Article Detail - JA DME

When billing Durable Medical Equipment (DME) for external infusion pumps, appending the correct modifier serves as a critical billing compliance indicator under Medicare rules. Here are the key reasons why the appropriate modifiers must be included:

Local Coverage Determination (LCD) L33794 and Policy Article (A52507) require that all external infusion pumps and associated drugs and supplies include either a KX, GA, or GZ modifier. Claims lacking one of these modifiers will be rejected.

The KX modifier signifies that all coverage requirements and medical necessity standards outlined in the LCD for external infusion pumps have been met and that supporting documentation is retained.

By appending the GA or GZ modifier, suppliers are indicating coverage criteria is not fully met. The GA modifier is a liability modifier used if a properly executed Advance Beneficiary Notice of Noncoverage (ABN) is issued. The GZ modifier is used if an ABN is not issued, or the ABN is deemed invalid. These modifiers indicate denial is expected or there is uncertainty in medical necessity requirements being met.

Medicare requires the KX, GA, or GZ usage across all categories of external infusion pumps (including insulin and non-insulin pumps) along with any related supplies and drugs to consistently confirm medical necessity.

By correctly appending the KX modifier, or GA/GZ modifier, suppliers maintain billing integrity and Medicare requirements.