External Infusion Pumps

Coverage

Documentation

Reviews/Audits

  • Medical Review - View notifications/findings of pre/post claim reviews completed by Noridian Medical Review

Tips

Topic Details
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
Modifiers
  • JK - One month supply or less of drug or biological
    • Effective for use for J1817 on April 1, 2023
    • May be used for May and June date of service
    • Required for use July 1, 2023
      • For all insulin administered through DME (J1811, J1813, and J1817)
  • JL - Three-month supply of drug or biological
    • Effective for use for J1817 on April 1, 2023
    • Required for use July 1, 2023
      • Required for all insulin administered through DME (J1811, J1813, and J1817)
    • May and June date of service with JL modifier will be returned as un-processable
  • NOTE: Any drug or biological 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
    • Effective for use January 1, 2023, and,
    • Required for use on applicable claims with dates of service July 1, 2023
    • Indicated when there are no discarded amounts from "single use vials or single use packages."
  • KX - all the coverage criteria in the "Coverage Indications, Limitations, and/or Medical Necessity" section in the related LCD have been met.
    • Required for use on claims with a receipt date March 1, 2023, and after
  • GA - policy criteria is not met. Waiver of Liability statement on file. Valid Advance Beneficiary Notice of Noncoverage (ABN) obtained.
    • Required for use on claims with a receipt date March 1, 2023, and after, if the KX modifier does not apply, and a valid ABN is received.
  • GZ - item or service expected to be denied as not reasonable or necessary, no valid ABN on file.
    • Required for use on claims with a receipt date March 1, 2023, and after, if the KX modifier does not apply, and no ABN is received.

 

Last Updated Dec 09 , 2023

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