS issued MLN SE article SE1037 Revised: Guidance on Hospital Inpatient Admission Decisions.

NGS CMDs recommend applying any screening criteria to the beneficiary at approximately six to eight hours after presenting to hospital, when appropriate.

The CMS IOM Publication 100-8, Medicare Program Integrity Manual, Chapter 6, Section 6.5.2 (248 KB) states:

  • The review of the medical record must indicate that inpatient hospital care was medically necessary, reasonable, and appropriate for the diagnosis and condition of the beneficiary at any time during the stay.
  • The beneficiary must demonstrate signs and/or symptoms severe enough to warrant the need for medical care and must receive services of such intensity that they can be furnished safely and effectively only on an inpatient basis.
  • Inpatient care, rather than outpatient care, is required only if the beneficiary's medical condition, safety, or health would be significantly and directly threatened if care was provided in a less intensive setting.

The CMS IOM Publication 100-2, Medicare Benefit Policy Manual, Chapter 1, Section 10 (437 KB) includes factors to be considered when making appropriate inpatient admission:

  • The severity of the signs and symptoms exhibited by the patient;
  • The medical predictability of something adverse happening to the patient;
  • The need for diagnostic studies that appropriately are outpatient services (i.e., their performance does not ordinarily require the patient to remain at the hospital for 24 hours or more) to assist in assessing whether the patient should be admitted;
  • The availability of diagnostic procedures at the time when and at the location where the patient presents;
  • Admissions of particular patients are not covered or noncovered solely on the basis of the length of time the patient actually spends in the hospital.

In conclusion, NGS Part A Medical Review, Appeals, and Mobile Medical Review, makes medical necessity determinations on short stay inpatient hospital claims per CMS’ instructions; and NGS CMDs recommend applying any screening criteria for the purpose of determining appropriate admissions at approximately six to eight hours after a patient presents to the hospital. It would be expected that after that amount of time, adequate evaluation of the patient could occur, thus providing a more detailed and accurate assessment of the patient’s condition and required plan of care. Additionally and importantly, if further testing reveals an acute finding or an unexpected event occurs, a decision to transition to inpatient status may be made.

Providers are reminded that observation services are provided on an outpatient basis; and orders for observation services are not considered to be valid inpatient admission levels of care orders. Also, a physician’s order to admit does not prove medical necessity; nor does documentation from a screening tool recommending admission. Medical necessity is determined on a case-by-case basis, considering the severity of illness, intensity of services and the physician’s instructions for the patient’s clinical course.  

NGS also encourages providers to participate in educational opportunities offered by POE. Training and educational materials are focused on addressing topics that assist providers in understanding Medicare policies.

Reminder: Requirements for Reporting of Units of Service

National Government Services would like to remind suppliers of the requirements for reporting units of service for capped rental items, parenteral/enteral nutrition pumps, oxygen equipment and contents, glucose testing supplies, and billing for items with a HCPCS narrative of “pair” or “each.”

Claims for capped rental items, oxygen equipment, and parenteral/enteral nutrition pumps are submitted on a monthly basis. For these items, one month’s rental is equal to “1” UOS. Therefore, the units of service for one month’s rental should not exceed “1” unit of service.

When billing bilateral items that are provided as a purchase or rental and the HCPCS code description indicates “pair,” report one unit of service and do not report modifiers LT/RT.

Oxygen Contents

Suppliers are responsible for providing whatever quantity of oxygen contents the beneficiary needs for use inside and outside the home. For stationary and portable liquid and gaseous oxygen contents, one month’s supply of oxygen equals “1” unit of service—regardless of the quantity of oxygen supplied.

A maximum of three months of oxygen contents can be delivered to the beneficiary at one time and billed on a monthly basis. In these situations, the delivery date of the oxygen contents does not have to equal the date of service (anniversary date) on the claim, but in order to bill for contents for a specific month (i.e. the second or third month in the three month period), the supplier must have delivered quantities of oxygen that are sufficient to last for one month following the date of service on the claim. In this situation, the supplier would submit a claim for one unit of service each of the three months on the anniversary date.

Suppliers should have proof-of-delivery for each actual delivery of oxygen, which may be less than monthly within the three-month period. If the supplier delivers more than one month of oxygen contents at a time, the supplier is not entitled to payment for additional months two and three if medical need ceases before the date when the supplier would be entitled to bill for those months.

