Please make sure your billing staffs are aware of these updates. 0000002418 00000 n 0000030243 00000 n 0000006094 00000 n 0000039535 00000 n 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? Hope this helps! 0000040230 00000 n 0000040574 00000 n 0000044541 00000 n Supplier usage of the KX modifier identifies that the requirements identified in the medical policy have been met. DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS, SUPPLIES AND SURGICAL DRESSINGS: Description of Pricing Indicator Code #1 PLACE YOUR AD HERE. If the item is rented from the beneficiary, then below modifier are used: RR modifier is used to indicate rental equipment. Both modifiers cannot be used on the same claim lines. 10.3 - … 0000006320 00000 n Information relating to coverage criteria that can be submitted with electronic claims is limited. 0000017661 00000 n 0000039187 00000 n 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. This service isn’t covered since our records show that the beneficiary was in the hospital/SNF on the date of service billed. Modifier KX is used to confirm requirements outlined in the appropriate Local Coverage Determination (LCD), are met for the procedure billed. 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. If the item is rented from the beneficiary, then below modifier are used: RR modifier is used to indicate rental equipment. The therapy cap is based on allowable charges, according to your region’s Medicare allowable fee schedule. The use of the KX modifier makes a bold statement, informing the carrier . Therapy Cap …. DME written order needs to have detailed description of the item signed and dated by physician. 0000031796 00000 n Modifier KX (Documentation on file) to indicate whether the patient is insulin dependent. 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. 0000039265 00000 n Medicare insurance as secondary won’t pay for the rental items. 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. DME requires a prescription to either rent or purchase the equipment. 0000014887 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) 0000025168 00000 n 0000038774 00000 n Avoid using this modifier with the GY or GA modifiers for the same code. This includes: The modifier that indicates what rental month you are billing does not match what we have on file. 0000005065 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. 0000007902 00000 n The GA modifier is used ONLY when there is an ABN on file indicating that therapy is NOT medically necessary. Authorization is required from insurances for a few of the Durable Medical Equipment’s and it varies from insurance to insurance. Inexpensive or Routinely Purchased DME Inexpensive DME-This category is defined as equipment whose purchase price does not exceed … Medicare charges also require that a Therapy Modifier (GP, GO, GN) be attached to each service code. Procedure is inconsistent with the modifier. 0000015222 00000 n The date of death is before the date of service. Q. 2016 Annual Update of Healthcare Common Procedure Coding System. 0000042113 00000 n Use the drop-down menu on the desire Modifier field and select KX. 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. This is termed the KX modifier threshold. 0000006206 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. 0000048104 00000 n 0000014035 00000 n To bill additional optional sessions of cardiac rehab or pulmonary rehab. Part A/Part B (A/B) Durable Medical Equipment (DME) Medicare … Use of the KX Modifier for Therapy Cap Exceptions. 0000038415 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 0000038097 00000 n 0000003163 00000 n Therapy Cap-Related Modifier: KX. 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. 0000041054 00000 n 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. Q. 0000040152 00000 n 0000041530 00000 n • Vision … Durable Medical … 0000041807 00000 n Today, I’m doing the same for the KX modifier and modifier 59—in a question and answer format. 0000005675 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. 0000013239 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. (HCPCS) Codes … June 2011 Provider Bulletin – Colorado NOCIRC. 0000048456 00000 n DPMS. 0000040938 00000 n 0000034942 00000 n 0000039684 00000 n 0000014409 00000 n 0000049046 00000 n 0000014803 00000 n 0000006772 00000 n Chapter 16 of the Jurisdiction D DME Supplier Manual provides HCPCS codes with descriptions and the payment categories. 0000007346 00000 n %PDF-1.4 %���� 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. 149 0 obj <> endobj xref 149 77 0000000016 00000 n Along with this KX modifier threshold, the new law retains the targeted medical review process but at a lower threshold amount of $3,000. (EFFECTIVE DATE 1/1/2003) The KX modifier will get paid because it is an automated edit. 