Modifier KX (Documentation on file) to indicate whether the patient is insulin dependent. Currently, there is a threshold for using KX modifiers and a trigger for possible medical review. 0000040938 00000 n Modifier JW Effective for dates of service on or after April 1, 2015, providers must submit modifier JW to identify unused drug or biologicals from single use vials or single use … the KX modifier when the requirements specified in the medical policy have been met; ... WASHINGTON – The DME MACs are retiring the “Dear Physician” letter for artificial limbs, according to a bulletin from the American Orthotics & Prosthetics Association. Currently, the following policies address KX modifier usage: • Automatic External Defibrillators • Cervical Traction Devices • Commodes • Continuous Positive Airway Pressure System 0000040152 00000 n 0000049046 00000 n 0000006206 00000 n Claims lines billed with codes without a KX, GA or GZ modifier will be rejected as missing information. 0000031796 00000 n Therapy Cap-Related Modifier: KX. Denials with solutions in Medical Billing, Denials Management – Causes of denials and solution in medical billing, CO 4 Denial Code – The procedure code is inconsistent with the modifier used or a required modifier is missing, CO 5 Denial Code – The Procedure code/Bill Type is inconsistent with the Place of Service, CO 6 Denial Code – The Procedure/revenue code is inconsistent with the patient’s age, CO 7 Denial Code – The Procedure/revenue code is inconsistent with the patient’s gender, CO 15 Denial Code – The authorization number is missing, invalid, or does not apply to the billed services or provider, CO 17 Denial Code – Requested information was not provided or was insufficient/incomplete, CO 19 Denial Code – This is a work-related injury/illness and thus the liability of the Worker’s Compensation Carrier, CO 23 Denial Code – The impact of prior payer(s) adjudication including payments and/or adjustments, CO 31 Denial Code- Patient cannot be identified as our insured, CO 119 Denial Code – Benefit maximum for this time period or occurrence has been reached or exhausted, ICD 10 Code for Sepsis Severe Sepsis and Septic shock with examples, Molina Healthcare Phone Number claims address of Medicare and Medicaid, Healthfirst Customer Service-Health First Provider Phone Number-Address and Timely Filing Limit, Kaiser Permanente Phone Number – Claims address and Timely Filing Limit, Amerihealth Caritas Phone Number, Payer ID and Claim address, Anthem Blue Cross Blue Shield Timely filing limit – BCBS TFL List, Workers Compensation Insurances List of United States, Workers Compensation time limit for filing Claim and reporting in United States, Amerihealth Caritas Directory – Healthcare, Health Insurance in United States of America, Place of Service Codes List – Medical Billing. DPMS. 0000038774 00000 n 0000040574 00000 n 0000041530 00000 n KX Modifier: HCPCS Codes Page 2 of 25 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 05/13/2020 Proprietary Information of UnitedHealthcare. KX Modifier Thresholds (formerly known as Therapy Cap Process) Under Medicare Part B, the annual limitations on per beneficiary incurred expenses for outpatient therapy services are commonly referred to as “therapy caps” now known as KX modifier thresholds. For claims paid by a carrier or A/B MAC, it is only appropriate to append the KX modifier to a service that reasonably may exceed the cap. Today, I’m doing the same for the KX modifier and modifier 59—in a question and answer format. Part A/Part B (A/B) Durable Medical Equipment (DME) Medicare … Use of the KX Modifier for Therapy Cap Exceptions. 0000040309 00000 n 0000003902 00000 n The KX modifier thresholds are determined on a calendar year basis, which means that all beneficiaries begin a new … 0000039535 00000 n The GA modifier is used ONLY when there is an ABN on file indicating that therapy is NOT medically necessary. 0000006094 00000 n Also it should have beneficiary name with complete address. Several DME categories and frequently used modifiers are listed below. If you need to rebill the charge, check the Rebill box. No certificate of Medical necessity received. 0000012418 00000 n 0000007165 00000 n 0000002583 00000 n Billing for DME When billing for durable medical equipment (DME), use the appropriate HCPCS code and modifier (s) to describe the items being billed. 0000013239 00000 n 0000039340 00000 n At CPAP Supply USA we provide you with low prices, great service, and expert advice for all of your sleep therapy purchases. 0000039187 00000 n Please contact Medicare and let them know of the billing mistake, this way it becomes a voluntary admission and is not used against you. Information relating to coverage criteria that can be submitted with electronic claims is limited. Medical equipment’s that are utilized by the provider in treatment of the procedure or it’s prescribed by the provider to the patient, which is appropriate to use in the home and helps to boost patient’s daily activities. 0000004527 00000 n Continued on page 52 Here, the main idea is that any outpatient therapy is now subject to a $2,010 threshold. Hope this helps! Supplier usage of the KX modifier identifies that the requirements identified in the medical policy have been met. 0000011166 00000 n 0000014409 00000 n 0000016896 00000 n 0000014887 00000 n 0000049474 00000 n 0000005065 00000 n %PDF-1.4 %���� 0000042113 00000 n trailer <]/Prev 135438/XRefStm 2241>> startxref 0 %%EOF 225 0 obj <>stream If all of the criteria in the Indications and Limitations of Coverage and /or Medical Necessity section have not been met, the GA or GZ modifier must be added to the code. The date of death is before the date of service. For more information about the medical review (MR) threshold see the below section 10.3.4. 0000048553 00000 n 0000049124 00000 n 0000034942 00000 n KX Modifier ◦ Requirements specified in the medical policy have been met ◦ Coverage criteria and documentation requirements must be met ◦ Documentation is essential in supporting the item is reasonable and necessary ◦ Review each specific LCD to confirm the documentation requirements and which codes require use of the KX 0000038415 00000 n Documentation is essential to support that the item is reasonable and necessary and that … This is termed the KX modifier threshold. This service isn’t covered since our records show that the beneficiary was in the hospital/SNF on the date of service billed. Avoid using this modifier with the GY or GA modifiers for the same code. Does anyone know if this only applies to Novitas MCR or does it apply all MCR plans, for example UHC Medicare Advantage, AARP Complete or Aetna Medicare? (EFFECTIVE DATE 1/1/2003) 0000014035 00000 n A. 0000048268 00000 n 2016 Annual Update of Healthcare Common Procedure Coding System. Durable Medical Equipment Modifiers for DME Services. 0000039684 00000 n It is a signature on the order form (Proof of Delivery) along with the date from the beneficiary, which states beneficiary received the ordered item and also it determines the DME carrier to pay the amount to the DME supplier. Along with this KX modifier threshold, the new law retains the targeted medical review process but at a lower threshold amount of $3,000. 0000009505 00000 n Authorization is required from insurances for a few of the Durable Medical Equipment’s and it varies from insurance to insurance. Apply the KX modifier when you provide medically necessary services above the soft cap. Procedure is inconsistent with the modifier. h�b```c`�hb`g`p�cd@ AV�(G�ʭ �pN�{�\&Npp�e���2X��[���f㴴� �bl��v�g'��'��E��d����?30>a��z3�eLb�cbeVb��t��c�^���|L_��t5��1]��^���G�kc)�8�c�L _�. 0000040425 00000 n Modifier Ordering. that the provider’s documentation supports the payer’s requirements for payment. 0000016439 00000 n 0000037685 00000 n DME FOR . 0000048699 00000 n RT – Right side. Let us see some of the important and frequently used modifier we come upon while billing DME in medical billing: KX modifier is used to indicate required documentation is on file to support the medical necessity of the item. It means Medicare insurance as secondary they pay just for the purchased items. • Vision … Durable Medical … The therapy cap is based on allowable charges, according to your region’s Medicare allowable fee schedule. 0000039265 00000 n Chapter 16 of the Jurisdiction D DME Supplier Manual provides HCPCS codes with descriptions and the payment categories. 0000039981 00000 n KX Modifier-Documentation on File Many policies require the KX modifier be added to the code to indicate specific required documentation is on file. Lifetime benefit maximum has been reached/ billing exceeds the rental months covered / Payment cannot be made after the reasonable purchase price has been met. Along with the RR modifier we used any one of the below modifier to identify the month of the rental item billed: If the item is purchased from the beneficiary, then below modifier are used: NU modifier is used to indicate Purchase of new equipment, UE modifier is used to indicate purchase of used equipment. Inexpensive or Routinely Purchased DME Inexpensive DME-This category is defined as equipment whose purchase price does not exceed … 0000006772 00000 n Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) submitted to the DME Medicare Administrative Contractors; Gender-specific services for beneficiaries who are transgender, hermaphrodites or have ambiguous genitalia ; For speech language pathology, physical therapy or occupational therapy services: Submit this modifier when the patient has already met the … 0000044541 00000 n This modifier is used for capped rental DME items. Q. DME written order needs to have detailed description of the item signed and dated by physician. 0000039419 00000 n The KX modifier will get paid because it is an automated edit. If the item is rented from the beneficiary, then below modifier are used: RR modifier is used to indicate rental equipment. The service delivered beyond that require a KX modifier that indicates that the service meets the criteria for payment exception. 0000048381 00000 n E1038 HCPCS Code Dates, Status, Action: Status: ACTUAL: Possible status values: Actual Actual HCPCS Code; Discontinued Discontinued HCPCS … 0000015222 00000 n 0000001836 00000 n Appending the KX modifier is an attestation by the provider that documentation is on file verifying the patient has non-reversible symptomatic bradycardia. The only time Medicare covers Orthotics is if the patient has a form of amputation and that is an L5000 code. For CY 2021, the KX modifier threshold amounts are: a) $2,110 for Physical Therapy (PT) and Speech-Language Pathology (SLP) services combined, and b) $2,110 for Occupational Therapy (OT) services. In addition to an appropriate HCPCS code for the DME item, many HCPCS codes require a modifier. Therapists should continue to affix the KX modifier to all medically necessary services above the designated limit ($2,010 in 2018), thus signaling Medicare to pay the claim. Both modifiers cannot be used on the same claim lines. DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS, SUPPLIES AND SURGICAL DRESSINGS: Description of Pricing Indicator Code #1 PLACE YOUR AD HERE. KX – The KX modifier should be added to the code to indicate that specific required documentation is on file to support the medical necessity of the item. 0000008743 00000 n Use the drop-down menu on the desire Modifier field and select KX. Proper Use of the KX Modifier. Therapy Cap …. KX Modifier – Documentation on File . For samples of Durable Medical Equipment is: Wheelchair, Walker, Hospital beds, CPAP devices, Oxygen equipment, Nebulizers, Blood testing strips, Commode Chairs, Crutches, Medical supplies and so on. If the requirements for the KX modifier are not met, the KX modifier must not be used. 0000002418 00000 n CAPPED RENTAL DME (PRICE SUBJECT TO FLOORS AND CEILINGS). 0000014803 00000 n 0000044242 00000 n The use of the KX modifier makes a bold statement, informing the carrier . Click Save. LT – Left side. 0000041054 00000 n A: The KX modifier is used whenever maximum service units have been met. Modifier KX is used to confirm requirements outlined in the appropriate Local Coverage Determination (LCD), are met for the procedure billed. When billing for durable medical equipment (DME), use the appropriate HCPCS code and modifier(s) to describe the items being billed.Also include an ICD-9/ICD-10 diagnosis code indicating the medical condition for which the item has been prescribed. 0000005152 00000 n Medicare allows 36 sessions, with the option for an additional 36 sessions for each of these services. Correct Use of the KX Modifier During the COVID-19 PHE. 0000030243 00000 n 0000007902 00000 n  Enter in the “remarks” section of the claim the condition for the exception  Append modifier KX  to the HIPPS code reported on the revenue code 0023 line  The Medicare Administrative Contractors (MACs) may request documentation from the HHA to support its request for an exception to waive of the consequences of late filing of a RAP when … 0000010767 00000 n To bill additional optional sessions of cardiac rehab or pulmonary rehab. If the item is rented from the beneficiary, then below modifier are used: RR modifier is used to indicate rental equipment. Please make sure your billing staffs are aware of these updates. 