Glucose Test Strips and Lancets

Medicare will reimburse for blood glucose test strips (A4253) and lancets (A4259) when the patient has met the coverage criteria outlined in the local medical policy. The quantity of test strips and lancets allowed per month depends on whether or not the patient is treated with insulin injections. For a patient who is not currently being treated with insulin injections, up to 100 test strips and up to 100 lancets every three months are covered if coverage criteria outlined in the local coverage determination (LCD) for glucose monitors are met. For a patient who is currently being treated with insulin injections, up to 100 test strips and up to 100 lancets every month are covered if coverage criteria outlined in the LCD for glucose coverage are met. When billing for diabetic testing supplies, the claim must indicate whether or not the patient is insulin treated by appending modifier KX (insulin treated) or modifier KS (noninsulin treated) to the each claim line for the test strips and lancets.

Suppliers must correctly indicate the quantity provided. A box of 50 test strips (A4253) is equal to one unit of service. Therefore, if the supplier provides two boxes of test strips, the supplier would submit a claim for two UOS. If 150 test strips are provided, the supplier would submit a claim with three UOS.

One box of 100 lancets (A4259) is equal to one unit of service. Therefore, if only one box is provided, only one unit of service is billed. If two boxes of 100 are provided, then the supplier indicates two units of service.

As an example, if an insulin-treated beneficiary is testing three times per day (KX modifier) and the supplier provides a 90-day supply—300 test strips (A4253) and 300 lancets (A4259)—the correct quantity reported in UOS would be as follows:

  • HCPCSmodifier: A4253KX, Units of Service: 6
  • HCPCSmodifier: A4259KX, Units of Service: 3

Suppliers should not indicate the total number of test strips or lancets in the box.

Also remember that the claim for the testing supplies must be spanned to reflect the number of days that the test strips which were dispensed are expected to last based on the frequency of testing ordered by the physician or performed by the beneficiary, whichever is less frequent.

Revised: Billing a Not Otherwise Classified Health Care Common Procedure Coding System Code

Effective immediately any HCPCS code with a narrative description that indicates “NOC," unlisted, or nonspecified that is billed to the DME MAC must include the following additional information to allow proper adjudication.

Common Electronic Data Interchange Edits

Any HCPCS code with a narrative description that indicates NOC, unlisted, or non-specified that is billed to the DME MAC electronically must include in the SV101-7 segment for HIPAA 5010A1 claims, a concise description of the NOC code. This segment is limited to 80 characters. If the claim is submitted without this information it will not pass the front-end edits and will be rejected by CEDI with:

  • CSCC A8: “Acknowledgement/Rejected for relational field in error” 
  • CSC 306: Detailed description of service
  • Edit Reference: X222.351.2400.SV101-7.020

Additional Information Required for Adjudication by the DME MAC

In addition, any HCPCS code with a narrative description that indicates NOC, unlisted, or nonspecified, that is billed to the DME MAC must also include the following in loop 2400 (line note), segment NTE02 (NTE01=ADD) of the ANSI X12N, version 5010A1 professional electronic claim format or in Item 19 of the paper claim form:

  • Concise description of the item billed
  • Manufacturer’s name
  • Product name/product number (if applicable)
  • Model number/serial number (if applicable)
  • Acronym “MSRP” or “MSP
  • MSRP

Note: In rare cases MSRP information is not available; in those rare cases suppliers should indicate “NO MSRP.”

There is a limit of 80 character spaces in the line note, so suppliers should abbreviate when possible. View the suggested abbreviations list on the National Government Services Web site.

Claims submitted to the DME MAC without the additional information required for adjudication will be rejected with ANSI code CO-16 with a reason code N350 which states, “Missing, incomplete, invalid description of service for a Not Otherwise Classified (NOC) code or an Unlisted procedure.” Appeal rights are not afforded and in order to correct these claim rejections suppliers must correct the claim and provide all of the required additional information needed for adjudication and resubmit.

Additional information regarding situations requiring a narrative explanation in loop 2400 (line note), segment NTE02 (NTE01=ADD) of the ANSI X12N, version 5010A1 professional electronic claim format or Item 19 of the claim form can be found in article titled “Situations Requiring a Narrative Explanation in Item 19,” available on the National Government Services Web site.

Revised Reminders on Billing the Appropriate Place of Service Code on Durable Medical Equipment Claims

Medicare payment is available for rental or purchase of DME used in a beneficiary's home. A beneficiary's home may be his/her own dwelling, an apartment, a relative's home, a home for the aged, or other type of institution. However, an institution may not be considered a beneficiary's home if it is a hospital or a SNF.

If an individual is a patient in an institution or a distinct part of an institution that meets the definition of a hospital or SNF, the individual is not entitled to have separate Part B payment made for rental or purchase of DME. This concept applies even if the patient resides in a bed or portion of the institution not certified for Medicare.

Therefore, separate payment for DME such as glucose monitors and supplies, support surfaces, wheelchairs, oxygen equipment, etc. is not available for beneficiaries residing in a nursing facility, even if it is not a Part A covered stay. If a DME claim is submitted while a beneficiary is in a SNF or nursing facility, suppliers may receive either a claim denial or an overpayment demand letter.

