New Modifier Requirements for Ventilators, Lymphedema Compression Treatment Items, and Pneumatic Compression Devices

Dear Supplier,

On December 4, 2025, the DME MACs issued new guidance regarding the use of SC, GA, GZ, and GY modifiers for Ventilators, Lymphedema Compression Treatment Items, and Pneumatic Compression Devices. This represents a significant and welcome development—one that we have long advocated for as stakeholders to facilitate automatic PR50 denials when a supplier obtains a properly executed advanced beneficiary determination (ABN) evidence by the appendage of the GA modifier on the claim.

We believe this change will streamline processes for these product categories and improve overall compliance and efficacy. Prior to the change, the presence of the GA modifier did not automatically guarantee a PR50 (patient responsibility) denial for these product categories, and it could result erroneous payments or inappropriate claim denials (CO50). In the event of erroneous denial or payment, supplier would have to appeal claims with the ABN and ask for a PR50 adjudication. That process is administratively burdensome for supplier and Medicare.

This update will also be highly beneficial for ventilator-related claims once further clarification is provided on ongoing medical need requirements. Given the short notice, it is imperative that we act swiftly to update price tables to prevent claim rejections.

Based on current trends, it is reasonable to anticipate that the MACs will incorporate this guidance into their upcoming educational materials, tools, and webinars in the coming days and weeks.

Important Note: The SC modifier functions as the equivalent of the KX modifier under other policies. It affirms that the billed item is reasonable and necessary and, therefore, meets Medicare requirements for payment consideration.

See the article below published by CGS, the Jurisdiction B and C DME Medicare Administrative Contractor.

“Starting for dates of service on or after January 1, 2026, suppliers must add one of these modifiers (SC, GA, GY, or GZ) on all claims for:

• Ventilators
• Lymphedema Compression Treatment Items
• Pneumatic Compression Devices and related accessories

The SC modifier (medically necessary service or supply) indicates applicable payment criteria are met based on the relevant National Coverage Determination (NCD) or regulation. Alternatively, the GA, GY, or GZ indicate the applicable payment criteria are not met. Claim lines billed without a SC, GA, GY or GZ modifier will be rejected for missing information and may be resubmitted with the appropriate modifier.

The DME MACs are implementing these modifiers to reduce Comprehensive Error Rate Testing (CERT) errors, prevent overpayments, and decrease administrative burden to the supplier community.

For more information, see:

• Lymphedema Compression Treatment Items – Correct Coding and Billing
• Pneumatic Compression Devices – Correct Coding and Billing
• Correct Billing and Coding of Ventilators“

For more information visit the MAC’s website at New Modifier Requirements for Ventilators, Lymphedema Compression Treatment Items, and Pneumatic Compression Devices – Effective January 1, 2026

If you have additional questions or concerns, please do not hesitate to reach out to your ACU-Serve representative or reach out to us.

Sincerely,
Noel Neil JM CDME
Chief Compliance Officer