Wednesday, May 5, 2010

DMEPOS modifiers - KH , BO, SJ, A1 AND K1

Michigan Medicaid for DMEPOS

This document contains information for interpreting the Michigan Medicaid Databases listed for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). The database contains the covered services for the following

provider groups:

* Medical Suppliers
* Prosthetists/Orthotists
The HCPCS Level 1 or Level 2 code for the service.

The DME/medical supplies, orthotics and prosthetics program uses the following sections from the HCPCS coding system:

�� A codes - Medical and Surgical Supplies and miscellaneous

�� B codes - Enteral and Parenteral Nutrition

�� E- codes - Durable Medical Equipment

�� K codes - Temporary Codes

�� L codes - Orthotic and Prosthetic devices

�� S codes - Temporary Codes

�� T codes - Medicaid Temporary Codes

Reimbursement Modifier

The following modifiers identify a set fee screen.

For medical supplies and/or durable medical equipment:

Breast Pump:

KH - DMEPOS item, initial claim, purchase or first month rental (Use with HCPCS code E0604 only if kit is provided)

Enteral Nutrition:

BO - Orally administered nutrition, not by feeding tube

Infusion Therapy:

SH - Second concurrently administered infusion therapy

SJ - Third concurrently administered infusion therapy

Powered Flotation/Air-Fluidized Bed:

MS - Six-month maintenance and servicing fee (report for HCPCS codes E0193 or E0194 only)


NU - New DME equipment

UE - Used durable medical equipment

RA - Replacement of a DME item

RB - Replacement of a part of DME furnished as part of a repair

RR - Rental (use when DME is to be rented)

A blank will appear for services other than those identified above and designates a purchase.

Informational Modifier

The following informational modifiers are required for payment.

For medical supplies

Surgical Dressings:

A1 - Dressing for one wound

A2 - Dressing for two wounds

A3 - Dressing for three wounds

A4 - Dressing for four wounds

A5 - Dressing for five wounds

A6 - Dressing for six wounds

A7 - Dressing for seven wounds

A8 - Dressing for eight wounds

A9 - Dressing for nine or more wounds

For prosthetics and orthotics

Functional Level Modifiers for Lower Extremity Prostheses:

K0- Lower extremity prosthesis functional level 0 – does not have the ability or potential to ambulate or transfer safely wit or without assistance and a prosthesis does not enhance their quality of life or mobility

K1- Lower extremity prosthesis functional level 1 – has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. Typical of the limited and unlimited household ambulator.

K2 - Lower extremity prosthesis functional level 2 – has the ability or potential for ambulation with the ability to traverse low level environmental barriers such as curbs, stairs or uneven surfaces. Typical of the limited community ambulator.

K3 - Lower extremity prosthesis functional level 3 – has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to transverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple

Left and Right Modifiers:

LT - Left Side of the Body (used to identify procedures performed on the left side of the body).

RT - Right Side of the Body (used to identify procedures performed on the right side of the body)

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