Related Claim Denials

Overlapping inpatient hospital stay:

  • CO-97 – DME claim submitted and beneficiary’s Medicare claim payment history contains an overlapping inpatient hospital stay.
  • OA-109 – Overpayment is identified due to an overlapping inpatient hospital stay, DME claim will be adjusted to deny and payment recouped.

Overlapping covered Part A SNF stay:

  • OA-109 – DME claim submitted and beneficiary’s Medicare claim payment history contains an overlapping covered Part A SNF stay
  • OA-109 – Overpayment is identified due to an overlapping covered Part A SNF stay, DME claim will be adjusted to deny and payment recouped.

Overlapping noncovered Part A SNF stay:

  • PR-96 – DME claim submitted and beneficiary’s Medicare claim payment history contains an overlapping noncovered Part A SNF stay
  • OA-109 – Overpayment is identified due to an overlapping noncovered Part A SNF stay, DME claim will be adjusted to deny and payment recouped.

Coverage for any DMEPOS item will be considered if the place of service is:

01 – Pharmacy
04 – Homeless Shelter
09 – Prison/Correctional Facility
12 – Home
13 – Assisted Living Facility
14 – Group Home
33 – Custodial Care Facility
54 – Intermediate Care Facility/Mentally Retarded
55 – Residential Substance Abuse Treatment Facility
56 – Psychiatric Residential Treatment Center
65 – ESRD Treatment Facility (valid POS for Parenteral Nutritional Therapy)

A complete list of place of service codes can be located in the Centers for Medicare & Medicaid Services (CMS) Interent-Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 26, Section 10.5.

Suppliers of prosthetics, orthotics, and supplies are reminded that coverage of prosthetics, orthotics, and supplies while a beneficiary resides in a NF or SNF, is dependent upon the status of the beneficiary’s Medicare Part A benefits. Additional information on payment of prosthetics, orthotics, and supplies while a patient resides in a NF or SNF can be located on the National Government Services Web site in the Jurisdiction B DME MAC Supplier Manual, Chapter 4.

Note: Place of service 54 should only be billed if the patient is mentally retarded and residing in an intermediate care facility strictly for the mentally retarded. A diagnosis of Alzheimer's disease, dementia, etc. does not meet this qualification.

Related Content

Original Posted 04/29/2011
Revised Posted 10/22/2013

Sequestration Questions and Answers

  1. How long is the 2% reduction to Medicare fee-for-service claim payments in effect?

    Answer:
    The sequestration order covers all payments for services with dates of service or dates of discharge (or a start date for rental equipment or multi-day supplies) on or after 4/1/2013, until further notice.

  2. If a durable medical equipment capped rental period started before 4/1/2013, are the rental payments for months after 4/1/2013, subject to the 2 percent reduction?

    Answer: 
    Any claims for rental payments with a “FROM” date of service on or after 4/1/2013, will be subject to the 2 percent reduction, regardless of when the rental period began. For example, if a capped rental wheelchair was provided in February 2013, the monthly rental payment for May 2013 would be subject to the 2 percent sequestration reduction. The initial and subsequent monthly rental payments billed with a “FROM” date of service beginning on or prior to 3/31/2013 would not be affected by the 2 percent reduction.

  3. Are drugs excluded from the 2 percent reduction?

    Answer:
    No. All FFS Medicare claim payments are subject to the 2 percent reduction. There are no exemptions provided in the law for drugs or any other health care item or service provided under the FFS program.

  4. Does the 2 percent payment reduction under sequestration apply to the payment rates reflected in Medicare FFS fee schedules or does it only apply to the final payment amounts?

    Answer:
    Payment adjustments required under sequestration are applied to all claims after determining the Medicare payment including application of the current fee schedule, coinsurance, any applicable deductible, and any applicable Medicare secondary oayment adjustments. All fee schedules, pricers, etc., are unchanged by sequestration; it’s only the final payment amount that is reduced.

  5. How is the 2 percent payment reduction under sequestration identified on the ERA and the SPR?

    Answer:
    CARC 253 is used to report the sequestration reduction on the ERA and SPR.

  6. What is the verbiage for CARC 253?

    Answer:
    “Sequestration – reduction in federal payment.” 

  7. Will the 2 percent reduction be reported on the remittance advice in a separate field?

    Answer:
    For institutional Part A claims, the adjustment is reported on the remittance advice at the claim level. For Part B physician/practitioner, supplier, and institutional provider outpatient claims, the adjustment is reported at the line level.

  8. How will the payments be calculated on the claims?

    Answer:
    The reduction is taken from the calculated payment amount, after the approved amount is determined and the deductible and coinsurance are applied.

