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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
  • JL - Three-month supply of drug or biological
    • Effective for use for J1817 on April 1, 2023
    • May and June date of service with JL modifier will be returned as un-processable
  • 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 Tue, 21 Mar 2023 12:35:00 +0000

The below are topic specific articles which have been published to "Latest Updates" and sent out in Noridian emails within the past two years. Exclusions to this include time sensitive related announcements such as: Noridian and CMS educational events, Ask-the-Contractor Teleconferences and claims processing downtime.

paginationType noridian
2023 Modifier Usage for the External Infusion Pumps (EIP) Policy 05/09/2023
Billing Insulin Furnished Through an External Infusion Pump May 1, 2023 and After 05/02/2023
LCD and Policy Article Revisions Summary for March 30, 2023 03/30/2023
Policy Article Revisions Summary for January 19, 2023 01/19/2023
KX Modifier Use for External Infusion Pumps 01/12/2023
External Infusion Pump (EIP) Supplies Utilization Expectations 01/11/2023
Tools Series: External Infusion Pumps (EIP) C-Peptide Calculator 11/17/2022
Tools Series: External Infusion Pump Drug Calculator 11/15/2022
Policy Article Revisions Summary for September 22, 2022 09/22/2022
External Infusion Pumps - Medical Record Documentation Requirements 09/12/2022
Eliminating Certificates of Medical Necessity & Durable Medical Equipment Information Forms - January 1, 2023 08/08/2022
LCD and Policy Article Revisions Summary for July 28, 2022 07/28/2022
LCD and Policy Article Revisions Summary for March 24, 2022 03/24/2022
Three External Infusion Pump (EIP) Tutorials Available 24/7 03/16/2022
New C-Peptide Calculator Tool - Now Available 01/20/2022
External Infusion Pumps & Glucose Monitors - Final LCDs and Response to Comments (RTC) Articles Published 06/03/2021
LCD and Policy Article Revisions Summary for June 3, 2021 06/03/2021