Wiki KX MODIFIER - help, please!


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Hi all,

Please bear with me on this....... I am trying to understand the APPROPRIATE use of the KX modifier. EVERYTHING I read under Medicare, sounds like it is for supplies issued DURING THERAPY that have EXCEEDED the cap for the therapy. (and when I see THERAPY, I am thinking this means physical/occupational therapy).

We are an urgent care clinic. We do not go through an approval process with a DME supplier. We carry supplies, i.e., bandages, crutches, boots, splints, etc., and apply as appropriate.

So, if we are treating someone who had an injury, laceration, or broke their ankle, and applying these items, would this be included in the range that would qualify for a KX modifier?

Recently, we have been told that we can use modifier KX on these which would normally be denied by Medicare and they will pay............... but does that apply to these types of services/injuries? As I said, I thought it meant physical or occupational type therapy.

I don't want to be using this if it is incorrect and I really need some sound advice. Can anyone offer any expertise in this matter?

Thanks so much in advance.
KX Modifier

The KX modifier is used by DME suppliers to ensure that the records exist and are available to support that the claim has followed Medical Policy and the LCD for that item. In other words, it is a way to signal to Medicare, "I know you have special rules for this item and I am certifying that we have met all of those requirements so please pay this claim." If you have not met the criteria for coverage, there is another modifier to state that- GZ. If this modifier is used, you are stating to Medicare, "I know we do not meet all the requirements so you can deny my claim." There are a number of codes that require EITHER KX or GZ, but one must be present. GA is the other option- indicating you have an ABN and the patient will be liable.

As a DME supplier, we use modifier KX for items below the waist: knee braces, AFO's, etc. Crutches would never require this modifier because they do not have these special coverage rules. I do not believe you can bill crutches or boots if you are not a DME supplier. The supplier program, which is unique to the US, was set up to prevent overprescribing of DME/POS and to separate the referring physician from the revenue stream of these devices. Below is an example of a policy for use of the KX modifier, as it relates to AFO's.

Reimbursement Guidelines
Ankle-Foot/Knee-Ankle-Foot Orthosis
Suppliers must add a KX modifier to the AFO/KAFO base and addition codes only if all of the coverage
criteria in the “Indications and Limitations of Coverage and or Medical Necessity” section of the LCDs
have been met and evidence of such is retained in the supplier’s files and available to the DME MAC
upon request.
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. When there is an expectation of a
medical necessity denial, suppliers must enter the GA modifier on the claim line if they have obtained a
properly executed Advanced Notice of Non-coverage (ANN) or the GZ modifier if they have not obtained
a valid ANN.
Claims lines billed with codes without a KX, GA or GZ modifier will be rejected as missing information.
That helps so much! I am glad to get an answer for this and it is very much appreciated!!
Thanks and have a great day!