    Example: A provider bills a service with an approved amount of $100.00, and $50.00 is applied to the deductible. A balance of $50.00 remains. We normally would pay 80% of the approved amount after the deductible is met, which is $40.00 ($50.00 x 80% = $40.00).The patient is responsible for the remaining 20 percent coinsurance amount of $10.00 ($50.00 - $40.00 = $10.00). However, due to the sequestration reduction, 2 percent of the $40.00 calculated payment amount is not paid, resulting in a payment of $39.20 instead of $40.00 ($40.00 x 2% = $0.80).
     

  9. Question: How are unassigned claims affected by the 2 percent reduction under sequestration?

    Answer:
    Though beneficiary payments toward deductibles and coinsurance are not subject to the 2 percent payment reduction, Medicare’s payment to beneficiaries for unassigned claims is subject to the 2 percent reduction. The nonparticipating physician who bills on an unassigned basis collects his/her full payment from the beneficiary, and Medicare reimburses the beneficiary the Medicare portion (e.g., 80 percent of the reduced fee schedule amount. Note: The “reduced fee schedule” refers to the fact that Medicare’s approved amount for claims from nonparticipating physicians/practitioners is 95 percent of the full fee schedule amount). This reimbursed amount to the beneficiary would be subject to the 2 percent sequester reduction just like payments to physicians on assigned claims. Both are claims payments, just to different parties. If the limiting charge applies to the service rendered, physicians/practitioners cannot collect more than the limiting charge amount from the beneficiary.

    Example: A nonparticipating provider bills an unassigned claim for a service with a limiting charge of $109.25.The beneficiary remains responsible to the provider for this full amount. However, sequestration affects how much Medicare reimburses the beneficiary. The nonparticipating fee schedule approved amount is $95.00, and $50.00 is applied to the deductible. A balance of $45.00 remains. Medicare normally would reimburse the beneficiary for 80 percent of the approved amount after the deductible is met, which is $36.00 ($45.00 x 80% = $36.00). However, due to the sequestration reduction, 2 percent of the $36.00 calculated payment amount is not paid to the beneficiary, resulting in a payment of $35.28 instead of $36.00 ($36.00 x 2% = $0.72).

    We encourage physicians, practitioners, and suppliers who bill unassigned claims to discuss with their Medicare patients the impact of the sequestration reductions to Medicare payments.

  10. Is this reduction based on the date of service or date of receipt?

    Answer:
    In general, Medicare FFS claims with dates-of-service or dates-of-discharge on or after 4/1/2013, will incur a 2 percent reduction in Medicare payment. Claims for DME, prosthetics, orthotics and supplies, including claims under the DME Competitive Bidding Program, will be reduced by 2 percent based upon whether the date-of-service, or the start date for rental equipment or multi-day supplies, is on or after 4/1/2013.

Updated 2/24/2016
Updated 3/18/2015
Updated: 3/31/2014
Updated: 4/19/2013
Updated: 4/8/2013
Updated: 3/26/2013
Issued: 3/18/2013

Situations Requiring a Narrative Explanation in Item 19

Following is a list of situations that require a supplier to submit additional information on an initial claim to assist in accurate claims processing. This list represents the most common situations requiring additional claim information; however, additional situations may exist and National Government Services, the Jurisdiction B DME MAC, may request additional claim information in other situations when necessary. Although the information listed below may be sufficient for initial claim processing, more detailed information specified in the Jurisdiction B Supplier Manual, medical policies, bulletin articles or the CMS manuals must be available upon request.

Several of these situations that require additional information on a claim are considered “Not Otherwise Classified” (NOC) codes. Any HCPCS that the narrative description indicates NOC, unlisted, or nonspecified that are billed to the DME MAC electronically must also include in the SV101-7 segment for HIPAA 5010 claims a concise description of the NOC code. This segment is limited to 80 characters.

Any additional information e.g., manufacturer, NDC number, size of the wound, etc. should be entered in loop 2400 (line note), segment NTE02 (NTE01=ADD) of the ANSI X12N, version 5010A1 professional electronic claim format. There is a limit of 80 character spaces in the line note, so suppliers should abbreviate when possible. If the supplier has an ASCA waiver on file and submits the CMS-1500 paper claim form, suppliers may report this information in Item 19 of the claim form.

View the suggested abbreviations list on our website. This resource and others can be found in the Related Content section at the end of this article.

