When billing for durable medical equipment (DME), use the appropriate HCPCS code and modifier(s) to describe the items being billed. Also, include an ICD-9/ICD-10 diagnosis code indicating the medical condition for which the item has been prescribed.
In addition to an appropriate HCPCS code for the DME item, many HCPCS codes require a modifier. The modifiers are used to provide more information about the item. For example, the modifier may tell HMSA that an item is new, used, or rented on a capped basis. For capped rentals, modifiers distinguish which month’s rental is being billed. If these modifiers are used incorrectly or missing, the claim may be denied. To expedite processing of your claims, please indicate the first-month rental by including the appropriate modifier code, and bill your claims in sequential order.
Inexpensive or Routinely Purchased DME
Inexpensive DME-This category is defined as equipment whose purchase price does not exceed $150. Routinely Purchased-This category consists of equipment that is purchased at least 75% of the time. Payment for this type of equipment is for rental or lump-sum purchase. The total payment may not exceed the actual charge or the fee for purchase. Common modifiers used in this category are:
- RR Rental
- NU Purchase of new equipment
- UE Purchase of used equipment
Modifiers RR, NU, and UE should be used for the following categories:
- Inexpensive or Routinely Purchased (IRP) Item
- Capped Rental item
- Items Requiring Frequent and Substantial Servicing
- Oxygen Equipment (not contents)
Items Requiring Frequent and Substantial Servicing
Equipment in this category is paid on a rental basis only. Payment is based on the monthly fee schedule amount until the medical necessity ends. No payment is made for the purchase of equipment, maintenance, and servicing or for replacement of items.
- Use the RR (Rental) modifier for items in this category.
Capped Rental Items
Items in this category are provided on a rental basis; therefore, RR is one of the modifiers appropriate with these items. There is an exception to the rental basis. For electric wheelchairs, suppliers must give beneficiaries the option of purchasing at the time the supplier first furnishes the item. The modifiers used with these items are:
- BR Beneficiary has elected to rent
- BP Beneficiary has elected to purchase
Modifiers used for capped rental items are:
- KH First rental month
- KI Second and third rental months
- KJ Fourth to thirteenth rental months
Replacement and Repair
RA – Replacement of a DME item due to loss, irreparable damage, or theft. This is used on the first-month rental claim for a replacement item.
RB – Replacement of a part of DME as part of a repair
KX Modifier – Documentation on File
KX – The KX modifier should be added to the code to indicate that specific required documentation is on file to support the medical necessity of the item. The KX modifier is allowed for the these categories: AFO/KAFO; Cervical traction unit; Commodes; CPAP; External infusion pumps (except E0784); Hospital Beds; Manual wheelchair bases (except K0004, K0005, K0009); Nebulizers; Orthopedic footwear; Patient lifts; Pre-fabricated knee orthoses; Pressure-reducing support surfaces; Walkers; Wheelchair options/accessories (except E1399,K0108); Wheelchair seating (except E1399, K0108).
Oxygen and Oxygen Equipment
For stationary and portable oxygen equipment furnished on or after January 1, 2006, a 36-month cap applies on monthly payments. Contractors began the 36-month count on January 1, 2006, for beneficiaries that were receiving oxygen therapy prior to January 1, 2006. Months prior to January 1, 2006, are not included in the 36-month count.
On the first day after the 36th month anniversary for which payment has been made, the supplier must transfer the title for the stationary and/or portable oxygen equipment to the beneficiary. On that same day, the title for the equipment is transferred to the patient and monthly payments can begin to be made for oxygen contents used with patient owned gaseous and liquid oxygen equipment. Modifiers appropriate for oxygen and oxygen equipment are:
- RR Rental
- QE Use if the prescribed amount of oxygen is less than 1 LPM
- QF Use if the prescribed amount of oxygen exceeds 4 LPM and portable oxygen is prescribed
- QG Use if the prescribed amount of oxygen is greater than 4 LPM
- QH Use if an oxygen conserving device is being used with an oxygen delivery system
Right and Left Modifiers
RT – Right
LT – Left
RT and LT modifiers should be used for the theses categories: AFO/KAFO; External east prosthesis; Eye prosthesis; Lower limb prosthesis; Orthopedic footwear; Therapeutic shoes for persons with diabetes. Wheelchair options/accessories
Used with complex power wheelchairs only:
- BP – Member has elected to purchase
- BR – Member has elected to rent
Note: Modifiers are not needed when billing for medical supplies (e.g., syringes, ostomy bags).
The KB modifier only applies to beneficiary upgraded claims for DMEPOS where the supplier obtained an ABN and there are more than four modifiers on the claim line. The 99 modifier is used in any other situation when a claim line has more than four modifiers.
When a supplier uses more than four modifiers, the KB or 99 must be added as the fourth modifier to the HCPCS code. On paper claims, the remainder of the modifiers must be listed in Item 19 with an indicator as to which line they apply to. On electronic claims, the remainder should be entered in the NTE segment, the 2400 loop.