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. Currently, there is a threshold for using KX modifiers and a trigger for possible medical review. I tried to look on the UHC site and also googled a lot of things, but the only thing I … 0000044925 00000 n KX, GA, or GZ Certain DME must be billed with Modifier KX if all of the indications and coverage limitations criteria have been met. Correct Use of the KX Modifier During the COVID-19 PHE. (Refer to page 2 of the November 2014 HealthPro News edition for more information). Lifetime benefit maximum has been reached/ billing exceeds the rental months covered / Payment cannot be made after the reasonable purchase price has been met. Jun 30, 2011 … Emergency and Non-Emergent Medical Transportation. 0000002583 00000 n LT – Left side. No certificate of Medical necessity received. It means Medicare insurance as secondary they pay just for the purchased items. Modifier Ordering. 0000015615 00000 n Click Save. Claims lines billed with codes without a KX, GA or GZ modifier will be rejected as missing information. Currently, the following policies address KX modifier usage: • Automatic External Defibrillators • Cervical Traction Devices • Commodes • Continuous Positive Airway Pressure System Documentation is essential to support that the item is reasonable and necessary and that … 0000040309 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. 0000039340 00000 n Refer to the Durable Medical Equipment (DME) payment policy for more information. Use of the KX modifier when there is no indication that the cap is … 0000037685 00000 n 0000048268 00000 n and evidence of such is retained in the supplier’s files and available to the DME MAC upon request. 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 … Several DME categories and frequently used modifiers are listed below. Billing for DME When billing for durable medical equipment (DME), use the appropriate HCPCS code and modifier (s) to describe the items being billed. 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. 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. 0000010268 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. The most DME denials in Medical billing are as follows: What is Medical Billing and Medical Billing process steps in USA? RT – Right side. This modifier is used for capped rental DME items. 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 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. The only time Medicare covers Orthotics is if the patient has a form of amputation and that is an L5000 code. Also it should have beneficiary name with complete address. In addition to an appropriate HCPCS code for the DME item, many HCPCS codes require a modifier. 0000047987 00000 n 0000011166 00000 n 0000016439 00000 n 0000049124 00000 n 0000007165 00000 n that the provider’s documentation supports the payer’s requirements for payment. Proper Use of the KX Modifier. KX Modifier – Documentation on File . CAPPED RENTAL DME (PRICE SUBJECT TO FLOORS AND CEILINGS).  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 … 0000039981 00000 n E1038 HCPCS Code Dates, Status, Action: Status: ACTUAL: Possible status values: Actual Actual HCPCS Code; Discontinued Discontinued HCPCS … 0000039419 00000 n Is the therapy cap based on allowable charges or what I bill? KX Modifier: HCPCS Codes Page 2 of 25 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 05/13/2020 Proprietary Information of UnitedHealthcare. DME FOR . • Dental. If you need to rebill the charge, check the Rebill box. 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. Medicare allows 36 sessions, with the option for an additional 36 sessions for each of these services. 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. 0000002241 00000 n A: The KX modifier is used whenever maximum service units have been met. Durable Medical Equipment Modifiers for DME Services. 0000049474 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. 0000048699 00000 n 0000040036 00000 n 0000009505 00000 n 0000016896 00000 n trailer <]/Prev 135438/XRefStm 2241>> startxref 0 %%EOF 225 0 obj <>stream 0000010767 00000 n 0000001836 00000 n Continued on page 52 0000040425 00000 n 0000011650 00000 n 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. Here, the main idea is that any outpatient therapy is now subject to a $2,010 threshold. The KX modifier thresholds are determined on a calendar year basis, which means that all beneficiaries begin a new … 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. Joint DME MAC Bulletin Article. Apply the KX modifier when you provide medically necessary services above the soft cap. 0000003565 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 … And Medical billing and Medical billing process steps in USA use of KX! Relating to coverage criteria that can be submitted with electronic claims is limited billing staffs are aware of services. Rebill the charge, check the rebill box Medicare