Article Detail - JD DME

Posted February 04, 2011

Per the Wheelchair Options/Accessories Policy Article, the right (RT) and left (LT) modifiers must be used when appropriate.

It is important to understand that different billing rules apply depending on whether the unit of service for the HCPCS code is described as "each" or "pair" and also whether the item is billed as a "purchase" or "rental".

The following billing rules apply to situations when two of the same bilateral items in the Wheelchair Options and Accessories LCD are dispensed on the same date of service for both the left (LT) and right (RT) side:

• Bilateral Items Billed as "Purchase" - Unit of Service is "Each" (See Billing Example #1)

If bilateral items are provided as a "purchase" and the unit of service described in the HCPCS code description is "each", bill both items on the same claim line using the LTRT modifiers and 2 units of service.

• Bilateral Items Billed as "Rental" - Unit of Service is "Each" (See Billing Example #1)

If bilateral items are provided as a "rental" and the unit of service described in the HCPCS code description is "each", bill the items on two separate claim lines with the LT modifier on one line and the RT modifier on the other. Each claim line will have 1 unit of service. Note exception in billing example below.

• Bilateral Items Billed as "Purchase or Rental" - Unit of Service is "Pair" (See Billing Example #2)

If bilateral items are provided as a "purchase or rental" and the unit of service described in the HCPCS code description is "pair", bill both items on the same claim line with 1 unit of service. The LT and RT modifiers are not reported when the unit of service is "pair".

The following billing rules apply to situations when a single item in the Wheelchair Options and Accessories LCD is dispensed for either the left (LT) or the right (RT) side, but not both:

• Single Item Billed as "Purchase or Rental" - Unit of Service is "Each" (See Billing Example #3)

If a single item is provided as a "purchase or rental" for either the left (LT) or right (RT) side bill one claim line using the appropriate modifier LT or RT and 1 unit of service. This only applies to HCPCS codes that have a unit of service description of "each". Note exception in billing example below.

Billing Example #1 - Bilateral Items Dispensed as "Each":

The following table represents billing examples for situations when two of the same bilateral items in the Wheelchair Options and Accessories LCD are dispensed on the same date of service for both the left (LT) and right (RT) side and are billed with a HCPCS code that has a unit of service described as "each". The table includes examples for both purchase and rental situations.

Exception: The HCPCS code description for E1020 does not indicate a unit of service of "each" or "pair"; however, it is an item that can be dispensed individually for one side or for both the left (LT) and right (RT) side.  As a result, billing instructions are based on "each".

Note: The examples in the following table are not all inclusive of all modifiers. Additional modifiers may be required to address whether coverage criteria are or are not met (KX, GA, GY, GZ). Claim lines billed without all required modifiers will be rejected for missing information.

Billing Example #2 - Bilateral Items Dispensed as "Pair"

The following table represents billing examples of situations when two of the same bilateral items in the Wheelchair Options and Accessories LCD are dispensed on the same date of service for both the left and right side that are billed with the same HCPCS code that describes the unit of service as "pair". The table includes separate billing examples for rental and purchase situations, if applicable. Currently, the Wheelchair Options/Accessories LCD includes three HCPCS codes, identified in the table below, that are dispensed as a "pair".

Note: The examples in the following table are not all inclusive of all modifiers. Additional modifiers may be required for capped rental items (KH, KI, KJ) and to address whether coverage criteria are or are not met (KX, GA, GY, GZ). Claim lines billed without all required modifiers will be rejected for missing information.

Billing Example #3 - Single Item Dispensed as "Each":

The following table represents billing examples of situations when a single item from the Wheelchair Options and Accessories LCD is dispensed as a "rental or purchase" for either the left (LT) or right (RT) side with a HCPCS code that describes the unit of service as "each".

Exception: The HCPCS code description for E1020 does not indicate a unit of service of "each" or "pair"; however, it is an item that can be dispensed individually for one side or for both the left (LT) and right (RT) side.  As a result, billing instructions are based on "each".

Note: The examples in the following table are not all inclusive of all modifiers. Additional modifiers may be required to address whether coverage criteria are or are not met (KX, GA, GY, GZ). Claim lines billed without all required modifiers will be rejected for missing information.

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