Competitive Bidding: Modifiers
Competitive Bidding, Round 2021, began January 1, 2021 and will continue until December 31, 2023.
The round of competitive bidding includes certain off the shelf knee braces and off the shelf back braces. Only the winning bidders in a specific geographical area are able to provide these braces to Medicare beneficiaries.
The exception to this rule is physicians and Physical Therapists/Occupational Therapists who provide braces to their patients as part of the overall treatment plan.
In this case, there are required modifiers to use when billing the brace:
DMEPOS item subject to Competitive Bidding Program that is furnished as part of a professional service (non-contract supplier, physicians and other treating practitioners.)
Physical therapists and occupational therapists furnishing DMEPOS item subject to Competitive Bidding Program as a non-contract supplier.
Requirements specified in the medical policy have been met. NOTE: this modifier is required for knee orthoses.
Left side (Used to identify item provided for the left side of the body.)
Right side (Used to identify item provided for the right side of the body.)
DMEPOS item subject to Competitive Bidding Program that is furnished as part of a professional service (non-contract supplier, physicians and other treating practitioners.)
Physical therapists and occupational therapists furnishing DMEPOS item subject to Competitive Bidding Program as a non-contract supplier.
Requirements specified in the medical policy have been met. NOTE: this modifier is required for knee orthoses.
Left side (Used to identify item provided for the left side of the body.)
Right side (Used to identify item provided for the right side of the body.)
Note: Suppliers must bill bilateral products on two separate claim lines. One line will have the HCPCS code with the RT modifier and the next claim line will have the same HCPCS code with the LT modifier. Each unit of service is one.
Recent guidance from Noridian specifically states:
- When providing brace as part of professional service in beneficiary’s CBA (must be same date of service)
- Beneficiary travels to non-CBA for procedure (surgery) and then goes home (KT not applicable)
- Beneficiary temporarily living in another CBA or non-CBA (KT not applicable)
Physicians/Practitioners - KV
Physical Therapists and Occupational Therapists - J5
You may find more information about Competitive Bidding Areas on dmecompetitivebid.com.
For information about modifiers, go to: