KX Modifier – Requirements for Use
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KX Modifier – Requirements for Use

The narrative description for the KX modifier is:

Requirements specified in the medical policy have been met

The primary use of the KX modifier is to enable the DME MAC to perform automated medical review of claims. Information relating to coverage criteria that can be submitted with electronic claims is limited.  Among the elements that can be used as screening tools for automated review are ICD-9 diagnosis codes, Certificates of Medical Necessity (CMNs), units of service, and dates of service.  However, the more complex coverage criteria in many medical policies cannot be assessed using that information.

The KX modifier serves as an attestation by the supplier that the requirements for its use that are defined in the particular Local Coverage Determination (LCD) are true for that specific beneficiary.  It must not be added indiscriminately just "because it is needed to get the claim paid”.

As the description of the KX modifier indicates, requirements for its use vary from policy to policy. In some policies, the modifier pertains to all HCPCS codes; in other policies, it applies to only select codes.  In some policies, use of the KX modifier refers to very limited information (e.g., in the Glucose Monitors policy, whether the patient uses insulin); whereas in other policies, it attests that multiple criteria have been met (e.g., Power Mobility Devices).  In some policies, absence of the KX modifier results in a medical necessity denial; in other policies, the lack of the modifier results in a statutorily noncovered denial.

In the following policies, the instructions for use of the KX modifier clearly specify that the supplier must have the documentation (e.g., copies of the patient's medical record, test reports, etc.) in their files before they may submit a claim line with the modifier.  If they do not, the modifier must not be added.

  • Ankle-Foot/ Knee-Ankle-Foot Orthoses
  • Cervical Traction Devices
  • Knee Orthoses
  • Patient Lifts
  • Pressure Reducing Support Surfaces – Group 1
  • Pressure Reducing Support Surfaces – Group 2
  • Pressure Reducing Support Surfaces – Group 3
  • Respiratory Assist Devices
  • Walkers

In the following policies, the requirements for use of the KX modifier do not specify that the supplier must have the documentation in their files before they submit the claim, saying instead that the information must be available "upon request”.   For these policies, at the very least, the supplier must have phone contact with the physician's office or use other means to verify that all of the specified coverage criteria have been met.   However, because multiple audits have shown that information verifying coverage is often not present in the physician's records and may be particularly difficult to obtain months or years after the item is provided, the DME MAC encourages suppliers to get that documentation up front and retain it in their files.

  • Automatic External Defibrillators
  • Commodes
  • External Infusion Pumps
  • Glucose Monitors
  • High Frequency Chest Wall Oscillation Devices
  • Hospital Beds
  • Immunosuppressive Drugs
  • Manual Wheelchair Bases
  • Nebulizers
  • Negative Pressure Wound Therapy Pumps
  • Oral Antiemetic Drugs
  • Orthopedic Footwear
  • Positive Airway Pressure Devices
  • Power Mobility Devices
  • Refractive Lenses
  • Therapeutic Shoes for Persons with Diabetes
  • Transcutaneous Electrical Nerve Stimulators
  • Urological Supplies
  • Wheelchair Options and Accessories
  • Wheelchair Seating

Adding the KX modifier without ascertaining that all the requirements specified in the policy have been met could be viewed as filing a false claim and potential abuse of the Medicare program.

It is imperative that suppliers review the Documentation Requirements section of each LCD in order to fully understand the criteria that must be met for the proper use of the KX modifier.  Obtaining physician records, test reports, and other documents is the best means of assuring that all of the information needed to support use of the KX modifier is present in the event of an audit. (121610)

Related Articles of Interest:

Sebelius and Holder Announce New Tools to Prevent and Fight Fraud at Boston Regional Health Care Fraud Prevention Summit (121610)

OIG Reports $25.9 Billion in Savings and Expected Recoveries in FY 2010 (121610)

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