​​Enhanced Claim Editor Program: Modifier requirements

May 24, 2022

​The Enhanced Claim Editing Program supports our commitment to ensure compliance with correct coding principles as endorsed by national and regional industry sources. The program encourages compliance with the Centers for Medicare & Medicaid Services (CMS) rules and reporting guidelines related to modifiers.

DME

CMS requires certain DME items be billed with Modifier KX, GA, or GZ. The following DME items have been added to this requirement:

  • negative pressure wound therapy pumps
  • high frequency chest wall oscillation devices
  • oxygen and oxygen equipment

Additional information on DME and modifiers can be found in the Billing & Reimbursement for Ancillary Serv​ices​ section of the Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers.

Always Therapy

CMS designates certain procedure codes as Always Therapy. Such procedure codes are assigned a therapy disposition code of "5" by CMS. These codes always represent therapy services when provided as part of an outpatient rehabilitation therapy plan of care and are required to be reported with one of the following therapy modifiers: CO, CQ, GN, GO, or GP.

PET for Oncologic Indications

According to CMS policy, positron emission tomography (PET) services must be billed with Modifier PI or PS to indicate initial or subsequent treatment strategy when performed for an oncologic indication.

Learn more

For additional resources on our enhanced claim editing process, please review the Enhanced Claim Editor Program: Frequently asked questions (FAQ). The FAQ includes additional information on our automated claim edits and coding validator reviews.