Starting July 1, 2023, Part B coinsurance for a month’s supply of insulin used in an insulin pump covered under the DME benefit can’t exceed $35.

The Centers for Medicare & Medicaid Services (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.

Don’t bill for supplies of insulin for July or subsequent months before July 2023. CMS will complete the system updates to make sure patients aren’t charged more than the $35 maximum allowed for the month of July. Your DME Medicare Administrative Contractor will also educate you about billing during the May – June transition period.

CMS is adding 2 new modifiers to the April 2023 HCPCS quarterly update file:

  • JK – Short Descriptor: Drug 1-month supply or less; Long Descriptor: One month supply or less of drug/biological
  • JL – Short Descriptor: Drug 3-month supply; Long Descriptor: Three month supply of drug/biological

Split Billing:

  • Before July 2023: For “from date of service” in May or June 2023, don’t bill a 3-month supply of insulin. Instead, bill a 1-month supply of insulin with the JK modifier.
  • Starting July 2023: For “from date of service” in July and later, bill a 3-month supply of insulin with the JL modifier or a 1-month supply with the JK modifier.

Source: U.S. Centers for Medicare & Medicaid Services (CMS)

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