Article - External Infusion Pumps - Policy Article (A52507)

The quantity administered is billed on one claim line without the JW modifier; and,The quantity discarded is billed on a separate claim line with the JW modifier.In this scenario, the JW modifier must be billed on a separate line to provide payment for the amount of discarded drug or biological. For example:A single use vial is labeled to contain 100 mg of a drug.The drug's HCPCS code UOS is 1 UOS = 1 mg.95 mg of the 100 mg in the vial are administered to the beneficiary by the supplier.5 mg remaining in the vial are discarded.The 95 mg dose is billed on one claim line as 95 UOS.The discarded 5 mg is billed as 5 UOS on a separate claim line with the JW modifier.Both claim line items would be processed for payment.Scenario 2When the HCPCS code UOS is equal to or greater than the total of the actual dose and the amount discarded, use of the JW modifier is not permitted. As of July 1, 2023, the JZ modifier is required in this situation. If the quantity of drug administered is less than a full UOS, the billed UOS is rounded to the appropriate UOS. For example:A single use vial is labeled to contain 100 mg of a drug.The drug's HCPCS code UOS is 1 UOS = 100 mg.70 mg of the 100 mg in the vial are administered to the beneficiary by the supplier.30 mg remaining in the vial are discarded.The 70 mg dose is billed correctly by rounding up to one UOS (representing the entire 100 mg vial) on a single line itemwith the JZ modifier.The single line item of 1 UOS would be processed for payment of the combined total 100 mg of administered and discarded drug.The discarded 30 mg must not be billed as another 1 UOS on a separate line item with the JW modifier. Billing an additional 1 UOS for the discarded drug with the JW modifier is incorrect billing and will result in an overpayment.GA, GY, GZ AND KX MODIFIERSFor claims submitted on or after March 1, 2023 suppliers must add the KX modifier to claim lines billed for the external infusion pump, drugs and supplies for dates of service on or after January 1, 2023, only if all of the coverage criteria in the Coverage Indications, Limitations, and/or Medical Necessity section in the related LCD have been met. Evidence supporting the use of the KX modifier must be retained in the suppliers files and available to the DME MAC upon request. The KX modifier requirement will continue to be required for HCPCS E0784 and J1817 for any date of service billed, if applicable.If all of the criteria in the Coverage Indications, Limitations, and/or Medical Necessity section of the related LCD have not been met, the GA or GZ modifier must be added to the code. 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 (ABN) or the GZ modifier if they have not obtained a valid ABN.Claim lines billed for the above services without a KX, GA, or GZ modifier will be rejected as missing information for claims submitted on or after March 1, 2023 for all codes.An infusion drug not administered using a durable infusion pump must be billed using the appropriate HCPCS code plus the GY modifier.CODING GUIDELINESAn ambulatory infusion pump (E0781) is an electrical or battery operated device, which is used to deliver solutions containing a parenteral drug under pressure at a regulated flow rate. It is small, portable, and designed to be carried by the beneficiary.A stationary infusion pump (E0791) is an electrical device, which serves the same purpose as an ambulatory pump but is larger and typically mounted on a pole.A disposable drug delivery system (A4305, A4306, A9274) is a device used to deliver solutions containing injectable drugs that is not reusable, i.e., it is used by a single beneficiary for a limited time and then discarded.An infusion controller (E1399) is an electrical device, which regulates the flow of parenteral solutions under gravity pressure.A reusable mechanical infusion pump (E0779) is a device used to deliver solutions containing parenteral drugs under pressure at a constant flow rate determined by the tubing with which it is used. It is small, portable, and designed to be carried by the beneficiary. It must be capable of a single infusion cycle of at least 8 hours.Code E0780 describes a mechanical infusion pump which is similar to an E0779 pump, but which is only capable of a single infusion cycle of less than 8 hours.Code K0455 describes an ambulatory electrical infusion pump, which is used for the administration of epoprostenol (J1325) and treprostinil (J3285).Code A4221 describes all necessary supplies, such as dressings for the catheter site and flush solutions, not directly related to non-insulin drug infusions. The catheter site may be a peripheral intravenous line, a subcutaneous infusion catheter, a peripherally inserted central catheter (PICC), a centrally inserted intravenous line with either an external or a subcutaneous port, or an epidural catheter.Code A4222 includes the cassette or bag, diluting solutions, tubing and other administration supplies, port cap changes, compounding charges, and preparation charges. This code is not used for a syringe-type reservoir.Code K0552 describes a syringe-type reservoir that is used with the K0455 pump when it is used to administer epoprostenol/treprostinil, or with an E0779 pump used to administer subcutaneous immune globulin. The reservoir may be either glass or plastic and includes the needle for drawing up the drug. This code does not include the drug for use in the reservoir. Code A4232 is invalid for submission to Medicare and should not be used for this purpose.Claims for codes A4221, A4222 and K0552 must only be used with a non-insulin external infusion pump (E0779, E0780, E0781, E0791 or K0455). Claims with dates of service on or after January 01, 2017 for codes A4221, A4222 and K0552 used with an external infusion pump HCPCS code E0784 are incorrectly coded.Code A4224 is all-inclusive and describes all necessary supplies (excluding the insulin reservoir  see code A4225) used with an external infusion pump (E0784) for the administration of continuous subcutaneous insulin and includes, but is not limited to, all cannulas, needles, dressings and infusion supplies. Separate billing for any item including an item using a specific HCPCS code, if one exists, will be denied as unbundling.Code A4225 describes a syringe-type reservoir that is used with the external insulin infusion pump (E0784).Claims for codes A4224 and A4225 must only be used with insulin infusion pumps (E0784). Claims with dates of service on or after January 01, 2017 for codes A4224 and A4225 used with an external infusion pump other than code E0784 are incorrectly coded.HCPCS Supply Codes Associated with External Infusion Pumps HCPCS CodesThe following table describes HCPCS supply codes that are used with different types of external infusion pumps. The HCPCS codes listed in the Associated Codes column should be used with the corresponding Pump HCPCS code. Claims for supply codes listed in the Non-Associated Codes column will be denied as incorrect coding, if they are being used with an external infusion pump listed in the Pump HCPCS Code column of the same line.Pump HCPCS CodeAssociated CodesNon-Associated CodesE0779A4221, A4222, K0552*A4224, A4225E0780A4221, A4222A4224, A4225, K0552E0781A4221, A4222A4224, A4225, K0552E0784A4224, A4225, A4238**, A4239**A4221, A4222, K0552E0791A4221, A4222A4224, A4225, K0552K0455A4221, A4222, K0552*A4224, A4225