License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

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POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

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July 7, 2023

Insulin Furnished Through an External Infusion Pump – Important Billing Instructions for Dates of Service on or After May 1, 2023

Starting July 1, 2023, Part B coinsurance for a month’s supply of insulin (HCPCS J1817, J1811, J1813) used in an insulin pump covered under the DME benefit cannot exceed $35 (as required by Section 11407 of the Inflation Reduction Act). In addition, the Part B deductible will not apply for the insulin starting July 1, 2023. Standard Medicare cost-sharing applies to the pumps, tubing, and any other supplies.

CMS will adjust payments to suppliers and pharmacies to account for the balance of the reduced coinsurance. Suppliers will continue to get the Medicare payment amount for the insulin (average sales price plus 6%) minus any applicable coinsurance, which is capped at $35 for a month’s supply.

If more than 1 claim for the same month is submitted, the coinsurance cap will apply to the first claim processed. The coinsurance will not exceed $35 per month or $105 for a 3-month supply.

System updates necessary to implement this coinsurance cap will be completed by July 3, 2023. To make sure Medicare beneficiaries are not charged more than the $35 maximum coinsurance for the month of July, do not bill for a 3-month supply of insulin during May or June. For dates of service in May and June, only bill a 1-month supply of J1817 at a time.

JK and JL Modifiers

The following modifiers are effective April 1, 2023:

JK: 1-month supply or less of drug/biological
JL: 3-month supply of drug/biological

For dates of service on or after May 1, 2023, claims for J1817 submitted without the JK or JL modifier will be denied. You must resubmit the claim with the correct modifier.

Billing Instructions for Dates of Service May 1 - June 30, 2023:

Bill for a 1-month supply of insulin at a time and report the JK modifier
Do not bill a 3-month supply of insulin

Billing Instructions for Dates of Service July 1, 2023, and After:

Bill a 3-month supply of insulin with the JL modifier or
Bill a 1-month supply of insulin with the JK modifier

The following table shows required usage of modifier and billing based on date of service:

Date of Service	Required Modifier with HCPCS J1817	Billing of insulin administered through DME
April 1, 2023 - April 30, 2023	JK or JL may be billed, but not required	Up to a 3-month supply
May 1, 2023 - June 30, 2023	JK	Up to a 1-month supply
July 1, 2023 and after	JK or JL	Up to a 3-month supply

For more information, see the MLN4443820 Fact Sheet - Billing Medicare Part B for Insulin with New Limits on Patient Monthly Coinsurance.

Date of Service (DOS) Billing Rules

The date of service reported on the claim depends on the method of delivery.

Direct delivery to the beneficiary: The DOS must be the date that the DMEPOS item was received by the beneficiary or designee.
If a supplier utilizes a shipping service or mail order, suppliers have 2 options for the DOS to use on the claim:
1. Suppliers may use the shipping date as the date of service. The shipping date is defined as the date the delivery/shipping service label is created or the date the item is retrieved by the shipping service for delivery. However, such dates should not demonstrate significant variation.
2. Suppliers may use the date of delivery as the DOS on the claim.

Refer to the Standard Documentation Requirements for All Claims Submitted to DME MACs Policy Article (A55426) for proof of delivery documentation rules.

Publication History

March 20, 2023	Originally published
July 7, 2023	Revised to add J1811 and J1813