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Which Modifiers are Required?

Posted by Linda Collins | June 20, 2017

Which Modifiers are Required?

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.
  • 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.
  • KV - Used by physicians and treating practitioners who are not contract suppliers and who furnish walkers and related accessories to beneficiaries in a Competitive Bidding Area.
  • 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
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