DME Modifiers

March 16, 2017

© 2017 Copyright. 1

TODAY’S PRESENTATION Once you are connected to the webinar,

select Handouts

Select modifiers_2017.pdf to download

the presentation

XXX

AUDIOOnce you are connected to the audio,

the PIN displays

Input the PIN on your screen into your

telephone

Dial-in number and PIN are unique for

each attendee

Type it here.

Hit send.

QUESTION BOXTo ask a question in the question box . . .

Acronyms

ABN: Advance Beneficiary Notice of Noncoverage

CBIC: Competitive Bid Implementation Contractor

DMEPOS: Durable Medical Equipment, Prosthetics, Orthotics & Supplies

IRP: Inexpensive or Routinely Purchased

LCD: Local Coverage Determination

PDAC: Pricing, Data Analysis and Coding

5

Agenda

◦ Payment Category Modifiers

◦ Oxygen Modifiers

◦ Parenteral, Enteral, and External Infusion Pump Modifiers

◦ KX and Related Modifiers

◦ Supply Specific Modifiers

◦ Miscellaneous Modifiers

◦ Repair and Replacement Modifiers

◦ Competitive Bid Modifiers

◦ Advanced Beneficiary Notice of Noncoverage (ABN) Modifiers

What is a Modifier?

◦ Modifiers are defined as:

Two digit codes that indicate services or procedures have been altered by some specific

circumstance. Modifiers do not change the definition of the reported procedure codes

Modifiers can be pricing, informational, or both

◦ A list of DMEPOS modifiers is available on the PDAD Website at:

https://www.dmepdac.com/dmecsapp/do/search

Leave the field blank and click “Go” in the modifier search engine for a full listing

Modifiers - Did you Know?

◦ Modifiers are consistently the number one reason for front end

claim rejections and return/reject claims

◦ There is a limit of four (4) modifiers per claim line; additional

modifiers can be accommodated by appending one of the

overflow modifiers (KB or 99)

◦ Pricing modifiers will be listed on the fee schedule next to the

HCPCS code

Order of Modifiers

◦ Pricing modifiers (NU, RR, or UE), where applicable, should be in the first modifier

position

◦ When billing 2 units of a capped rental item, modifiers RT and LT must be in

positions two and three

◦ Overflow modifiers, 99 or KB, must be in the 4th modifier position when utilized

◦ Other modifiers can be in any position and the DME MAC will

re-organize for appropriate processing

Payment Category Modifiers

Payment Categories

Most DMEPOS fall into the following categories:

◦ Capped Rental

◦ Inexpensive or Routinely Purchased DME

◦ Frequent and Substantial Servicing DME

◦ Oxygen and Oxygen Equipment

◦ Prosthetics and Orthotics

◦ Customized DMEPOS

How to Determine the

Payment Category?

Look up the HCPCS on the DMECS Website or view on the DME MAC Fee Schedule:

http://www.dmepdac.com

How to Determine

the Payment Category?

Capped Rental Modifiers

◦ Paid on rental basis only

RR - Rented Item

◦ Identify the rental month being billed:

KH - First rental month

KI - Second and third rental month

KJ - Fourth through thirteenth month

◦ CPAP Example:

E0601RRKHKX - Month 1

E0601RRKIKX - Month 2 and 3

E0601RRKJKX - Month 4 - 13

Capped Rental Modifiers

◦ Exception: Certain motorized wheelchairs (K0835 – K0891) may be purchased in the

first month.

When purchased, use:

NU - New purchased item or UE - Used purchase

BP - Beneficiary purchase

Example: K0835NUKHBPKX or K0835UEKHBPKX

When rented, use:

RR - Rental Item

BR - Beneficiary Rental

Example: K0835RRKHBRKX

◦ K0813-K0831 and K0898 cannot be purchased in the first month

Frequently and

Substantially Serviced (FSS)

