Part B Insider (Multispecialty) Coding Alert

Published on Fri Aug 12, 2011 PDF

Crutches, refractive lenses, and other supplies will require you to get sharp on modifiers.

Suppose a patient leaves your office with crutches. You report E0110 (Crutches, forearm, includes crutches of various materials, adjustable or fixed, pair, complete with tips and handgrips) to your MAC, but find denials waiting for you in return. This is a common issue that practices face when dispensing equipment, which can lead to slowed claims and frequent denials. Get a leg up on collecting for equipment by getting to know two important modifiers.

Consider Modifier NU

When you dispense crutches, your work is cut out for you from a billing standpoint--unless you know the correct modifiers to append to your claim. "Crutches will more than likely need an NU modifier (New durable medical equipment purchase), and the codes for lower leg DME require a modifier KX (Specific required documentation on file) and an RT (Right side) or LT (Left side) modifier in Massachusetts for Medicare," says Rebekah Constant, CPC, coding and billing associate with Hawthorn Medical Associates, LLC in North Dartmouth, Mass. "You only use the KX modifier if the patient meets the criteria set up by Medicare for the DME," Constant adds. The tricky part? Those criteria can change from one state carrier to the next, so be sure to get your MAC's policy in writing.

Heed this: "What I was advised by Noridian was to follow these steps," says Dawn Silva with Marin Medical Practice Concepts, Inc. in California. "Check if there is an LCD. If there is an LCD and the criteria are met, then the claim will require the KX modifier," she advises.

Next, Silva says, check the fee schedule for the code. "If it is on the fee schedule and there is a modifier listed, the claim will need to be billed with that modifier. In the example of billing crutches (E0110), this code is listed three times with the following modifiers - NU, RR (Rental) and UE (Used equipment). Therefore, choose the appropriate modifier for billing."

Consider modifier position: The modifier listed on the fee schedule must be listed in the first position, Silva says. So for example, the claim would be billed as: E0110-NU-KX. "As a quick reference for accurate billing, I keep handy the DMEPOS HCPCS codes 2011 for my jurisdiction, as well as the LCD and fee schedules," Silva advises. "Please always review the chart note for accurate coding and to accurately append the correct modifiers, the documentation in the patient's chart must always support the services and modifiers billed."

KX Goes Beyond Crutches

You'll probably find the KX modifier coming in handy for more than just splints and crutches. For instance, if you're providing refractive lenses for cataract surgery patients, you'll need to use KX as your go-to modifier to tell the payer that your physician ordered the lenses.

Medicare will only pay for refractive lenses for aphakic beneficiaries (patients who are lacking the organic lens of the eye due to surgical removal, e.g., after cataract surgery, or who have congenital absence). Medicare covers one complete pair of glasses or contact lenses after each cataract surgery with insertion of an artificial intraocular lens.

The key to DME Medicare Administrative Contractor (DME MAC) reimbursement for refractive lens features is medical necessity, and this involves more than just choosing the right ICD-9 code.

The standard benefit is a flat-top (FT) 25/28 bifocal or trifocal in plastic or glass. If the patient or the doctor want more features, a modifier will be necessary on the claim.

The prescribing physician must specifically order the special lens; it cannot be the patient's preference for one type of lens over another. If a physician specifically orders a particular type of lens or lens treatment, append modifier KX to the HCPCS code. This modifier tells Medicare that you have documentation to support the medical necessity of the item you're claiming.

Example: In most cases, Medicare will not pay for polycarbonate lenses (HCPCS code V2784). Patients often prefer polycarbonate lenses because they are sturdier and lighter than regular lenses. However, many ophthalmologists prescribe polycarbonate lenses for patients with monocular vision to help protect the remaining eye.

In these cases, report the lens with modifier KX (V2784-KX) and make sure documentation of the patient's condition is on file. For example, a note in the patient's record saying, "best corrected VA OS 20/400" should suffice.