Modifiers and Billing

Common modifiers for orthotic and prosthetic claims include:

• CG - Elastic garments, which do not meet the statutory definition of a brace. Hand orthoses billed with L3923, and spinal orthoses billed with L0450, L0454, L0625, and L0628 must use the CG modifier.
• GA – indicates the item is likely to be denied by Medicare and an ABN is on file.
• GK - Reasonable and necessary item ordered when a piece of equipment is upgraded. (See The Right Way to Give a Custom Brace)
• GY - The item is statutorily excluded from Medicare benefits. A4467 is one code always billed with this modifier.
• GX – the item is not covered by Medicare and a voluntary ABN has been issued. The item will be automatically denied when this modifier is used.
• KX - Specific required documentation on file. Suppliers must add a "KX" modifier to knee orthoses base and addition codes only if all of the coverage criteria in LCD are met and appropriate documentation is retained in the supplier's files.
• LT - Left side
• RT - Right side
• K0-K4 - Functional level. All prosthetic claims require the use of a functional level modifier
• RA -  Replacement of a DME, Orthotic or Prosthetic Item
• RB - Replacement of a Part of a DME, Orthotic or Prosthetic Item Furnished as Part of a Repair

More information about modifiers can be found here.