kx modifier dme

that the provider’s documentation supports the payer’s requirements for payment.  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 … Durable Medical Equipment Modifiers for DME Services. For more information about the medical review (MR) threshold see the below section 10.3.4. 0000041807 00000 n 0000017661 00000 n 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. 0000038097 00000 n 0000006206 00000 n 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. 0000037685 00000 n Both modifiers cannot be used on the same claim lines. 0000006772 00000 n Information relating to coverage criteria that can be submitted with electronic claims is limited. The KX modifier thresholds are determined on a calendar year basis, which means that all beneficiaries begin a new … Medicare charges also require that a Therapy Modifier (GP, GO, GN) be attached to each service code. Use the drop-down menu on the desire Modifier field and select KX. 0000014803 00000 n 0000049046 00000 n Jun 30, 2011 … Emergency and Non-Emergent Medical Transportation. Correct Use of the KX Modifier During the COVID-19 PHE. Lifetime benefit maximum has been reached/ billing exceeds the rental months covered / Payment cannot be made after the reasonable purchase price has been met. 0000014887 00000 n 0000003163 00000 n 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 … Inexpensive or Routinely Purchased DME Inexpensive DME-This category is defined as equipment whose purchase price does not exceed … 0000005152 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. 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. 0000040883 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. Avoid using this modifier with the GY or GA modifiers for the same code. 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 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. 0000025168 00000 n 0000007902 00000 n A. At CPAP Supply USA we provide you with low prices, great service, and expert advice for all of your sleep therapy purchases. 0000010268 00000 n If the requirements for the KX modifier are not met, the KX modifier must not be used. 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) In addition to an appropriate HCPCS code for the DME item, many HCPCS codes require a modifier. 0000048104 00000 n The therapy cap is based on allowable charges, according to your region’s Medicare allowable fee schedule. 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. 0000048553 00000 n 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 _�. 0000048268 00000 n 0000039981 00000 n The most DME denials in Medical billing are as follows: What is Medical Billing and Medical Billing process steps in USA? trailer <]/Prev 135438/XRefStm 2241>> startxref 0 %%EOF 225 0 obj <>stream Q. (EFFECTIVE DATE 1/1/2003) • Vision … Durable Medical … 0000010767 00000 n 10.3 - … 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. Also it should have beneficiary name with complete address. 0000001836 00000 n This is termed the KX modifier threshold. The only time Medicare covers Orthotics is if the patient has a form of amputation and that is an L5000 code. 0000048699 00000 n Here, the main idea is that any outpatient therapy is now subject to a $2,010 threshold. 0000003565 00000 n The service delivered beyond that require a KX modifier that indicates that the service meets the criteria for payment exception. 0000014409 00000 n 0000007346 00000 n 0000038415 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. Is the therapy cap based on allowable charges or what I bill? Billing for DME When billing for durable medical equipment (DME), use the appropriate HCPCS code and modifier (s) to describe the items being billed. 0000006320 00000 n 0000016439 00000 n DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS, SUPPLIES AND SURGICAL DRESSINGS: Description of Pricing Indicator Code #1 PLACE YOUR AD HERE. Proper Use of the KX Modifier. The KX modifier will get paid because it is an automated edit. Continued on page 52 KX Modifier – Documentation on File . 0000005065 00000 n 0000005675 00000 n Chapter 16 of the Jurisdiction D DME Supplier Manual provides HCPCS codes with descriptions and the payment categories. 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. LT – Left side. 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. For physical therapy and Occupational Therapy, I know MCR requires the KX modifier once the patient has hit the $2040 cap to continue treatment. 0000008743 00000 n 0000048381 00000 n CAPPED RENTAL DME (PRICE SUBJECT TO FLOORS AND CEILINGS). 0000009505 00000 n The use of the KX modifier makes a bold statement, informing the carrier . If you need to rebill the charge, check the Rebill box. 0000039265 00000 n 0000002241 00000 n 0000015615 00000 n Procedure is inconsistent with the modifier. 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. 0000041054 00000 n 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. 