CMS - External Infusion Pumps Policy

Changes in the Medicare Part B program will improve access to high quality, affordable biosimilars for people with Medicare as well as impose a $35 per month cost-sharing cap on insulin used in DME pumps.

The JK and JL modifiers are effective for claims with dates of service on or after April 1, 2023, for insulin (J1817) administered through an external insulin infusion pump (E0784): For a one-month or less supply of insulin, the JK modifier must be added to HCPCS code J1817. For a three-month supply of insulin, the JL modifier must be added to HCPCS code J1817.

Effective for claims with dates of service on or after July 1, 2023, a beneficiary’s coinsurance for a month’s supply of insulin furnished through an external insulin infusion pump is not to exceed $35. To ensure beneficiaries are not charged more than the $35 maximum allowed for the month of July 2023, providers must not bill a three-month supply of insulin from May 1 through June 30, 2023.

For claims with dates of service in May or June 2023, providers must only bill a one-month supply of insulin and append the JK modifier. Claims with dates of service in May or June 2023 with the JL modifier appended will be denied. The denial code will be D46-MODIFIER INVALID/MISSING.

Learn more about Billing Medicare Part B for Insulin with New Limits on Patient Monthly Coinsurance