0000040036 00000 n 0000005675 00000 n 0000038097 00000 n Medicare charges also require that a Therapy Modifier (GP, GO, GN) be attached to each service code. DME requires a prescription to either rent or purchase the equipment. • Dental. Certain DME equipment require CMN form from a doctor to support the medically necessity of the item to a beneficiary in order to reimburse the claim for DME supplier. Q. 0000041807 00000 n Jun 30, 2011 … Emergency and Non-Emergent Medical Transportation. The modifier that indicates what rental month you are billing does not match what we have on file. Below is an example of the KX modifier on a Medicare DME claim: The LCD's for oral appliances for OSA state: "Suppliers must add a KX modifier to a code only if all of the criteria in the "Indications and Limitations of Coverage and/or Medical Necessity" section of this policy have been met. 149 0 obj <> endobj xref 149 77 0000000016 00000 n 0000011650 00000 n When using the KI modifier, you are indicating you are billing for the second and/or third month of the capped rental period A8 — DRESSING FOR EIGHT WOUNDS. Use of the KX modifier when there is no indication that the cap is … Also include an ICD-9/ICD-10 diagnosis code indicating the medical condition for which the item has been prescribed. RB – Replacement of a part of DME as part of a repair . 0000047987 00000 n 0000006320 00000 n Let us see some of the important and frequently used modifier we come upon while billing DME in medical billing: KX modifier is used to indicate required documentation is on file to support the medical necessity of the item. 0000048104 00000 n 0000015615 00000 n 0000040230 00000 n (Refer to page 2 of the November 2014 HealthPro News edition for more information). 0000025168 00000 n 0000044925 00000 n Note: The KX modifier may also be used in conjunction with other medical policies, for example durable medical equipment. 0000003565 00000 n The most DME denials in Medical billing are as follows: What is Medical Billing and Medical Billing process steps in USA? (HCPCS) Codes … June 2011 Provider Bulletin – Colorado NOCIRC. 0000017661 00000 n Medicare insurance as secondary won’t pay for the rental items. 0000040883 00000 n 0000002241 00000 n 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. It means DME is principally used to help in for a medical purpose, can endure for repeated use and suitable to use in the home. 0000003163 00000 n 0000007346 00000 n This includes: 0000048456 00000 n For those LCD s listed below, application of the KX or CG modifier attests that a Standard Written Order (SWO) is on file for the item and the medical record supports the item is reasonable and necessary: Oxygen and Oxygen Equipment (L33797) Positive Airway Pressure Devices for the Treatment of Obstructive Sleep Apnea (L33718) and evidence of such is retained in the supplier’s files and available to the DME MAC upon request. For physical therapy and Occupational Therapy, I know MCR requires the KX modifier once the patient has hit the $2040 cap to continue treatment. The therapy cap was permanently eliminated 1/1/2018,however the KX modifier must be used at the threshold amount of $2040 to indicate that therapy is medically necessary. Joint DME MAC Bulletin Article. 10.3 - … KX, GA, or GZ Certain DME must be billed with Modifier KX if all of the indications and coverage limitations criteria have been met. 0000010268 00000 n Refer to the Durable Medical Equipment (DME) payment policy for more information. Is the therapy cap based on allowable charges or what I bill? I tried to look on the UHC site and also googled a lot of things, but the only thing I … Effective for claims with dates of service on or after March 1, 2020 and for the duration of the COVID-19 Public Health Emergency (PHE), for the following LCDs in which the Face-to-Face evaluation or other services with an implied Face-to-Face evaluation such as a home assessment are waived during the … 0000048026 00000 n

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