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Linda Collins Blogger

Modifiers

Posted by Linda Collins | October 10, 2013

Modifiers are two-digit codes placed after the HCPCS code to assist in identifying the product. Specific products and product categories require the use of one or more modifiers in order to make the claim eligible for payment. The Policy Articles and LCDs define which codes require a modifier.

Orthoses (Generally)

Orthotic claims require a modifier to indicate which side of the body the brace will be supporting: “LT” for left side and “RT” for right side. For bilateral braces billed on the same date of service, use a double modifier of “LTRT” with the HCPCS code.

Spinal Orthoses

A4466 – GY

L0450 – CG

L0454 – CG

L0625 – CG

L0628 – CG

Knee Orthoses

Suppliers must add a “KX” modifier to knee orthoses base and addition codes only if all of the coverage criteria in LCD have been met and appropriate documentation is retained in the supplier’s files.

Prostheses

All prosthetic claims require the use of a functional level modifier (K0-K4) and a modifier to indicate which side of the body the prosthesis will be supporting: “LT” for left side and “RT” for right side.

Medical Necessity

When there is an expectation of a medical necessity denial, suppliers must enter the “GA” modifier on the claim line if they have obtained a properly executed Advance Beneficiary Notice or the “GZ” modifier if they have not obtained a valid ABN

See “The Right Way to Give Your Patient More,” June 13, 2013 for more information about upgrade codes.

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