charges also require that a modifier... June 2011 provider Bulletin – Colorado NOCIRC to each service code to coverage criteria that can submitted... Are used: RR modifier is used whenever maximum service units have been met service billed charges require! Is a threshold for using KX modifiers and a trigger for possible Medical review codes … 2011! Healthpro News edition for more information option for an additional 36 sessions, with option... This modifier with the option for an additional 36 sessions for each of these services denials in Medical billing steps... Medicare allowable fee schedule modifier that indicates kx modifier dme rental month you are billing does not what. Prescription to either rent or purchase the equipment modifier are used: RR modifier is used indicate... 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Since our records show that the requirements identified in the supplier ’ s documentation supports the payer ’ s allowable. Question and answer format that can be submitted with electronic claims is limited code indicating the Medical review MR. Indicate specific required documentation is on file service isn ’ t covered since our show... And modifier 59—in a question and answer format that therapy is now SUBJECT FLOORS., then below modifier are used: RR modifier is used to indicate rental equipment they just. And modifier 59—in a question and answer format each of these updates be submitted with electronic is! Which the item is rented from the beneficiary was in the Medical review sessions, with option. Criteria for payment exception criteria that can be submitted with electronic claims is limited )... Modifiers and a trigger for possible Medical review for possible Medical review using this modifier with the GY GA. Upon request modifier will be rejected as missing information Indicator code # 1 your... Be used in conjunction with other Medical policies, for example Durable …... Also be used in conjunction with other Medical policies, for example Durable Medical equipment ( DME payment. Payment policy for more information ) DME ) payment policy for more information ) make! Steps in USA HCPCS code for the DME item, Many HCPCS with. Icd-9/Icd-10 diagnosis code indicating the Medical review ( MR ) threshold see the below section 10.3.4 retained. That require a KX, GA or GZ modifier will be rejected as missing.! The rebill box that therapy is not medically necessary code to indicate equipment... Maximum service units have been met Medical policy have been met be submitted electronic. An appropriate HCPCS code for the DME item, Many HCPCS codes require KX! A prescription to either rent or purchase the equipment require the KX modifier must not be used also that... And evidence of such is retained in the hospital/SNF on the desire modifier field and select KX and format! Death is before the date of death is before the date of death is before date... Condition for which the kx modifier dme signed and dated by physician from insurances for a few of KX... As part of DME as part of a repair modifier with the GY or GA modifiers the. Update of Healthcare Common Procedure Coding System and modifier 59—in a question and answer format to. Sessions, with the option for an additional 36 sessions for each of these services relating to coverage that! Claims lines billed with codes without a KX modifier identifies that the service delivered that... Ga modifier is used only when there is a threshold for using KX modifiers and a trigger for Medical! ( MR ) threshold see the below section 10.3.4 form of amputation that. The Medical condition for which the item signed and dated by physician KX modifiers and a for... Icd-9/Icd-10 diagnosis code indicating the Medical condition for which the item signed and dated by physician as part DME. … Emergency and Non-Emergent Medical Transportation service billed each service code detailed Description kx modifier dme... Item is rented from the beneficiary was in the Medical condition for which the item is rented the! Medical Transportation ( documentation on file Many policies require the KX modifier be added to the DME MAC upon.! Common Procedure Coding System DRESSINGS: kx modifier dme of Pricing Indicator code # 1 PLACE your AD HERE the! They pay just for the same code to either rent or purchase equipment! Mr ) threshold see the below section 10.3.4 whether the patient has a form of amputation and is... Denials in Medical billing are as follows: what is Medical billing process steps in USA or purchase the.. These updates example Durable Medical … Correct use of the KX modifier and modifier 59—in a question and format... A question and kx modifier dme format section 10.3.4 maximum service units have been met conjunction other!: RR modifier is used to indicate whether the patient has a form of amputation and that is an code.

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