LEEDer Group Inc.
8508 North West 66th St.
Miami, Florida 33166 USA

Phone: 305.436.5030
Fax: 305.436.0086
E-mail Address: info {at] LEEDerGroup [dot] com

2013-05 HCPCS Code and Modifier Combinations

May 30, 2013
HCPCS Code and Modifier Combinations

Which modifier should I use? That is a common question we hear from suppliers who submit claims to Jurisdiction C.

Knowing which modifier to use with a given HCPCS code can be tricky. If you omit a needed modifier or use an unnecessary modifier, your claim may be rejected by CEDI (edit A7:507) or denied by the DME MAC.

Many HCPCS codes require a modifier to let us know if the item is being rented (RR), purchased new (NU), or purchased used (UE). If you submit a claim without an RR, NU, or UE modifier for a HCPCS code that requires one of these modifiers, your claim will be rejected by CEDI.

To help you, we’ve put together a few tips to help you make sure you have the modifiers you need on your claim.
Determine the Payment (Fee Schedule) Category of the HCPCS Code

The DME MAC Jurisdiction C Supplier Manual, Appendix A contains a list of HCPCS codes with their Payment Category. If the code falls into one of the following categories, then it will require an RR, NU, or UE modifier: Inexpensive or Routinely Purchased (IRP) Item Capped Rental Item Items Requiring Frequent and Substantial Servicing Oxygen Equipment (not contents)

Note that some of these categories may require additional modifiers (such as KH, KI, or KJ for capped rental items). Refer to Chapter 5 of the Supplier Manual for details.
Check the DMEPOS Fee Schedule

An easy way to determine if an RR, NU, or UE modifier is required is by looking up the HCPCS code on the CMS DMEPOS Fee Schedule. If the fee schedule shows a modifier next to the HCPCS code, then that modifier is required for claim submission. When there are multiple modifier possibilities (such as RR, NU, or UE), then the HCPCS code will be listed multiple times with a different modifier next to each code.

Note that there are exceptions to this rule. For instance, certain capped rental items that can be purchased in the first month do not have an NU or UE value on the fee schedule. Also note that inclusion or exclusion of a fee schedule amount for an item or service does not imply any health insurance coverage.

Fee Schedules are available on our website at http://www.cgsmedicare.com/jc/coverage/fees/index.html.
Check the Appropriate Local Coverage Determination and Policy Article

Some Local Coverage Determinations (LCDs) and/or Policy Articles include information about required modifiers for certain HCPCS codes. You should always be familiar with the appropriate LCD and Policy Article before submitting a claim to the DME MAC.

You can access LCDs and Policy Articles via our website by going to http://www.cgsmedicare.com/jc/coverage/LCDinfo.html.