  • Not Otherwise Classified Drugs
    Claims for drugs not otherwise classified (NOC) must include the name of the drug, the manufacturer, the national drug code (NDC) number, the dosage amount (i.e., 50 mg) and the number of tablets, capsules, vials, etc. dispensed.
  • Oral Anti-Cancer Drugs
    Claims for codes J8498 or J8597 must identify the name of the drug, the manufacturer, and the dosage strength of each tablet/suppository/etc. and the prescribed frequency of administration.
  • Oral Antiemetic Drugs (Q0181)
    Claims for code Q0181 must be accompanied by the name of the drug, the manufacturer, the dosage strength dispensed, the number of tablets and frequency of administration during the covered time period (24–48 hours) as specified on the order.
  • Immunosuppressive Drugs
    When submitting claims for immunosuppressive drugs, suppliers are encouraged to provide the following information to ensure efficient claim submission: transplant date, transplant facility name or number, and discharge date.
  • Unlisted Procedure Code/Miscellaneous Code (HCPCS E1399, K0108)
    Enter a concise description of an “unlisted procedure code.” Enter a description of the item, the manufacturer's name and product name/number, HCPCS or name of related base item (if applicable), and MSRP. In rare cases MSRP is not available; in those rare cases suppliers should indicate “NO MSRP.”
  • Replacement Parts for Equipment Repair/Miscellaneous HCPCS codes E1399 or K0108
    Replacement parts for equipment repair are billed using the specific HCPCS code (if one exists) or a miscellaneous HCPCS code, E1399 or K0108, for other accessories/parts. If HCPCS code E1399 or K0108 is billed, there must be a description, including the manufacturer name, model/serial number, product name of each item that is billed, and MSRP information for each item billed. In rare cases MSRP is not available; in those rare cases suppliers should indicate “NO MSRP”.
  • HCPCS K0739/Labor Associated Repair of Beneficiary-Owned DME
    A claim for HCPCS code K0739 must be accompanied by an explanation of what is being repaired and the HCPCS code or narrative description of the base item.
  • HCPCS L4205 and L7520/Labor Component of Repairs of Orthotics and Prosthetics
    A claim for HCPCS code L4205 or L7520 must be accompanied by an explanation of what is being repaired and the HCPCS code or narrative description of the base item.
  • HCPCS L4210 and L7510/Repair of Orthotic and Prosthetic Device, Replace Minor Parts
    Replacement of minor parts for orthotic or prosthetic repairs are billed using the specific HCPCS code (if one exists) or a miscellaneous HCPCS code, L4210 or L7510, for other accessories/parts. If HCPCS code L4210 or L7510 is billed, there must be a concise detailed description of the minor part being replaced. If available include the manufacturer name, model/serial number, product name of each item that is billed, and MSRP information for each item billed. In rare cases MSRP is not available; in those rare cases suppliers should indicate “NO MSRP”.
  • Temporary Loaner Equipment (K0462)
    The temporary loaner equipment (K0462) must be submitted on the same claim as the claim for repairs (labor and parts). The date of service billed for the temporary loaner equipment (K0462) must be the date the loaner equipment is delivered to the patient..
  • More Than Four modifiers/Modifier 99
    Enter all applicable modifiers when modifier 99 (multiple modifiers) is entered in Item 24d. If modifier 99 is entered on multiple line items of a single claim form, all applicable modifiers for each line item containing a 99 modifier should be listed as follows: 1=(mod), where the number 1 represents the line item and “mod” represents all modifiers applicable to the referenced line item. The modifiers should be listed first before any other narrative information and should not include any spaces. NTE
    Line Example: RRKHKX99
    NTE Example: RRKHKXBRRA
  • More Than Four Modifiers on Claim Line/Upgrade/Modifier KB
    When modifier KB (beneficiary requested upgrade, for ABN, more than four modifiers on claim line) is entered in fourth modifier position in Item 24d, enter all remaining modifiers in NTE. The remaining modifiers should be listed first before any other narrative information and should not include any spaces.
    Line Example: NUKHKXKB
    NTE Example: RABPGK
  • Upgrade/Modifier GL
    When providing a free upgrade, specify the make and model of the upgraded item/service that was provided and describe why the item/service was an upgrade.
  • Break in Need (BIN)
    For capped rental equipment, parenteral and enteral nutrition pumps, and oxygen equipment during the 36-month capped rental period only, claims following an interruption due to break in need must include a narrative statement describing the reason for the interruption which shows that medical necessity in the prior episode ended. Narrative must be in the following format:
    BIN MMDDYY MMDDYY DX DX
    1. The abbreviation “BIN” for break in need
    2. The “pick up” date and the “delivery” date
    3. The beneficiary’s previous ICD-9-CM diagnosis code and the new ICD-9-CM diagnosis code
  • If the previous diagnosis code and the new diagnosis code are the same, indicate the reason for the BIN, (i.e., patient’s condition improved to the point they no longer needed the item)

