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DEPARTMENTS: Payment Strategies

Modifier Tips for Physicians Who Submit Their Own Claims for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies

Schaum, Kathleen D. MS

Author Information
Advances in Skin & Wound Care: August 2020 - Volume 33 - Issue 8 - p 401-402
doi: 10.1097/01.ASW.0000684276.38137.50
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The novel coronavirus 2019 (COVID-19) public health emergency (PHE) has presented many challenges to wound/ulcer management physicians and other qualified healthcare professionals (QHPs). Since the PHE was announced, this author has spent many hours consulting with physicians/QHPs about implementing new services such as telehealth into their business models. In addition, many physicians/QHPs who supply durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) to their patients requested assistance when their coders and billers were unavailable to submit their Medicare claims during the PHE. These physicians/QHPs had no choice but to prepare and submit their own DMEPOS claims to Medicare, although some had not done so for many years. Although the claim preparation and submission processes are not difficult, the physicians/QHPs realized that details matter. Nearly every caller was confused about the use of modifiers and surprised when I told them about two relatively new modifier processes for DMEPOS claims. This month’s column will cover these processes in case you have to prepare and submit your own Medicare claims for DMEPOS during the COVID-19 PHE, or at any other time when you experience a staff shortage.

New Coding Instructions

Many of the physicians/QHPs reported that their claims for bilaterally applied items were denied. Upon review, this author identified that the claims were not really denied; instead, they were returned as unprocessable because of improper reporting of the right (RT) and left (LT) modifiers and had to be resubmitted. (They cannot be appealed and cannot be reopened or submitted for adjustment.) In every case, the claims were returned because the physician/QHP reported the Healthcare Common Procedure Coding System (HCPCS) code for the bilaterally applied item with RTLT on the same claim line with two units of service (UOS). Although this type of modifier reporting on Medicare claims was previously allowed, it is no longer correct.

The modifier reporting rule changed on December 6, 2018, when the DME Medicare Administrative Contractors (MACs) issued a joint publication that addressed the use of the RT and LT modifiers when billing for two of the same DMEPOS items (with same HCPCS code) used bilaterally on the same date of service: https://med.noridianmedicare.com/web/jddme/policies/dmd-articles/2018/correct-coding-rt-and-lt-modifier-usage-change. This new coding instruction became effective on March 1, 2019: the DMEPOS providers and suppliers must bill each item used bilaterally on two separate claim lines. One claim line should include the HCPCS code with the RT modifier and one UOS. A separate claim line should include the same HCPCS code with the LT modifier and one UOS. For a complete list of affected DMEPOS items and their pertinent DME MAC coding articles, see the joint publication at the aforementioned link.

In case you are wondering why the coding articles are so important, they list the HCPCS codes in each category that are impacted by the DME MACs’ new coding instruction for RT and LT modifiers. For example, the Surgical Dressings article (A54563) says:

The RT and/or LT modifiers must be used with codes A6531, A6532, and A6545 for gradient compression stockings and wraps. Effective for claims with dates of service on or after March 1, 2019, when the same code for bilateral items (left and right) is billed on the same date of service, bill each item on two separate claim lines using the RT and LT modifiers and 1 UOS on each claim line. Do not use the RTLT modifier on the same claim line and billed with 2 UOS. Claims billed without modifiers RT and/or LT, or with RTLT on the same claim line and 2 UOS, will be rejected as incorrect coding.

You can locate the coding articles by entering the document ID in the Medicare Coverage Database: www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx.

Advanced Modifier Engine

Nearly every physician/QHP who has contacted this author during the COVID-19 PHE and who supplied and billed for DMEPOS items was struggling to decide when a modifier was needed and what modifier was needed on their claims. Not one person who contacted this author about the use of modifiers on DME claims knew about the self-service educational tool, the Advanced Modifier Engine (AME) developed by and exclusive to the CGS DME MACs for Jurisdictions B and C. When DME providers or suppliers select a specific HCPCS code and billing scenario, the AME tool recommends modifiers for claim submission. The educational tool is available at http://cgsmedicare.com/medicare_dynamic/jb/advanced_modifier_engine (no username or password is required) and can even be used by providers and suppliers who submit their claims to the other DME MAC, Noridian Healthcare Solutions. However, CGS does remind users that the AME is an educational tool, it does not replace coverage guidelines and Medicare supplier manuals, and documentation must support the modifier(s) reported.

Once this author provided physicians/QHPs with a link to the AME tool and walked them through its use, they quickly appreciated it. Here are some simple steps to follow in using the tool:

  • Begin by selecting the required appropriate HCPCS code and the scenario that best describes the product used. You may also select a subscenario that will further refine your request.
  • Submit your request.
  • If you only selected the required HCPCS code and scenario, the AME will provide one or more possible modifiers: if different subscenarios require different modifiers, the AME will list each subscenario and its description. The subscenario and modifier that applies to that product can then be selected.
  • If you selected the required HCPCS code and scenario, and the optional subscenario, the AME will select the one modifier that is pertinent to your specific search.
  • In either type of search, the AME also provides some helpful general information:
    • —The description of the HCPCS code that was the subject of the search
    • —If a pertinent Local Coverage Determination (LCD) and/or Policy Article(s) exists, the title and document ID will appear
  • Some AME searches will include important modifier options based on the patient’s case.

See the Table for a real-life example of a podiatrist who used the AME educational tool during the COVID-19 PHE. Then, if you need to learn which modifiers are required on Medicare claims for the various DMEPOS items that you supply to your patients for home use, visit the AME tool. Try it! You will like it!

Table 1.
Table 1.:
Real-Life Example of a Podiatrist who Used the AME Educational Tool During the COVID-19 Emergency
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