These are items that require frequent and substantial servicing in order to

avoid risk to the health of the beneficiary

◦ Must be rented, never purchased

◦ RR modifier - Rented Item

◦ Will be paid on a monthly rental basis for as long as the equipment is medically

necessary

◦ Ventilator Example: E0466RR

Inexpensive or Other Routinely

Purchased (IRP) DME

◦ May be purchased or rented

RR - Rented item or

NU - New purchased item or

UE - Used purchased item

◦ Crutches example:

E0110RR

E0110NU

E0110UE

Oxygen Modifiers

Oxygen and Oxygen Equipment

◦ Portable and Stationary units are paid as rental up to 36 months

RR - Rental

Example: E1390RR

◦ Prescribed liter flow rate must be identified for high

or low liter flow and will affect payment rate:

QE - Less than 1 liter per minute (LPM) prescribed

QF - Greater than 4 LPM prescribed with portable system

QG - Greater than 4 LPM prescribed

Example: E1390RRQE, E1390RRQF, E1390RRQG

Oxygen and Oxygen Equipment

◦ Oxygen conserving devices must be identified for informational purposes only and

will not affect payment rate:

QH - Oxygen conserving device used with oxygen delivery system

◦ Contents

No modifiers on content codes (E0441-E0444)

Oxygen and Oxygen Equipment

◦ Maintenance & Service

Medicare can pay for a general MS fee starting six (6) months after the end of the 36-month

rental period for concentrators and transfilling equipment

Only applies to equipment falling under HCPCS codes E1390, E1391, E1392, and K0738

Supplier must physically make an in-home visit to inspect the equipment and provide any

necessary maintenance and service

Example: E1390MS

Parenteral, Enteral, and

External Infusion Modifiers

Parenteral and Enteral Nutrition Pumps

◦ HCPCS: B9002, B9004, B9006

Can be rented or purchased

Modifiers:

NU, UE, RR

KH, KI, KJ

BP, BR

First billing month examples: B9002NUKHBP, B9002RRKHBR, B9002UEKHBP

If rented, will rent for a maximum of 15 months

Ownership remains with the supplier after 15 months and maintenance and service can be

billed when performed

MS billable once every six months for enteral pumps

MS billable once every three months for parenteral pumps

Example: B9002MS

Enteral Nutrition - Oral Administration

◦ Enteral nutrition products that are administered orally and related supplies are

noncovered

◦ When enteral nutrients (B4149-B4162) are administered by mouth:

Bill the appropriate procedure code, and

Append the BO modifier

Example: B4150BO

IV Poles (HCPCS: E0776)

◦ IV Pole with

Enteral Nutrition

Billed as a continuous rental or

purchase and must be billed

with the “BA” modifier and a

KG if provided in a competitive

bid area

E0776NUBAKG

(competitive bid area only)

E0776UEBAKG

(competitive bid area only)

E0776RRBAKG

(competitive bid area only)

IV Pole with Parenteral Nutrition

• Billed as a continuous rental or

purchase and must be billed with

the “BA” modifier

– E0776NUBA

– E0776UEBA

– E0776RRBA

IV Pole with External Infusion Pump

• Billed as a purchase or rents to

purchase price and billed without

“BA” modifier

– E0776NU

– E0776UE

– E0776RR

External Infusion

◦ JB - Administered subcutaneously

◦ Route of Administration is subcutaneous, and

◦ Billing for immune globulin J1559, J1561, J1562, and

◦ Infusion pump E0779

Example:

E0779RRKHJB

J1559JB

J1561JB

J1562JB

KX and Related Modifiers

KX Modifier

◦ Requirements specified in the medical policy have been met

◦ Coverage criteria and documentation requirements must be met

◦ Documentation is essential in supporting the item is reasonable

and necessary

◦ Review each specific LCD to confirm the documentation requirements and which

codes require use of the KX

JA: https://med.noridianmedicare.com/web/jadme/policies/lcd/active

JB: http://www.cgsmedicare.com/jb/coverage/lcdinfo.html

JC: http://www.cgsmedicare.com/jc/coverage/lcdinfo.html

JD: https://med.noridianmedicare.com/web/jddme/policies/lcd/active

LCDs with a KX Modifier Requirement◦ Ankle-Foot/Knee-Ankle-Foot Orthosis

◦ Automatic External Defibrillators

◦ Cervical Traction Devices

◦ Commodes

◦ External Infusion Pumps

◦ Glucose Monitors

◦ High Frequency Chest Wall Oscillation Devices

◦ Hospital Beds

◦ Immunosuppressive Drugs

◦ Knee Orthoses

◦ Manual Wheelchair Bases

◦ Nebulizers

◦ Negative Pressure Wound Therapy Devices

◦ Oral Antiemetic Drugs

◦ Oral Appliances for Obstructive Sleep Apnea

Orthopedic Footwear

Patient Lifts

Positive Airway Pressure Devices

Power Mobility Devices

Pressure Reducing Support Surfaces

Refractive Lenses

Respiratory Assist Devices

Speech Generating Devices

Therapeutic Shoes for Persons with Diabetes

Transcutaneous Electrical Nerve Stimulators

Urological Supplies

Walkers

Wheelchair Options and Accessories

Wheelchair Seating

KX Modifier

◦ GA, GY, and GZ modifiers have been added to LCDs to indicate that the relevant KX

modifier requirements have not been met

Glucose Monitor LCD is the only exception

◦ Claims without KX, GA, GZ, or GY modifiers will be rejected and must be

resubmitted with the appropriate modifier

◦ A KX, GA, GZ, or GY modifier cannot be added/removed/updated through claim

reopenings

KX Modifier Examples

◦ CPAP Device

Criteria met per PAP LCD

E0601RRKHKX

Criteria not met per PAP LCD - ABN on file

E0601RRKHGA

Criteria not met per PAP LCD - No ABN on file

E0601RRKHGZ

◦ Intermittent Urinary Catheter

Criteria met per Urological Supplies LCD and Policy Article

A4353KX

Criteria not met per Urological Supplies Policy Article

A4353GY

Supply Specific Modifiers

Non-End Stage Renal Disease (ESRD)

Related Supplies (AY)

AY - Item or service furnished to an ESRD patient that is not

for the treatment of ESRD

◦ A4215

◦ A4216

◦ A4217

◦ A4218

◦ A4244

◦ A4245

◦ A4246

◦ A4247

◦ A4248

A4450

A4452

A4657

A4660

A4663

A4670

A4927

A4928

A4930

A4931

A6215

A6250

A6260

A6402

E0210

E1639

Surgical Dressings (AW)

◦ AW - Item furnished in conjunction with a surgical dressing

◦ AW required for the following HCPCS when provided under the Surgical Dressing

LCD requirements:

A4450 - Tape, non-waterproof, per 18 square inches (requires A1-A9)

A4452 - Tape, waterproof, per 18 square inches (requires A1-A9)

A6531 - Gradient compression stocking, below knee, 30-40 MMHG,

each (requires RT and/or LT)

A6532 - Gradient compression stocking, below knee, 40-50 MMHG,

each (requires RT and/or LT)

A6545 - Gradient compression wrap, non-elastic, below knee,

30-50 MM HG, each (requires RT and/or LT)

Surgical Dressings (A1-A9)

◦ Indicates that a particular item is being used as a primary or secondary dressing on a

surgical or debrided wound and indicates the number of wounds the dressing is used

on

◦ Modifier number must correspond to the number of wounds on which the dressing is

being used, not the total number of wounds treated

◦ Not used with codes A6531, A6532, and A6545

◦ If A9 is billed, the claim must include the number of wounds

Glucose Supplies (KS or KX)

◦ KS - Glucose monitor supply for diabetic beneficiary not treated

by insulin

Patient is not being treated with insulin injections

Must be added to the code for the monitor and each related supply

Example: E0607NUKS, A4253NUKS, A4259KS

◦ KX - Specific required documentation on file

Effective 08/01/2013 - KX is defined as “Requirements specified in the

medical policy have been met”

Patient is being treated with insulin injections

Must be added to the code for the monitor and each related supply

Example: E0607NUKX, A4253NUKX, A4259KX

Glucose Supplies (KL)

◦ Suppliers must use the KL modifier on all claims for diabetic supply codes (A4233,