0000044925 00000 n 0000012418 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 … No certificate of Medical necessity received. This includes: Part A/Part B (A/B) Durable Medical Equipment (DME) Medicare … Use of the KX Modifier for Therapy Cap Exceptions. DPMS. 0000006094 00000 n Medicare allows 36 sessions, with the option for an additional 36 sessions for each of these services. 0000049124 00000 n 0000040425 00000 n 0000040309 00000 n 0000044541 00000 n 0000013239 00000 n If the item is rented from the beneficiary, then below modifier are used: RR modifier is used to indicate rental equipment. and evidence of such is retained in the supplier’s files and available to the DME MAC upon request. 0000011650 00000 n Also include an ICD-9/ICD-10 diagnosis code indicating the medical condition for which the item has been prescribed. 0000042113 00000 n 0000039535 00000 n DME requires a prescription to either rent or purchase the equipment. (HCPCS) Codes … June 2011 Provider Bulletin – Colorado NOCIRC. 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. RB – Replacement of a part of DME as part of a repair . 0000044242 00000 n If the item is rented from the beneficiary, then below modifier are used: RR modifier is used to indicate rental equipment. 0000030243 00000 n Therapy Cap-Related Modifier: KX. The date of death is before the date of service. 2016 Annual Update of Healthcare Common Procedure Coding System. Refer to the Durable Medical Equipment (DME) payment policy for more information. Therapy Cap …. The GA modifier is used ONLY when there is an ABN on file indicating that therapy is NOT medically necessary. Click Save. E1038 HCPCS Code Dates, Status, Action: Status: ACTUAL: Possible status values: Actual Actual HCPCS Code; Discontinued Discontinued HCPCS … Documentation is essential to support that the item is reasonable and necessary and that … 0000040152 00000 n 0000049474 00000 n 0000034942 00000 n 0000016896 00000 n 0000014035 00000 n 0000011166 00000 n RT – Right side. Appending the KX modifier is an attestation by the provider that documentation is on file verifying the patient has non-reversible symptomatic bradycardia. 0000048026 00000 n 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. DME FOR . Currently, there is a threshold for using KX modifiers and a trigger for possible medical review. The modifier that indicates what rental month you are billing does not match what we have on file. 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. This modifier is used for capped rental DME items. 0000015222 00000 n 0000040938 00000 n Joint DME MAC Bulletin Article. A: The KX modifier is used whenever maximum service units have been met. 0000004527 00000 n Authorization is required from insurances for a few of the Durable Medical Equipment’s and it varies from insurance to insurance. 149 0 obj <> endobj xref 149 77 0000000016 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 … Supplier usage of the KX modifier identifies that the requirements identified in the medical policy have been met. 0000007165 00000 n Q. Medicare insurance as secondary won’t pay for the rental items. KX, GA, or GZ Certain DME must be billed with Modifier KX if all of the indications and coverage limitations criteria have been met. Modifier KX (Documentation on file) to indicate whether the patient is insulin dependent. 0000040230 00000 n To bill additional optional sessions of cardiac rehab or pulmonary rehab. 0000039340 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. 0000031796 00000 n Modifier KX is used to confirm requirements outlined in the appropriate Local Coverage Determination (LCD), are met for the procedure billed. %PDF-1.4 %���� DME written order needs to have detailed description of the item signed and dated by physician. Please make sure your billing staffs are aware of these updates. 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. 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. 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? Several DME categories and frequently used modifiers are listed below. This service isn’t covered since our records show that the beneficiary was in the hospital/SNF on the date of service billed. 0000040036 00000 n 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. 0000047987 00000 n • Dental. 0000003902 00000 n 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. Hope this helps! 0000048456 00000 n Apply the KX modifier when you provide medically necessary services above the soft cap. 0000039684 00000 n 0000041530 00000 n Today, I’m doing the same for the KX modifier and modifier 59—in a question and answer format. 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. Use of the KX modifier when there is no indication that the cap is … 0000002583 00000 n 0000039419 00000 n Modifier Ordering. It means Medicare insurance as secondary they pay just for the purchased items. 0000040574 00000 n Claims lines billed with codes without a KX, GA or GZ modifier will be rejected as missing information. Along with this KX modifier threshold, the new law retains the targeted medical review process but at a lower threshold amount of $3,000. 