    The “pick up” date refers to the date the new and/or previous supplier removes the piece of equipment from the patient’s home. The “delivery” date will be the most recent date the new item was delivered. The format does not require spacing between the required elements.
  • Break in Billing
    When a beneficiary’s admission to an institutional provider overlaps the supplier’s “anniversary date,” the date of discharge from the inpatient admission becomes the new “anniversary date” for subsequent supplier claims. The claim must include an annotation in either the NTE segment of the electronic claim or Item 19 of the CMS-1500 claim form, explaining the reason for the interruption and change in anniversary date. An example annotation would be: ADM TO SNF 060108 DISC 081508.
  • Replacement Equipment/Reasonable Useful Lifetime of Equipment Has Been Met
    When submitting the initial claim for a replacement item when the reasonable, useful lifetime of the item has been reached, indicate the reason for replacing equipment and the date the beneficiary received the original equipment that is being replaced. The abbreviation RUL, indicating reasonable useful lifetime, is sufficient.
    The abbreviation “RUL” which indicates “reasonable useful lifetime”
    The date the beneficiary received the original equipment that is being replaced (MMDDYY)
    Example:
    RUL 050103
  • Replacement Equipment/Lost, Stolen, Irreparably Damaged Equipment
    Include a narrative explanation when submitting the initial claim for a replacement item. Include information as to why the patient can no longer use the prior item, or why the item cannot be repaired. Example: “item lost,” “item stolen,” or “item irreparably damaged.” This information should appear first in the NTE segment, followed by details about the replacement item, including the manufacturer and/or model number.
  • Supplies and Accessories used with Beneficiary-Owned Equipment
    Supplies and accessories used with beneficiary-owned equipment which was not paid for by traditional Medicare, i.e., equipment that was paid by other insurance or by the beneficiary, must contain the following information on the initial claim:
    • HCPCS code of base equipment
    • A notation that this equipment is beneficiary-owned
    • Date the patient obtained the equipment
  • Surgical Dressing/Modifier A9
    If modifier A9 (Dressing for nine or more wounds) is used, information must be submitted indicating the number of wounds to which the dressing is being applied.
  • Surgical Dressing (A4649, A6261, A6262, A6512)
    Enter the size of the wound(s), the manufacturer and/or brand name, manufacturer retail price, product name/number, wound covers—pad size (not including adhesive border), wound fillers - number of fluid ounces or grams in each individual tube/packet.
  • Dressing Provided in Noncovered Situations
    When gauze is used in the cleansing of a wound or intact skin, modifier GY must be added to the code and a brief description of the reason for noncoverage included.
    Example: A6216GY—used for wound cleansing.
  • Patient Refuses to Assign Benefits
    Enter the statement, “patient refuses to assign benefits” when the beneficiary absolutely refuses to assign benefits to a participating provider. In this case, no payment may be made on the claim.
  • Billing for a CPM Device
    The claim must include all the following information:
    • The type of surgery performed (such as “total knee replacement”) or provide the CPT code for the surgical procedure (e.g., 27447, 27486, or 27487)
    • Date of the surgery
    • Date the device was initiated
    • Date of discharge from the hospital or NH (if the patient is discharged from the hospital to a SNF or rehabilitation center before going home, please use the discharge date when the patient went home)

      The following is an example of the information provided in the NTE segment using abbreviations:

      SURGERY DT 6/1/09 DT APPLIED 6/2/09 DT D/C HOME 6/5/09 CPT 27447
  • Oxygen Patient on Four Liters per Minute with Portable Equipment
    When beneficiary is using more than 4 LPM, and is using a portable oxygen system also, submit narrative information stating the beneficiary is using the portable unit along with the HCPCS of the item
  • Oxygen Claims for Diagnosis Unrelated to Lung Disease Where Testing Has Not Been Performed
    Suppliers billing for denial for secondary insurance purposes will also include a ‘GA’ modifier. Include a narrative in the NTE segment or Item 19 of the paper claim followed by the ICD-9 code.
    Example: NO TEST PERFORMED BILLING FOR DENIAL ICD-CODE
  • Oxygen Modality Change – after 36 month cap
    The LCD for Oxygen and Oxygen Equipment (L27221) states that if the beneficiary was not using gaseous or liquid equipment (stationary or portable) in the 36th month, but was subsequently switched to gaseous or liquid oxygen based on a physician order, contents may be paid.

