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MedRx Medicare Part B - CMS POLICY ON INHALATION HCPCS
Scheduled Maintenance
Report for Optum Solutions
Completed
The scheduled maintenance has been completed.
In progress
Scheduled maintenance is currently in progress. We will provide updates as necessary.
Scheduled
MedRx Medicare Part B DME Clients
***************UPDATE TO CMS POLICY ON INHALATION HCPCS**************
On 2/1/26 CMS implemented a new policy requiring KX modifier be submitted on inhalation drug claims & the Medicare MedRx system was updated accordingly. Subsequently, on 2/17/26 CMS released an update to this requirement as follows – retroactive for claims date of service 2/1/26 forward:
• In addition to all inhalation HCPCS requiring a KX modifier, the KX modifier must also be submitted on the corresponding dispensing fee claim (one per month per patient).
As CMS has never required a modifier on a dispensing fee claim previously, this policy change will require coding within the Medicare MedRx system to accommodate. As such, we will be putting inhalation drug + dispensing fee claims on hold going forward until such coding can be completed. This will prevent further denials from occurring. We are assessing scope and will provide an updated alert containing delivery timeline soon. Once the coding updates are in place, we will release any held claims to Medicare with the appropriate modifier on both claim lines.
For inhalation claims date of service 2/1/26 – forward which have already been released to Medicare, Medicare is denying the dispensing fee portion of inhalation drug claims while paying the inhalation drug HCPCS. In order to obtain payment for the dispensing fee portion, you will need to take the claims to re-openings.
Action Needed/ How to reopen:
MedRx Recovery customers claims will be worked as part of the standard MedRx Recovery denial management service.
Non-MedRx Recovery customers should perform the following steps:
1. Identify dispensing fee denials with a DOS on or after 2-1-2026 where the drug paid (ANSI denial code CO4).
2. When reopening claims, ensure that the same modifier(s) submitted on the drug is applied to the dispensing fee
Note: All regions handle reopenings via their payer portals, whereas Jurisdictions B and C also take reopenings via fax.
For more information on this policy change, see:
https://cgsmedicare.com/jb/pubs/news/2026/02/cope195982.html
https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=33370
https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=52466
***************UPDATE TO CMS POLICY ON INHALATION HCPCS**************
On 2/1/26 CMS implemented a new policy requiring KX modifier be submitted on inhalation drug claims & the Medicare MedRx system was updated accordingly. Subsequently, on 2/17/26 CMS released an update to this requirement as follows – retroactive for claims date of service 2/1/26 forward:
• In addition to all inhalation HCPCS requiring a KX modifier, the KX modifier must also be submitted on the corresponding dispensing fee claim (one per month per patient).
As CMS has never required a modifier on a dispensing fee claim previously, this policy change will require coding within the Medicare MedRx system to accommodate. As such, we will be putting inhalation drug + dispensing fee claims on hold going forward until such coding can be completed. This will prevent further denials from occurring. We are assessing scope and will provide an updated alert containing delivery timeline soon. Once the coding updates are in place, we will release any held claims to Medicare with the appropriate modifier on both claim lines.
For inhalation claims date of service 2/1/26 – forward which have already been released to Medicare, Medicare is denying the dispensing fee portion of inhalation drug claims while paying the inhalation drug HCPCS. In order to obtain payment for the dispensing fee portion, you will need to take the claims to re-openings.
Action Needed/ How to reopen:
MedRx Recovery customers claims will be worked as part of the standard MedRx Recovery denial management service.
Non-MedRx Recovery customers should perform the following steps:
1. Identify dispensing fee denials with a DOS on or after 2-1-2026 where the drug paid (ANSI denial code CO4).
2. When reopening claims, ensure that the same modifier(s) submitted on the drug is applied to the dispensing fee
Note: All regions handle reopenings via their payer portals, whereas Jurisdictions B and C also take reopenings via fax.
For more information on this policy change, see:
https://cgsmedicare.com/jb/pubs/news/2026/02/cope195982.html
https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=33370
https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=52466
This scheduled maintenance affected: Pharmacy Solutions (MedRx).