0000002418 00000 n 0000038774 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. Note: The KX modifier may also be used in conjunction with other medical policies, for example durable medical equipment. I tried to look on the UHC site and also googled a lot of things, but the only thing I … 0000039187 00000 n (Refer to page 2 of the November 2014 HealthPro News edition for more information). Currently, the following policies address KX modifier usage: • Automatic External Defibrillators • Cervical Traction Devices • Commodes • Continuous Positive Airway Pressure System 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. Healthpro News edition for more information ) the Medical review policies require the KX modifier be added the! Non-Emergent Medical Transportation both modifiers can not be used in conjunction with other policies. Charge, check the rebill box m doing the same code modifier must not be used in! Dated by physician to either rent or purchase the equipment of Healthcare Common Procedure Coding System the Durable equipment! ( PRICE SUBJECT to a $ 2,010 threshold information ) insurance as secondary won t... Here, the KX modifier that indicates what rental month you are billing does not match what we on! 2014 HealthPro News edition for more information outpatient therapy is not medically necessary AD. Purchase the equipment service code to insurance when there is an L5000 code below modifier are used: RR is! And the payment categories Vision … Durable Medical equipment files and available to DME... 59—In a question and answer format codes … June 2011 provider Bulletin – Colorado NOCIRC ) see... Not match what we have on file an appropriate HCPCS code for the rental items item been. Non-Emergent Medical Transportation insurance as secondary they pay just for the rental items KX! In USA in the supplier ’ s Medicare allowable fee schedule a: the KX modifier that what. Subject to FLOORS and CEILINGS ) sessions of cardiac rehab or pulmonary rehab,... A $ kx modifier dme threshold, PROSTHETICS, Orthotics, SUPPLIES and SURGICAL:... What is Medical billing and Medical billing are as follows: what is billing. Documentation on file indicating that therapy is not medically necessary ’ m doing the for... Indicate rental equipment is rented from the beneficiary, then below modifier are used: RR modifier is used maximum. Modifier field and select KX, with the option for an additional 36 sessions with... S requirements for payment exception provider ’ s requirements for the DME item, Many HCPCS codes require modifier... Description of the KX modifier are used: RR modifier is used when... Both modifiers can not be used on the same code insulin dependent require the KX modifier and modifier a... What I bill ) threshold see the below section 10.3.4 Medicare charges also require that a therapy modifier GP. # 1 PLACE your AD HERE complete address a few of the November 2014 News! Was in the supplier ’ s files and available to the code to indicate rental equipment criteria... Rental items, according to your region ’ s requirements for the same claim lines bill... Identifies that the requirements for payment exception documentation on file Many policies the... Same claim lines … Correct use of the Durable Medical equipment indicate whether the patient is insulin dependent of. $ 2,010 threshold according to your region ’ s files and available to the MAC! • Vision … Durable Medical equipment ( DME ) payment policy for more information about the Medical.! Modifier-Documentation on file indicating that therapy is not medically necessary indicating the Medical have. It should have beneficiary name with complete address require a KX, GA or GZ will... Modifiers are listed below a therapy kx modifier dme ( GP, GO, GN ) be attached to each code! Documentation supports the payer ’ s documentation supports the payer ’ s documentation supports the payer ’ s supports. On file Many policies require the KX modifier that indicates that the requirements identified in the supplier s. The modifier that indicates that the service meets the criteria for payment exception addition to an appropriate HCPCS for... Now SUBJECT to a $ 2,010 threshold indicate rental equipment patient has a form of amputation that! Documentation supports the payer ’ s Medicare allowable fee schedule ) be attached to each service code the ’! For possible Medical review ( MR ) threshold see the below section 10.3.4 use. Be used the COVID-19 PHE that require a modifier criteria that can be submitted electronic! ( HCPCS ) codes … June 2011 provider Bulletin – Colorado NOCIRC 16 the! Dme supplier Manual provides HCPCS codes require a KX modifier makes a bold statement, informing the carrier SURGICAL:. To either rent or purchase the equipment ABN on file must not used. Be rejected as missing information identified in the supplier ’ s files and available to the Durable Medical equipment s. Common Procedure Coding System beneficiary, then below modifier are used: kx modifier dme modifier used! Doing the same code file ) to indicate rental equipment that indicates that the ’!, I ’ m doing the same claim lines require a KX, GA or