A4234, A4235, A4236, A4253, A4256, A4258, and A4259) that are furnished via mail

order to beneficiaries

Example: A4253NUKSKL or A4253NUKXKL

◦ The KL modifier is not used with diabetic supply codes that are not delivered to the

beneficiary’s residence; however, are obtained from local supplier storefronts

◦ Must be a contract supplier

Miscellaneous Modifiers

RT and LT Modifiers

◦ LT - Left side

◦ RT - Right side

◦ RT and LT are required for specified items in the following LCDs:

AFO/KAFO

External Breast Prosthesis

Eye Prosthesis

Facial Prosthesis

Knee Orthoses

Lower Limb Prosthesis

◦ Refer to the appropriate LCD for specific billing details

• Orthopedic Footwear

• Refractive Lenses

• Surgical Dressings

• Therapeutic Shoes for Persons

with Diabetes

• Wheelchair Options/Accessories

Nebulizer Drugs

Unit dose formulation modifiers

◦ KO: Single drug unit dose formulation

◦ KP: First drug of multiple drug unit dose formulation

◦ KQ: Second or subsequent drug of multiple drug unit dose formulation

Unit dose codes billed without appropriate modifier deny as invalid code

◦ Exception: J7620 (Albuterol/Ipratroprium) does not require KO, KP, or KQ

JW Modifier• Effective for claims with DOS on or after 1/1/17

• JW modifier- drug amount discarded/not administered to any patient

• For the DME MACs, the JW modifier only applies to the following LCDs:

◦ External Infusion Pumps

◦ Intravenous Immune Globulin (IVIG)

◦ Nebulizers

• Claims for drugs billed to Medicare must use drug dosage formulations

and/or unit dose sizes that minimize wastage

41

JW Modifier

Scenario 1: HCPCS code Unit of Service (UOS) is less than the drug

quantity contained in the single use vial or single dose package:

◦ The quantity administered is billed on one claim line without the JW

modifier

◦ The quantity discarded is billed on a separate claim line with the JW

modifier

◦ Both claim lines would be processed for payment

Scenario 2: HCPCS code UOS is equal to or greater than the total of

the actual dose and the amount discarded

◦ Use of the JW modifier is not permitted.

◦ If the quantity of drug administered is less that a full UOS, the billed

UOS is rounded to the appropriate UOS.

42

Special Power Wheelchair Interface

◦ KC - Replacement of special power wheelchair interface

Used for the following situations:

Integrated joystick and controller is being replaced by another drive control

interface due to patient’s condition

Interface (e.g., joystick, head control, sip and puff) and the controller electronics

are being replaced due to irreparable damage, such as:

E2321-E2322, E2325, E2327-E2330, or E2373

KC modifier would never be used at initial use of wheelchair, only for replacement

RB Modifier is not necessary since KC specifically indicates replacement

Class III Devices

◦ KF - Item designated by FDA as Class III device

Must be submitted for HCPCS, when the specific device has been classified by the FDA as a

Class III device

• E0617

• E0747

• E0748

• E0760

• E0764

• E0766

• E0766

• K0606

• K0607

• K0608

• K0609

• K0861

EY Modifier

◦ EY - No physician or other licensed health care provider order

for this item or service

◦ Items submitted without order will deny as not reasonable

and necessary

Exception for items which require a Written Order Prior to Delivery,

which will deny as not meeting the benefit category

PR - Patient Responsibility

◦ ABN is recommended to protect supplier from liability

GY Modifier

◦ GY - Item or service statutorily excluded or does not meet

the definition of any Medicare benefit

◦ Examples:

Hearing aids

Personal comfort items

Wheelchairs exclusively for use outside the home

Statutorily non-covered items

GW Modifier

◦ GW - Item or service not related to the hospice patient’s

terminal condition

Used specifically for beneficiaries enrolled in a Medicare Advantage Plan while receiving

hospice care and whom are receiving items unrelated to their hospice diagnosis

Any items related to the patient’s terminal condition are included in the hospice payment rate

and are not payable by the DME MAC

Overflow Modifiers

◦ KB - Beneficiary requested upgrade for ABN, more than 4 modifiers identified on

claim

Replace the fourth modifier with the KB modifier and place the remaining ABN modifiers in

