Modifiers

Modifiers can be alphabetic, numeric or a combination of both, but will always be two digits for Medicare purposes. Some modifiers cause automated pricing changes, while others are used to convey information only. They are not required on all HCPCS codes; however, if required and not submitted, the claim will deny as unprocessable. Be sure to distinguish between zeros and the letter "O".

Please utilize the Modifier Lookup Tool to assist in determining potential modifiers that may be used in billing DMEPOS HCPCS codes. Many pricing and informational modifiers can be found by utilizing this tool.

Most DMEPOS fall into the following DMEPOS payment categories:

  • Capped Rental
  • Items Requiring Frequent and Substantial Servicing
  • Inexpensive or Routinely Purchased (IRP)
  • Oxygen and Oxygen Equipment
  • Other Prosthetics and Orthotics Devices
  • Parenteral/Enteral nutrition (PEN) Therapy
  • Customized Items

Each DMEPOS payment category has requirements that must be followed that may include the use of specific modifiers when billing claims.

The claim form has the ability to capture up to four modifiers. If more than four modifiers are needed, use modifier 99 (overflow) as the fourth modifier and enter the additional modifiers in the narrative field of the claim.

  • Modifier placement on claim
    • First position - Pricing modifiers (i.e. RR, KH, KI, KJ, NU)
    • Second position - Modifiers to indicate requirements specified in the medical policy have been met (i.e. KX)
    • Other positions - any additional informational modifiers required

RT and LT modifiers - When billing for bilateral items on the same date of service:

  • Bill bilateral items on two separate claim lines using the RT and LT modifiers and 1 unit of service (UOS) on each claim line

GA, GZ or 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.

Some miscellaneous codes may require a specific modifier according to the policy and laterality modifiers shown on the tool, as well as additional details provided in the claim line narrative.

Note: To search for a valid specific modifier with a brief description, enter the modifier you are searching for in the search field, and the relevant modifier (e.g., KX) will display. Click on the desired modifier in the chart to view detailed information about that specific modifier.