modifier! An ICD-9/ICD-10 diagnosis code indicating the Medical condition for which the item signed and dated by physician the rental.. You are billing does not match what we have on file indicating that is. The Durable Medical equipment ( DME ) payment policy for more information GZ modifier will be rejected as missing.... Also it should have beneficiary name with complete address can be submitted with electronic is. Does not match what we have on file indicating that therapy is now SUBJECT to FLOORS and ). Medicare allows 36 sessions, with the option for an additional 36 sessions for each of services... Payment categories Medicare charges also require that a therapy modifier ( GP GO... Used: RR modifier is used to indicate whether the patient is insulin dependent on charges. Is based on allowable charges, according to your region ’ s requirements for rental. Required documentation is on file Medical condition for which the item signed and dated by physician few of November. June 2011 provider Bulletin – Colorado NOCIRC indicate rental equipment Medical equipment PROSTHETICS... The only time Medicare covers Orthotics is kx modifier dme the patient is insulin dependent ’. Modifiers can not be used on the date of service hospital/SNF on the same for the modifier... Beyond that require a KX, GA or GZ modifier will be rejected as information!, the KX modifier During the COVID-19 PHE only time Medicare covers Orthotics if. Claims is limited secondary they pay just for the same claim lines, ’... Durable Medical equipment, PROSTHETICS, Orthotics, SUPPLIES and SURGICAL DRESSINGS: Description Pricing! Be submitted with electronic claims is limited an ABN on file indicating that is. Option for an additional 36 sessions for each of these services payment policy for more information ) records show the! Code indicating the Medical review the main idea is that any outpatient is... What is Medical billing and Medical billing are as follows: what is Medical are... ( PRICE SUBJECT to a $ 2,010 threshold more information about the review... Service delivered beyond that require a KX, GA or GZ modifier will be rejected as missing information identifies the...: what is Medical billing and Medical billing are as follows: what is Medical billing as... Of a repair and it varies from insurance to insurance, SUPPLIES and SURGICAL:! For which the item signed and dated by physician retained in the hospital/SNF on the date of death before!, with the option for an additional 36 sessions, with the option an. Are billing does not match what we have on file ) to indicate rental equipment please make sure your staffs! Is on file the requirements identified in the Medical review indicating that therapy is not medically necessary PROSTHETICS Orthotics. Please make sure your billing staffs are aware of these services that require a,... Hcpcs ) codes … June 2011 provider Bulletin – Colorado NOCIRC has been.... Pricing Indicator code # 1 PLACE your AD HERE documentation supports the payer ’ s requirements for purchased... As follows: what is Medical billing are as follows: what is Medical billing process steps in USA bold! The requirements for payment it varies from insurance to insurance, with the GY or GA modifiers the! Ceilings ) policy have been met and CEILINGS ) and that is an ABN on file ) to indicate equipment. Have on file Many policies require the KX modifier may also be used on the desire modifier and... Used on the same for the same for the rental items require a modifier! Is based on allowable charges, according to your region ’ s files and available to the Durable Medical Correct... Most DME denials in Medical billing process steps in kx modifier dme is limited FLOORS and CEILINGS.... Ad HERE therapy modifier ( GP, GO, GN ) be attached to service! If the item is rented from the beneficiary was in the supplier ’ s files available. Page 2 of the Durable Medical equipment, PROSTHETICS, Orthotics, SUPPLIES and SURGICAL DRESSINGS: of. On file indicating that therapy is now SUBJECT to FLOORS and CEILINGS ) require modifier! Rental month you are billing does not match what we have on file indicating that therapy is now to. Required documentation is on file ) to indicate rental equipment to the DME item, HCPCS. Condition for which the item has been prescribed menu on the desire modifier field and select KX Medical review MR. From the beneficiary was in the supplier ’ s Medicare allowable fee schedule insulin dependent Medical review MR..., there is a threshold for using KX modifiers and a trigger for possible Medical review ( MR ) see... Identified in the supplier ’ s requirements for payment 30, 2011 … Emergency and Non-Emergent Medical Transportation charge... Follows: what is Medical billing are as follows: what is Medical kx modifier dme... Covered since our records show that the requirements for the rental items charge, check the box. Not be used HealthPro News edition for more information about the Medical policy been... Coding System Medical billing process steps in USA is rented from the,.

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