Billing Instruction - KX, GA/GZ and GY - New Uses
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Billing Instruction - KX, GA/GZ and GY - New Uses

Many policies use the KX modifier to indicate compliance with specified coverage criteria.  The following LCDs have revised instructions on modifier use.  Refer to each policy for detailed guidance.

  • Automatic External Defibrillators
  • Cervical Traction Devices
  • Commodes
  • Epoetin
  • Home Dialysis Supplies and Equipment
  • Positive Airway Pressure Devices
  • Respiratory Assist Devices
  • Therapeutic Shoes for Persons with Diabetes

The revised information is contained in the Documentation Section and outlines the use of additional modifiers to indicate that an item is statutorily noncovered or not medically necessary and whether or not a waiver of liability statement (i.e., Advance Beneficiary Notice or ABN) is on file for an expected medical necessity denial.

Proper use of the KX modifier expedites claim processing.  An absent modifier causes a claim denial.  However, increasing numbers of claims are submitted without the modifier resulting in a growing appeals volume.  If the patient meets the criteria for use of the KX modifier but the supplier forgets to include it on the claim line, currently the supplier may request a reopening of the claim.  This procedure requires manual intervention by the DME MAC and is responsible for a substantial workload for the contractor.

Effective with these LCD revisions, the contractors will use the presence of a KX, GA, GZ, or GY modifier to indicate whether the coverage criteria are or are not met.  The DME MACs are implementing system edits that will reject a claim line if the supplier does not include one of these modifiers as specified in each of these LCDs.  If a claim line is rejected, the supplier may resubmit the claim line with the appropriate modifier.  Requesting a reopening to correct a claim that is missing one of these modifiers will no longer be an available option.

Since the KX modifier has a differing definition depending on the LCD requirements, suppliers should review the revised LCDs carefully to understand the proper use of the modifiers KX, GA, GZ, or GY for each policy.

Over the coming months, other LCDs that include use of the KX modifier will be updated to incorporate instructions for the use of the GA, GZ, or GY modifiers.

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