Item 19 of a paper claim or the NTE 2400 field of an electronic claim

◦ 99 - Modifier overflow

Used for non-upgrade claims with more than 4 modifiers

Replace the fourth modifier with the 99 modifier and place the

remaining modifiers in Item 19 of a paper claim or the NTE 2400

field of an electronic claim

Repair and

Replacement Modifiers

Repair and Replacement Modifiers

◦ RA - Replacement of a DME, Orthotic or Prosthetic item

Replacement of DME, Orthotic or Prosthetic item due to loss, stolen, irreparable damage or

reached it’s useful lifetime

◦ RB - Replacement of a part of a DME, Orthotic or Prosthetic item furnished as part of

a repair

Competitive Bid Modifiers

Competitive Bid Modifiers

◦ KE Modifier - Bid under round one of DMEPOS Competitive Bidding Program for use

with a non-competitive bid base equipment

The KE modifier must be used to identify an accessory code that can be dually billed with

either a competitive or non-competitive bid base item and is not subject to the fee schedule

reduction under MIPAA

KE modifier use was suspended for dates of service on or after July 1, 2016

◦ KY Modifier - For wheelchair accessories, modifier “KY” is used to identify a

competitively bid wheelchair accessories that should be paid at fee schedule when

billed for use with a base unit that was not bid, even when provided to a beneficiary

that resides in a CBA and without regard to the contract status of the supplier

KU Modifier

◦ KU Modifier – Wheelchair accessory and seat and back cushions used with a Group

3 Complex Rehab wheelchair base (K0848 – K0864)

Effective for Dates of Service: January 1, 2016 – June 30, 2017

◦ List of accessories to which the KU modifier applies is located in

CR 9520:

https://www.cms.gov/Regulations-and-

Guidance/Guidance/Transmittals/Downloads/R3535CP.pdf

Competitive Bid Modifiers

◦ KT Modifier - Beneficiary resides in a CBA and travels outside that CBA and receives

a competitive bidding item

◦ KV Modifier - DMEPOS item subject to DMEPOS Competitive Bidding Program that

is furnished as part of a professional service

◦ J4 Modifier - DMEPOS item subject to DMEPOS Competitive Bidding Program that

is furnished by a hospital upon discharge

KG Modifier

◦ KG Modifier – Used to identify when the same supply or accessory is furnished in

multiple competitive bidding product categories or when the same code can be used

to describe both competitively and non-competitively bid items

◦ Suppliers should only apply modifier KG to competitive bid HCPCS codes according

to current policy instructions. HCPCS codes designated as valid for use with the KG

modifier are listed in the Single Payment Amount Files at:

http://dmecompetitivebid.com

Advanced Beneficiary

Notice of Noncoverage (ABN)

Modifiers

Definitions of ABN Modifiers

◦ GA - Waiver of liability (expected to be denied as not reasonable and necessary,

ABN on file)

◦ GZ - Item or service not reasonable and necessary (expected to be denied as not

reasonable and necessary, no ABN on file)

◦ GK - Actual item or service ordered by physician, item associated with GA or GZ

modifier

◦ GL - Medically unnecessary upgrade provided instead of standard item no charge,

no ABN on file

GX Modifier

◦ GX - Notice of liability issued, voluntary under payer policy

◦ Used to report instances where a voluntary ABN was issued

for an item

◦ May be reported on the same line as certain other liability-related modifiers (i.e. GY

modifier)

Example: J3370GYGX

(Vancomycin not administered via external infusion pump)

