|Durable Medical Equipment Modifiers for DME Services|
Durable Medical Equipment Modifiers for DME Services
Several DME categories and frequently used modifiers are listed below. Chapter 16 of the Jurisdiction D DME Supplier Manual provides HCPCS codes with descriptions and the payment categories.
Inexpensive or Routinely Purchased DME
Routinely Purchased-This category consists of equipment that is purchased at least 75% of the time.
Payment for this type of equipment is for rental or lump sum purchase. The total payment may not exceed the actual charge or the fee for a purchase.
Common modifiers used in this category are:
Items Requiring Frequent and Substantial Servicing
Use the RR (Rental) modifier for items in this category.
Capped Rental Items
There is an exception to the rental basis. For electric wheelchairs, suppliers must give beneficiaries the option of purchasing at the time the supplier first furnishes the item. The modifiers used with these items are:
Modifiers used for capped rental items are:
For capped rental items provided prior to January 1, 2006, suppliers must give beneficiaries the option to purchase their rental equipment during the tenth continuous rental month. Beneficiaries have one month from the date the supplier makes the offer to accept the option. If the beneficiary declines, rental payments continue until the 15th month. If the beneficiary accepts the purchase option, rental will continue until 13 continuous rental months have been paid. On the first day after 13 continuous months have been paid, the supplier must transfer the title of the equipment to the beneficiary.
Modifiers used for capped rental items prior to January 1, 2006 are:
Beginning January 1, 2006, payment for capped rental items may not exceed a period of continuous use longer than 13 months. After 13 months of rental have been paid, the supplier must transfer the title of the equipment to the beneficiary.
The BR, BP and BU modifiers are not required on most capped rental items where the first rental period began on/after January 1, 2006. They are still required, however, on PEN pumps and electric wheelchairs regardless of the date of the first rental period.
Oxygen and Oxygen Equipment
For stationary and portable oxygen equipment and oxygen contents furnished prior to January 1, 2006, payments were made for the duration of use of the equipment when medically necessary.
Contractors began the 36-month count on January 1, 2006, for beneficiaries that were receiving oxygen therapy prior to January 1, 2006. Months prior to January 1, 2006, are not included in the 36-month count.
On the first day after the 36th month anniversary for which payment has been made, the supplier must transfer the title for the stationary and/or portable oxygen equipment to the beneficiary. On that same day, the title for the equipment is transferred to the patient and monthly payments can begin to be made for oxygen contents used with patient owned gaseous and liquid oxygen equipment.
Modifiers appropriate for oxygen and oxygen equipment are:
Maintenance and Servicing
Maintenance and servicing is covered for capped rental items prior to January 1, 2006. Payment will no longer be made for maintenance and servicing on capped rental items in which the first rental month occurs on or after January 1, 2006.
Maintenance and servicing payments will be made for oxygen equipment every six months, starting six months after the beneficiary owns the equipment. The payment will be paid in 15 minute intervals and shall not exceed 30 minutes.
Additional information regarding maintenance and servicing for items on or after January 1, 2006, is found in MLN Matters 5461, available in the What's New section of our website.
Replacement and Repair
Equipment the beneficiary owns may be replaced in cases of loss or irreparable damage without a physician's order. Claims involving replacement equipment necessitated because of wear or a change in the patient's condition must be supported by a current physician's order.
Repairs to equipment the beneficiary owns are covered when necessary to make the item serviceable. If the expense for repair exceeds the estimated expense of purchasing or renting another item for the remaining period of medical need, no payment can be made for the amount of the excess. Repairs of rented equipment are not covered.
Prosthetics and Orthotics
K0 Lower limb extremity prosthesis functional Level 0 - Does not have the ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance their quality of life or mobility
Modifiers AU (item furnished in conjunction with a urological, ostomy or tracheostomy supply), AV (item furnished in conjunction with a prosthetic or orthotic device) and AW (item furnished in conjunction with a surgical dressing) are used when billing codes for tape, A4450 and A4452.
KO, KP, KQ Modifiers
When there is a single drug in a unit dose container, the KO modifier is added to the unit form code. When two or more drugs are combined and dispensed to the patient in the same unit dose container (except for code J7620, Albuterol, up to 2.5 mg and Ipratropium Bromide, up to 0.5 mg, non-compounded inhalation solution), each of the drugs is billed using its unit dose form code. The KP modifier is added to only one of the unit dose form codes and the KQ modifier is added to the other unit dose code(s). See the Nebulizer policy article for additional information.
Right and Left Modifiers
KX Modifier-Documentation on File
EY Modifier-No Doctor's Order on File
GA, GZ, GY Modifiers-ABN/Not Reasonable and Necessary/Statutorily Excluded
An ABN is a written notice a supplier gives to a Medicare beneficiary before items or services are furnished when the supplier believes that Medicare will not pay because there is a lack of medical necessity.
Keep in mind that not all items submitted with the GA modifier are denied as patient responsibility. Items must be denied based on medical necessity in order to receive a patient responsibility denial.
Additional information on ABNs is found in Chapter 6 of the Supplier Manual and on the CMS website at www.cms.hhs.gov/transmittals/downloads/ab02168.pdf.
The GZ modifier is used to indicate suppliers expect Medicare will deny an item or service as not reasonable and necessary and they do not have an ABN on file.
The GY modifier is submitted when suppliers indicate an item or service is statutorily non-covered or is not a Medicare benefit.
Examples of items to use the GY modifier with are infusion drugs that are not administered through a durable infusion pump, personal comfort items and enteral nutrients administered orally. Also, many of the LCDs provide instructions on when to use the GY modifier.
GK, GL Modifiers-Upgrades
When billing for upgrades, suppliers must use two lines on the same claim. Line one contains the HCPCS code for the upgraded item the supplier actually provided to the beneficiary with the dollar amount of the upgraded item. If an ABN was obtained, the GA must be billed. If an ABN was not obtained, use the GZ modifier. Line two is billed with the HCPCS code for the reasonable and necessary item with modifier GK and for the full amount of that item.
Suppliers must also list the upgrade features in Item 19 of the CMS-1500 form or the electronic equivalent.
GL Item is a medically unnecessary upgrade provided instead of a standard item at no charge to the beneficiary and an ABN does not apply.
If a supplier furnishes an upgraded DMEPOS item but charges Medicare and the beneficiary for the non-upgraded item, the supplier must bill for the non-upgraded item rather than the item the supplier actually furnished. The claim is billed with the HCPCS code for the non-upgraded item with the charge of that item and modifier GL.
Item 19 of the CMS-1500 form, or the electronic equivalent, must contain the make and model of the item actually furnished and describe why it is an upgrade.
KB and 99 Modifiers-More than Four Modifiers
99 Modifier overflow.
The KB modifier only applies to beneficiary upgraded claims for DMEPOS where the supplier obtained an ABN and there are more than four modifiers on the claim line. The 99 modifier is used in any other situation when a claim line has more than four modifiers.
When a supplier uses more than four modifiers, the KB or 99 must be added as the fourth modifier to the HCPCS code. On paper claims, the remainder of the modifiers must be listed in Item 19 with an indicator as to which line they apply to. On electronic claims, the remainder should be entered in the NTE segment, the 2400 loop.
These are not all inclusive lists. For additional information on modifiers, see the Supplier Manual in the News and Publications section of our website. A complete listing of modifiers is available in Chapter 16, Coding. Also, remember to verify modifier usage in the policies. To locate the LCDs from our website, see the Accessing Local Coverage Determinations article from the What's New section for instructions.