External Infusion Pumps - JA DME
External Infusion Pumps
Coverage
Documentation
- Standard Documentation Requirements for All Claims Submitted to DME MACs
- Clinician Letter - Insulin for Insulin Infusion Pumps - Letter may be sent to clinicians to help obtain documentation
- Clinician Letter - Medical Records - Letter may be sent to clinicians to help obtain documentation
- External Infusion Pump Documentation Checklist - Checklist to ensure suppliers gather all required documentation
Reviews/Audits
- Medical Review - View notifications/findings of pre/post claim reviews completed by Noridian Medical Review
Tips
Documentation
For continued coverage of an external insulin pump and supplies, the treating physician must see the patient at least every 3 months. Documentation must be available upon request or in the event of a review.
Drugs Used With External Infusion Pumps
Coverage of drugs used with external infusion pumps may have differing denials. It is important for suppliers of these drugs to understand issues related to coverage and denials.
Billing Drugs or Supplies When the External Infusion Pump (EIP) is Beneficiary-Owned
- Suppliers must ensure that beneficiary-owned equipment information is on file with Medicare Fee-for-Service (FFS) to avoid denials. Additional documentation to support medical necessity is required for supplies and accessories when the base equipment, such as a pump, has been provided and was not initially paid for by Medicare FFS.
- Claims submitted for drugs and supplies used with beneficiary-owned equipment require three elements as listed below.
- Healthcare Common Procedure Coding System (HCPCS) code of base equipment (pump); and
- A notation that the pump is beneficiary-owned; and
- Approximate date the beneficiary obtained the pump
- Example narrative for EIP supplies for a beneficiary owned pump:
- BENEFICIARY OWNED K0455 PURCHASED MARCH 2016
- Claims submitted for drugs and supplies used with beneficiary-owned equipment require three elements as listed below.
Modifiers
- JK - One month supply or less of drug or biological
- For all insulin administered through DME (J1811, J1813, and J1817)
- JL - Three-month supply of drug or biological
- Required for all insulin administered through DME (J1811, J1813, and J1817)
- Any insulin supply billed in excess of one-month, append JL modifier
- See the MLN Fact Sheet for more information
- JW - Drug amount discarded/not administered to any patient
- Indicated for discarded drugs and biologicals from "single use vials or single use packages."
- JZ - Zero drug amount discarded/not administered to any patient
- Indicated when there are no discarded amounts from "single use vials or single use packages."
- See the Discarded Drugs and Biologicals - JW Modifier and JZ Modifier Policy Frequently Asked Questions for more information
- KX - All the coverage criteria in the "Coverage Indications, Limitations, and/or Medical Necessity" section in the related LCD have been met.
- GA - Policy criteria is not met. 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, no valid ABN on file.
Resources
Last Updated Jun 26 , 2025
