Community Health Plan of Washington (CHPW) would like to remind our provider community that the Centers for Medicare Medicaid Services (CMS) require specific modifiers to be submitted on all claims for all Medicare Advantage plans. CMS has distinct modifiers for different services.
As you may know, Medicare already rejects claims with missing modifiers. Effective Monday, September 18, 2017, CHPW will have a new claim edit in place to deny claims that do not have the required modifiers. Missing modifiers are a billing error; upon notification of a denial due to missing modifier(s), providers may resubmit corrected claims with the necessary information.
During a recent claims audit, we found a high volume of claims with durable medical equipment (DME) and medical supplies that had missing CMS-required modifiers. We have provided some examples of services and modifiers from that audit below. If you have any questions, please contact CHPW Medicare Advantage Customer Service, 1-800-942-0247 (TTY Relay: 7-1-1).
DME and Medical Supplies—Examples
Service or Supply and Local Coverage Determination (LCD = LXXXXX)
• Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (L33718)
• Respiratory Assist Devices (L33800) • Negative Pressure Wound Therapy Pumps (L33821)
• Manual Wheelchair Bases (L33788)
• Power Mobility Devices (L33789)
• Surgical Dressings (L33831) • PET for Perfusion of the Heart (A54668)
• Hospital Beds And Accessories (L33820)
• Urological Supplies (L33803)
• Wheelchair Options/Accessories (L33792) Please visit the CMS Regulations and Guidance to search for an LCD: https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Guidance.html Commonly Omitted Modifiers
• A1 – Dressing for one wound
• A2 – Dressing for two wounds
• A3 – Dressing for three wounds
• A4 – Dressing for four wounds
• A5 – Dressing for five wounds
• A6 – Dressing for six wounds
• A7 – Dressing for seven wounds
• A8 – Dressing for eight wounds
• A9 – Dressing for nine wounds
• AU – Item furnished in conjunction with a urological, ostomy, or tracheostomy supply
• AW – Item furnished in conjunction with a surgical dressing
• EY – No physician or other licensed health care provider order for this item or service
• GA – Waiver of liability statement issued as required by payer policy, individual case
• GK – Reasonable and necessary item/service associated with a GA or GZ modifier
• GL – Medically unnecessary upgrade provided instead of non-upgraded item, no charge, no ABN
• GY – Item or service statutorily noncovered or does not meet the definition of any Medicare benefit
• GZ – Item or service expected to be denied as not reasonable and necessary
• KC – Replacement of special power wheelchair interface
• KX — Requirements specified in the medical policy have been met
• LT – Left side
• PI – PET or PET/computed tomography (CT) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing.
• PS – PET or PET/CT to inform the subsequent treatment strategy of cancerous tumors when the beneficiary’s treatment physician determines that the PET study is needed to inform subsequent anti-tumor strategy.
• RB – Replacement of a part of DME furnished as part of a repair
• RT – Right side
What kind of care do you need? Not every medical issue needs emergency care. If you have a medical issue that doesn’t seem to be life-threatening, but you’re not sure what to do, see if your local Community Health Center clinic or primary care doctor offers virtual care. If they do, they will tell you how to set up your virtual care appointment.