DME Upgrades

ABN and Claims Modifiers

ABN

Required

Required

Modifier(s)DMAC Payment

Beneficiary Pays

for Upgrade

1) Physician orders upgrade:

a) Supplier provides upgrade free of charge

to beneficiaryNo GL

R&N item only

(GL line)No

b) Supplier bills beneficiary for upgrade Yes GA/GKR&N item only

(GL line)Yes

2) Patient requests upgrade:

a) Supplier providers upgrade free of charge

to beneficiaryNo

GZ/GK R&N item only

(GL line)No

b) Supplier bills beneficiary for upgrade YesGA/GK R&N item only

(GL line)Yes

3) Supplier providers upgrade for supplier convenience

a) Supplier provides upgrade free of charge

to beneficiaryNo GL

R&N item only

(GL line)No

Resources

JA and JD Modifier Resources

◦ Browse by Topic – Modifiers

◦ JA - https://med.noridianmedicare.com/web/jadme/topics/modifiers

◦ JD - https://med.noridianmedicare.com/web/jddme/topics/modifiers

◦ One stop includes

Modifier definitions

Modifier presentations

Modifier Q & A

DME on Demands for Modifiers (A1-A9, Au, AV, AW, GA, GZ, CX, EY, GY, KX, RT/LT and Upgrades)

◦ Policies

◦ JA – https://med.noridianmedicare.com/web/jadme/policies

◦ JD - https://med.noridianmedicare.com/web/jddme/policies

JB and JC Modifier Resources

◦ Modifier Finder Tool:

JB: http://www.cgsmedicare.com/medicare_dynamic/modifiers_jb/search.asp

JC: http://www.cgsmedicare.com/medicare_dynamic/modifiers_dme/search.asp

◦ KE & KY Modifier Tool: http://www.cgsmedicare.com/medicare_dynamic/dme/

ke_ky_modifier_tool.asp

◦ KX Table:

JB: http://www.cgsmedicare.com/jb/help/kx_table.html

JC: http://www.cgsmedicare.com/jc/pubs/news/2010/0510/cope12183.html

◦ Repair Modifier Tool: http://www.cgsmedicare.com/medicare_dynamic/dme/

repair_modifier_tool.asp

◦ LCDs and Policy Articles

JB: http://www.cgsmedicare.com/jb/coverage/lcdinfo.html

JC: http://www.cgsmedicare.com/jc/coverage/lcdinfo.html

Jurisdiction A

◦ https://med.noridianmedicare.com/web/jadme

◦ Contact Center 866-419-9458

Jurisdiction B

◦ https://www.cgsmedicare.com/jb/index.html

◦ Contact Center 866-590-6727

Jurisdiction C

◦ http://www.cgsmedicare.com/jc/index.html

◦ Contact Center 866-270-4909

Jurisdiction D

◦ https://med.noridianmedicare.com/web/jddme

◦ Contact Center 877-320-0390

© 2016 Copyright. 63

Contacts

Additional Resources

◦ Coding - PDAC

1.877.735.1326

http://www.dmepdac.com

◦ National Supplier Clearinghouse

1.866.238.9652

http://www.palmettogba.com/nsc

◦ CEDI

1.866.311.9184

http://www.ngsedi.com

NGS.CEDIHelpdesk@wellpoint.com

Questions?

How to Participate Today

How to Participate Today

◦ To Ask a Verbal Question:

Raise your hand

◦ The Green Arrow means

your hand is not raised

(Click to raise your hand)

◦ The Red Arrow means your

hand is raised (Click to lower

your hand)

To Ask a Question

By Raising Your Hand

To Ask a Question

Using the Question Box

Disclaimer

The presentations herein were current at the time they were published or uploaded onto the Web.

Medicare policy changes frequently so links to the source documents have been provided within the

document for your reference. The presentations herein were prepared as tools to assist providers

and are not intended to grant rights or impose obligations. Although every reasonable effort has

been made to assure the accuracy of the information within these pages, the ultimate responsibility

for the correct submission of claims and response to any remittance advice lies with the provider of

services.

The Centers for Medicare & Medicaid Services (CMS) employees and agents, including CGS and its

staff, make no representation, warranty, or guarantee that this compilation of Medicare information is

error free and will bear no responsibility or liability for the results or consequences of the use of this

guide. This publication is a general summary that explains certain aspects of the Medicare Program,

but is not a legal document. Official Medicare Program provisions are contained in relevant laws,

regulations, and rulings.