KX Modifier Use for External Infusion Pumps - JA DME

Joint DME MAC Publication
Posted January 12, 2023

The External Infusion Pumps LCD-related Policy Article (A52507) was revised on January 12, 2023, to expand use of the KX, GA, and GZ modifiers to all external infusion pumps, drugs, and supplies which are eligible for coverage under the External Infusion Pumps LCD (L33794). Previously, the External Infusion Pumps LCD-related Policy Article (A52507) only required the use of the KX, GA, or GZ modifier for insulin and insulin infusion pumps (J1817 and E0784). This LCD-related Policy Article revision is effective for claims with dates of service on or after January 1, 2023; however, the modifiers will only be required for use on claims with a date of receipt on or after March 1, 2023, to allow ample time for suppliers to make any necessary systems changes. Per the updated External Infusion Pumps LCD-related Policy Article:

Suppliers must add the KX modifier to claim lines billed for the external infusion pump, drugs and supplies only if all of the coverage criteria in the "Coverage Indications, Limitations, and/or Medical Necessity" section in the related LCD have been met and evidence of such is retained in the supplier’s files and available to the DME MAC upon request.

If all of the criteria in the "Coverage Indications, Limitations, and/or Medical Necessity" section of the related LCD have not been met, the GA or GZ modifier must be added to the code. When there is an expectation of a medical necessity denial, suppliers must enter the GA modifier on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or the GZ modifier if they have not obtained a valid ABN.

Claims for external infusion pumps, drugs, and supplies billed without a KX, GA, or GZ modifier, with a date of receipt on or after March 1, 2023 (and a "from" date of service on or after January 1, 2023), will be rejected for missing information. Claims for infusion drugs not administered via an infusion pump must continue to be billed with a GY modifier.

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