    When submitting claims for contents following a change in oxygen modality that occurs after month 36. Narrative must be in the following format:
  1. Change in modality prescribed by physicianE0424E0431
  2. A notation indicating a change in modality was prescribed by the physician
  3. The HCPCS code(s) of the gaseous or liquid (stationary or portable) equipment currently being used by the patient for which the contents are necessary
  • HCPCS A5507—For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe, per shoe
    When billing for HCPCS A5507 suppliers must indicate in Item 19 of the CMS-1500 claim form or in the NTE segment field of the electronic claim, a detailed description of the item being billed and any additional information to aid in the correct adjudication of the claim.
  • Custom fabricated cushion (E2609, E2617)
    When billing for a custom fabricated cushion (E2609, E2617), the claim must include the manufacturer and model name/number of the product (if applicable), or if not, a detailed description of the product that was provided.
  • Walker (E0147)
    When code E0147 is billed, the claim must include the manufacturer’s name and product name/number.
  • Beneficiary Noncompliance with Medical Policies
    When submitting claims for items when a beneficiary is noncompliant with continued coverage requirements specified in medical policies. Examples of medical policies that specify continued coverage criteria would be oxygen and positive airway pressure devices. Suppliers should report the months of service when a beneficiary is noncompliant to extend the payment record on file with Medicare so they receive 13/36 monthly rental payments they are entitled to without having to go through the appeals process. This information should be reported on all claims when the beneficiary becomes compliant per the medical policy and the supplier resumes billing with the DME MAC. Narrative must be in the following format:

    NONCOMPLIANT070112082712
    1. The word “NONCOMPLIANT” for noncompliant months of service
    2. The “noncompliant date” (MMDDYY)
    3. The “compliant date” (MMDDYY)
  • Secondary ventilators (E0463)
    Patients may qualify for both a primary ventilator and a secondary ventilator in certain situations. When submitting claims for secondary ventilators, suppliers must enter the reason for medical necessity of the secondary ventilator.

    Patients may qualify for both a primary ventilator and a secondary ventilator in certain situations. Below are examples of when a patient will qualify:
    • A patient requires one type of ventilator (e.g., a negative pressure ventilator with a chest shell) for part of the day and needs a different type of ventilator (e.g., positive pressure ventilator with a nasal mask) during the rest of the day.
    • A patient who is confined to a wheelchair requires a ventilator mounted on the wheelchair for use during the day and requires a stationary ventilator of the same type for use while in bed. Without two pieces of equipment the patient may be prone to certain medical complications, may not be able to achieve certain appropriate medical outcomes, or may not be able to use the medical equipment effectively.

Related Content

Revised 10/30/2015

Suggested Abbreviation List for Submitting Narrative Information

The following abbreviations may be used in the NTE 2400 (line note) or NTE 2300 (claim note) segments of the American National Standard Institute (ANSI X12) format or field 498-PP of the National Council for Prescription Drug Program (NCPDP) format. These abbreviations may also be used in Item 19 of the CMS-1500 claim form.

Abbreviation Description
ABN Advance Beneficiary Notice of Noncoverage
ADMC Advanced Determination of Medical Coverage
ADMD Admit Date
AFO Ankle-foot orthotic
ANND Anniversary Date
AOB Assignment of Benefits
ASP Average sales price
AWP Average wholesale pricing
BiPAP Bi-level Positive Airway Pressure
BIB Break In Billing
BIS Break In Service
BBR Broken Beyond Repair
DISC Discount
DISD Discharge Date
DLD Delivery Date
DOP Date of Purchase
DOS Date of Service
EPO Epoetin
EQ Equipment
EN Enteral Nutrition
ESRD End Stage Renal Disease
FFS Fee-for-Service
GT CL BE Greater Clinical Benefit
IC Requesting Individual Consideration
IDD Irreparable Damage Date
IOL Intraocular lens
IP Inpatient
IPPB Intermittent Positive Pressure Breathing
IV Intravenous
KAFO Knee-ankle foot orthotic
LOS Length of stay
LPM Liters per minute
LSO Lumbar-sacral orthosis
MDL Model Number
MFG Manufacturer Number
MISC K0108 or E1399
MS Maintenance/Service
MWC Manual Wheelchair
NDC National drug code
NDX New Diagnosis Code
#WNDS Number of Wounds
NPWT Negative pressure wound therapy
ODX Old Diagnosis Code
OP Outpatient
ORIG Original
OWN Patient/Beneficiary Owned
PAP Positive Airway Pressure
PEN Parenteral and enteral nutrition
PN Parenteral nutrition
PUR Purchased
P&O Prosthetic and orthotic
PORTO2 Portable Oxygen Unit
PMD Power mobility device
POS Place of service
POV Power-operated vehicle
PUD Pick Up Date
PWC Power Wheelchair
RAD Respiratory Assist Device
RDF Renal dialysis facility
RPL Replacement
RPR Repair
RUL Reasonable Useful Lifetime
SD Surgery Date
SNF Skilled nursing facility
SOB Shortness of breath
SRL Serial Number
TENS Transcutaneous Electrical Nerve Stimulator
TENS 2L or 4L TENS 2 Leads or 4 Leads
TPN Total Parenteral Nutrition
TLSO Thoracic-Lumbar-Sacral Orthosis
UOS Units of Service
WC Wheelchair
WOPD Written order prior to delivery

Supplier Replacement of Beneficiary-Owned Capped Rental Equipment Based Upon Accumulated Repair Costs

Recently, the DME MAC have received inquiries about the CMS Fact Sheet, Power Mobility Devices (PMDs): Complying with Documentation & Coverage Requirements.

