MDS Alert

Published on Fri Jun 02, 2006 PDF

--Use the KX modifier to request an automatic exception to the therapy cap for patients who qualify. But before you do, make sure you have the documentation to back up your request or your claim won't have a leg to stand on. How so? The modifier shows you have proof. Documentation is the key to justifying why your patient qualifies for the automatic exception process to the therapy cap, according to a Centers for Medicare & Medicaid Services' representative speaking during the agency's recent therapy cap exemption process special open door forum (ODF).

The KX modifier (Specific required documentation on file) indicates that you have all the information needed to support your claim.

Drawback: If you repeatedly use the KX modifier, you could be opening yourself up to additional medical review, say billing experts. 

When a case does exceed the cap, you should have documentation to explain why the case is so complex that it needs to exceed the cap, said the CMS representative during the ODF.

You can master the KX modifier with the following do's and don'ts from CMS staff.

• Do append the KX modifier to the procedure codes on individual claim lines for therapy services for claims that qualify for the automatic exception process and claims for services that have received a manual exception.

• Do include the KX modifier on claims for therapy services that exceed the cap and qualify for the automatic exception process, or else the claim will be denied.

•  Don't submit supporting information along with your claim. Hold the supporting data in your files and make it available upon your FI's request.

• Don't append the KX modifier for a manual exception unless you have your FI's approval letter on file at your location.

• Don't append the KX modifier before you exceed the cap. If you think you're close to exceeding the cap, add it, but if you know you're below the cap, don't use it.

Tip: For patients who exceed the cap earlier in the year with a complicated situation such as a stroke or an orthopedic problem and then later require therapy for a simpler problem such as a sprained wrist, simply append KX to the service line.

Bottom line: You won't need to include any additional information on the claim itself. The KX modifier indicates that you have reviewed the claim and determined that it is appropriate to bill using the automatic exception process.

For full details on the automatic exception process, see www.cms.hhs.gov/Transmittals/downloads/R855CP.pdf.

--Ready for a whole new diagnosis coding ballgame? The ICD-9 to ICD-10 transition will begin heating up soon. You'll get a warning from the Department of Health and Human Services two years before implementation, so you'll have time to ramp up, Sheri Poe Bernard, CPC, CPC-H, CPC-P, clinical technical writer for Ingenix Inc. told attendees at the American Academy of Professional Coders' annual conference in St. Louis, MO.

Probably the change will come Oct. 1, 2009, she tells Eli, but no earlier than Oct. 1, 2008. HHS will announce the adoption of the code set and implementation schedules as a final rule.

You can download the current ICD-10-CM draft at www.cdc.gov/nchs/about/otheract/icd9/icd10cm.htm.