Billing DME Insulin (J1811, J1813, J1817) - Modifier Reminders

Suppliers billing Medicare for insulin administered through Durable Medical Equipment (DME), must ensure claims include the appropriate Healthcare Common Procedure Coding System (HCPCS) modifier. Claims submitted without the required modifier will be denied.

Medicare policy requires that claims for external infusion pumps and associated drugs and supplies, including insulin, include either a KX, GA, or GZ modifier for billing. Claims that do not include one of these modifiers will be denied. Recent data analysis has identified insulin claims (e.g., HCPCS codes J1811, J1813, J1817) being submitted without the required modifiers, resulting in avoidable denials.

Scenario Modifier What It Means
Coverage criteria met KX The supplier attests that all Medicare coverage requirements are met and documentation is on file.
Coverage criteria not met, valid ABN obtained GA A valid Advance Beneficiary Notice (ABN) is on file and a denial is anticipated.
Coverage criteria not met, no valid ABN GZ A denial is expected and no valid ABN is on file.

Key Reminders

  • Either a KX, GA, or GZ modifier is required on every claim line.
    • These modifiers may not be billed on the same claim line.
  • Claims submitted without these modifiers will be denied.
  • KX modifier indicates coverage criteria in the policy have been met; GA and GZ indicate criteria is not met.

Suppliers are encouraged to review Local Coverage Determination (LCD) L33794 and Policy Article A52507 for detailed billing requirements, including documentation expectations for insulin administered through DME.

Last Updated Aug 11 , 2026