The Fact Sheet states:

Under a special rule established for certain patient-owned equipment, such as a power wheelchair for which the title has been transferred to the patient after 13 continuous months of rental, the supplier must replace the equipment free of charge if it does not last the full 5-year period (i.e., is no longer serviceable or needs substantial repairs). This replacement equipment does not need to be ‘new’. For more information, refer to 42 Code of Federal Regulations (CFR) Section 414.210(e)(4).

This passage references regulations that implemented the DRA of 2005. This regulation stipulates that the supplier is responsible for replacement of a capped rental item if it is determined to be incapable of lasting for the entire 5 year reasonable useful lifetime. Replacement is provided at no cost to the beneficiary or to the Medicare Program. 42 CFR Section 414.210(e)(4) states:

(4) Supplier replacement of beneficiary-owned equipment based on accumulated repair costs. A supplier that transfers title to a capped rental item to a beneficiary in accordance with §414.229(f)(2)* is responsible for furnishing replacement equipment at no cost to the beneficiary or to the Medicare program if the carrier determines that the item furnished by the supplier will not last for the entire reasonable useful lifetime established for the equipment in accordance with §414.210(f)(1)**. In making this determination, the carrier may consider whether the accumulated costs of repair exceed 60 percent of the cost to replace the item.

* Section 414.229(f)(2) describes requirements for providing a capped rental item
** Section 414.210(f)(1) describes reasonable useful lifetime requirements

The default RUL of DME is five years unless otherwise specified. Therefore, DME dispensed to Medicare beneficiaries is expected to remain in proper working condition throughout the required five year RUL. If it is determined based upon accumulated repair costs that the item is unable to last for the entire five-year RUL, the supplier must replace the equipment with properly working equipment at no charge to the beneficiary or the Medicare Program.

“Accumulated repair costs” refer to all repair claims from all suppliers for a given item after the rental period ends. These repair costs represent the total of all repair costs after the beneficiary has assumed ownership of the item.

The DME MACs encourage suppliers to provide DME items of sufficient quality to last for the entire five-year RUL.

Refer to the Jurisdiction B (JB) Supplier Manual and/or the applicable local coverage determination and related policy article located on the National Government Services Web site for additional information on repairs and replacement.

Related Content

“Fragmented” Billing for Nonparticipating Suppliers

Suppliers who enroll in the Medicare Program have an option of being a participating or nonparticipating supplier. A supplier who enters into a participation agreement (CMS form 460) with Medicare agrees to accept assignment on all claims for Medicare services. Suppliers who do not enter into a participation agreement with Medicare (i.e., nonparticipating suppliers) may accept assignment on a claim-by-claim basis unless they are required by law to accept assignment.

The CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 30.3.2 advises that nonparticipating suppliers may not attempt to circumvent the Medicare allowed amount limitation by “fragmenting” bills. Bills are considered “fragmented” when a supplier accepts assignment for some services, and payment from the enrollee for other services performed at the same place and on the same date of service.

The DME MACs consider “fragmented” billing when a supplier bills the same HCPCS code as some of the services assigned and some as nonassigned. In particular, there have been many questions regarding “fragmented billing” for external breast prostheses. For example, if a beneficiary receives two mastectomy bras (L8000) on the same day and at the same place, and the beneficiary assigns the claim to a supplier, the nonparticipating supplier may not bill one claim as nonassigned for an L8000 and another claim as assigned for an L8000. If so, this is considered fragmented billing. The nonparticipating supplier must choose to submit the two mastectomy bras (L8000) as either assigned or nonassigned claims.

However, if on the same day a beneficiary receives two mastectomy bras (L8000) and a silicone prosthetic (L8030) and the beneficiary assigns the claim to a nonparticipating supplier, the nonparticipating supplier may choose to either:

  1. Submit the claims as assigned or nonassigned for all services, or
  2. Submit one claim as assigned and the other as nonassigned (e.g., submit the prosthetic (L8030) as assigned on one claim and the mastectomy bras (L8000) as nonassigned on the other claim (or vice versa).

Suppliers may contact the National Supplier Clearinghouse for information on being a participating or nonparticipating supplier at 866-238-9652 from 9 a.m. until 5 p.m. eastern time to reach a customer service representative.

Related Content

Web Content Viewer
Complementary Content