Medicare AdvantageBilling CodesHigh impact
[Georgia] Claim Edits for Durable Medical Equipment
CareSource·GA · Orthopedics, General Practice, Family Medicine +5 more·Claims & Billing
Effective date
Jan 17, 2026
We identified it
May 9, 2026
Summary
CareSource is implementing new claim edits for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) effective January 17, 2026, requiring correct use of modifiers (rental, anatomical, functional, surgical dressings, and other) to prevent claim denials. The policy also establishes a limitation of one breast pump per delivery (240 days/eight months) and applies CMS payment policies across multiple DMEPOS categories.
Action Required
By January 17, 2026: Billing team must audit and update all DMEPOS billing processes to ensure correct modifier usage, including rental modifiers (RR), anatomical modifiers (LT, RT), functional modifiers (K0-K4), surgical dressing modifiers (A1-A9, GY), and other required modifiers (KF, KX, GA, GZ). Update billing software validation rules to enforce proper modifier combinations per CMS guidelines and state requirements. Train billing staff on modifier requirements for all affected DMEPOS categories (wheelchairs, hospital beds, oxygen equipment, respiratory assist devices, orthosis, orthopedic footwear, urological supplies, surgical dressings, and capped rentals). Implement system edit to limit breast pump codes E0602, E0603, E0604 to one per delivery per 240-day period across all providers. Test claims processing before the effective date. Failure to apply correct modifiers will result in claim denials. Contact CareSource Provider Services with questions: D-SNP (1-833-230-2176), Marketplace (1-833-230-2101), or Medicaid (1-855-202-1058).