 
Modifier Brief Description
Mod 99 Modifier overflow
Mod A1 Dressing for one wound
Mod A2 Dressing for two wounds
Mod A3 Dressing for three wounds
Mod A4 Dressing for four wounds
Mod A5 Dressing for five wounds
Mod A6 Dressing for six wounds
Mod A7 Dressing for seven wounds
Mod A8 Dressing for eight wounds
Mod A9 Dressing for nine or more wounds
Mod AI Principal physician of record
Mod AU Item furnished in conjunction with a urological, ostomy or tracheostomy supply
Mod AV Item furnished in conjunction with a prosthetic device, prosthetic or orthotic
Mod AW Item furnished in conjunction with a surgical dressing
Mod AY Item or service furnished to an ESRD patient that is not for the treatment of ESRD
Mod BA Item furnished in conjunction with parenteral enteral nutrition (PEN) services
Mod BO Orally administered nutrition, not by feeding tube
Mod BP The beneficiary has been informed of the purchase and rental options and has elected to purchase the item
Mod BR The beneficiary has been informed of the purchase and rental options and has elected to rent the item
Mod BU The beneficiary has been informed of the purchase and rental options and after 30 days has not informed the supplier of his/her decision
Mod CC Procedure code change (use 'CC' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) (Suppliers should not submit modifier CC)
Mod CG Policy criteria applied
Mod CR Catastrophe/disaster related
Mod CS Cost sharing waiver for COVID-19 testing
Mod EA ESA, anemia, chemo-induced
Mod EB ESA, anemia, radio-induced
Mod EC ESA, anemia, non-chemo/radio
Mod EJ Subsequent claims for a defined course of therapy, E.G., EPO, Sodium Hyaluronate, Inflaximab
Mod EM Emergency reserve supply (for ESRD benefit only)
Mod EX Purchased item/service delivered while an expatriate beneficiary was present in the U.S.
Mod EY No physician or other licensed health care provider order for this item or service
Mod FA Left hand, thumb
Mod F1 Left hand, second digit
Mod F2 Left hand, third digit
Mod F3 Left hand, fourth digit
Mod F4 Left hand, fifth digit
Mod F5 Right hand, thumb
Mod F6 Right hand, second digit
Mod F7 Right hand, third digit
Mod F8 Right hand, fourth digit
Mod F9 Right hand, fifth digit
Mod GA Waiver of Liability statement on file. Valid Advance Beneficiary Notice of Noncoverage (ABN) obtained.
Mod GK Actual item/service ordered by physician, item associated with GA or GZ modifier
Mod GL Medically unnecessary upgrade provided instead of standard item, no charge, no Advance Beneficiary Notice of Noncoverage (ABN)
Mod GS Dosage of EPO or Darbepoetin alfa has been reduced and maintained in response to hematocrit or hemoglobin level
Mod GW Service not related to the hospice patient's terminal condition
Mod GX A voluntary Advance Beneficiary Notice of Noncoverage (ABN) has been issued to the beneficiary upon receipt of their DMEPOS item because the item was statutorily noncovered or does not meet the definition of a Medicare benefit.
Mod GY Item or service statutorily excluded or does not meet the definition of any Medicare benefit
Mod GZ Item or service expected to be denied as not reasonable or necessary (items submitted with GZ are automatically denied and not subject to complex medical review)
Mod J4 DMEPOS item subject to DMEPOS competitive bidding program that is furnished by a hospital upon discharge
Mod J5 DMEPOS item subject to DMEPOS Competitive Bidding Program that is furnished as part of a professional service by physical or occupational therapists
Mod JB Administered subcutaneously
Mod JG Drug or biological acquired with 340B drug pricing program discount, reported for informational purposes
Mod JK Short Descriptor: Drug supply 1 month or less; Long Descriptor: One month supply or less of drug or biological
Mod JL Short Descriptor: Drug 3-month supply; Long Descriptor: Three-month supply of drug or biological
Mod JW Drug amount discarded/not administered to any patient
ModJZ Zero drug amount discarded/not administered to any patient
Mod K0 Lower 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
Mod K1 Lower extremity prosthesis functional level 1 - Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. Typical of the limited and unlimited household ambulatory.
Mod K2 Lower extremity prosthesis functional level 2 - Has the ability or potential for ambulation with the ability to traverse low level environmental barriers such as curbs, stairs or uneven surfaces. Typical of the limited community ambulator.
Mod K3 Lower extremity prosthesis functional level 3 - Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to transverse most environmental barriers and may have vocational, therapeutic or exercise activity that demands prosthetic utilization beyond simple locomotion.
Mod K4 Lower prosthesis functional level 4 - Has the ability or potential for prosthetic ambulation that exceeds the basic ambulation skills, exhibiting high impact, stress, or energy levels, typical of the prosthetic demands of the child, active adult, or athlete
Mod KB Beneficiary requested upgrade for ABN, more than 4 modifiers identified on claim
Mod KC Replacement of special power wheelchair interface
Mod KD Drug or biological infused though DME
Mod KE Bid under round one of the DMEPOS Competitive Bidding Program for use with non-competitive bid base equipment
Mod KF Item designated by FDA as Class III Devices
Mod KG DMEPOS item subject to Competitive Bidding Program I
Mod KH DMEPOS item, initial claim, purchase or first month rental
Mod KI DMEPOS item, second or third month rental
Mod KJ DMEPOS item, parenteral enteral nutrition (PEN) pump or capped rental, months four to fifteen
Mod KK DMEPOS item subject to Competitive Bidding Program II
Mod KL DMEPOS item delivered via mail
Mod KM Replacement of facial prosthesis including new impression/moulage
Mod KN Replacement of facial prosthesis using previous master model
Mod KO Single drug unit dose formulation
Mod KP First drug of a multiple drug unit dose formulation
Mod KQ Second or subsequent drug of a multiple drug unit dose formulation
Mod KR Rental item, billing for partial month
Mod KS Glucose monitor supply for diabetic beneficiary not treated with insulin
Mod KT Beneficiary resides in a competitive bidding area and travels to a non-competitive bidding area and receives item from a non-contract supplier
Mod KU DMEPOS item subject to DMEPOS Competitive Bidding Program Number 3
Mod KV DMEPOS item subject to DMEPOS Competitive Bidding Program that is furnished as part of a professional service
Mod KW DMEPOS Item Subject to DMEPOS Competitive Bidding Program Number 4
Mod KX Requirements specified in the medical policy have been met
Mod KY DMEPOS Item Subject to DMEPOS Competitive Bidding Program Number 5
Mod LT Left side (Used to identify item provided for the left side of the body)
Mod MS Six month maintenance and servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warranty
ModN1 Group 1 Oxygen Coverage Criteria Met
ModN2 Group 2 Oxygen Coverage Criteria Met
ModN3 Group 3 Oxygen Coverage Criteria Met
Mod NU New durable medical equipment purchase
Mod Q0 Investigational clinical service provided in a clinical research study that is in an approved clinical research study
Mod Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study
Mod QA Prescribed amounts of stationary oxygen for daytime use while at rest and nighttime use differ and the average of the two amounts is less than 1 liter per minute (LPM)
Mod QB Prescribed amounts of stationary oxygen for daytime used while at rest and nighttime use differ and the average of the two amounts exceeds 4 liters per minute (LPM) and portable oxygen is prescribed
Mod QE Prescribed amount of oxygen is less than 1 liter per minute (LPM)
Mod QF Prescribed amount of oxygen exceeds 4 liters per minute and portable oxygen is prescribed
Mod QG Prescribed amount of oxygen is greater than 4 liters per minute
Mod QH Oxygen conserving device is being used with an oxygen delivery system
Mod QJ Service/items provided to a prisoner or patient in state or local custody, however the state or local government, as applicable, meets the requirement in 42 CFR 411.1(B)
Mod QQ Claim submitted with a written statement of intent
Mod QR Prescribed amounts of stationary oxygen for daytime use while at rest and nighttime use differ and the average of the two amounts is greater than 4 liters per minute (LPM)
Mod RA Replacement of a DME, Orthotic or Prosthetic Item due to loss, stolen or irreparable damage
Mod RB Replacement of a Part of a DME, Orthotic or Prosthetic Item Furnished as Part of a Repair
Mod RR Rental (Use this ‘RR' modifier when DME is to be rented)
Mod RT Right side (Used to identify procedures performed on the right side of the body)
Mod ST Related to trauma or injury
Mod TA Left foot, great toe
Mod T1 Left foot, second digit
Mod T2 Left foot, third digit
Mod T3 Left foot, fourth digit
Mod T4 Left foot, fifth digit
Mod T5 Right foot, great toe
Mod T6 Right foot, second digit
Mod T7 Right foot, third digit
Mod T8 Right foot, fourth digit
Mod T9 Right foot, fifth digit
Mod TB Drug or biological acquired with 340B drug pricing program discount, reported for informational purposes for select entities
Mod UE Used durable medical equipment purchase

Resource

Last Updated Aug 23 , 2024

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