Article Detail - JA DME

Modifiers can be alphabetic, numeric, or a combination of both, but will always be two digits for Medicare purposes. Some modifiers initiate automated pricing changes, while others are used only to convey information. Modifiers are not required on all HCPCS codes; however, if required and not submitted, the claim will deny as unprocessable and the claim will need to be corrected and rebilled.

Modifiers that are applicable to a policy are listed in the Local Coverage Determination (LCD) with requirements for those modifiers listed in the specific policy article, except for items that can be rented or purchased.

Rental or purchase item modifiers

• NU New durable medical equipment purchase
• UE Used durable medical equipment purchase
• RR Rental

These modifiers are identified on the Pricing Data Analysis Coding (PDAC) website under each applicable HCPCS code fee schedule lookup.

Capped rental modifiers

• RR Rental
• KH First rental month
• KI Second and third rental months
• KJ Fourth to the thirteenth rental months

Capped rental items allowable - First three months calculated 10% allowed purchase. Months 4-13 limited to 7.5% allowed purchase

Note: Capped Rental items cannot be sold to the beneficiary and billed to Medicare as a purchase, as they are statutorily non-covered as the item would not meet the definition of any benefit category for DME.

Liability modifiers

• GA Waiver of Liability statement on file. Valid Advance Beneficiary Notice of Noncoverage (ABN) obtained
• GZ Item or service expected to be denied as not reasonable or necessary or ABN not obtained or was invalid. (Items submitted with GZ are automatically denied and not subject to complex medical review).
• GY Item or service statutorily excluded or does not meet the definition of any Medicare benefit

Note: The modifiers GA, GZ, GY, and KX must never be used on the same claim line together as the claim will deny as unprocessable and the claim will need to be corrected and rebilled.

Informational modifiers most frequently used (not all-inclusive list)

KX Requirements specified in the medical policy have been met

• LT Left side
• RT Right side
• K0-K4 Lower extremity prosthesis functional level modifiers
• N1, N2, N3, QA, QB, QE, QF, QG, QH, or QR Oxygen modifiers as indicated in the LCD

Note: The LT and RT modifiers are often billed incorrectly.

• Bill bilateral items on two separate claim lines using the RT and LT modifiers and 1 unit of service (UOS) on each claim line
  • Claims billed with the RTLT modifier on the same claim line with 2 UOS will deny as unprocessable and the claim will need to be corrected and rebilled.

Please refer to the Modifier Lookup Tool to assist in determining potential modifiers that may be used in billing DMEPOS HCPCS codes.