KX Marks the Spot

The KX modifier is the most deadly modifier in this industry. Providers must be educated on the true meaning of this modifier and when to add it — and when not to add it.

With anything this modifier is attached to being on the OIG workplan for HME providers, it becomes even more vital that you have audit procedures in place for these claims prior to transmitting. Once you have transmitted, you have taken ownership in stating that this claim meets guidelines and that you have the documentation to prove it.

Are you certain you would pass an audit on all of the KX modifier items you have billed and collected? Just because you were reimbursed does not mean you will keep that money!

The KX modifier is added to equipment that once required a Certificate of Medical Necessity (CMN) or that requires a Written Order Prior to Delivery (WOPD) or just high utilization areas of fraud and abuse. Verify that your intake and billing personnel read the entire policy for each item requiring the KX modifier, and that the patient qualifies under Medicare guidelines.

You must train all of your staff, including marketing personnel, retail showroom personnel and any other employees who can assist in obtaining the information you may require for billing. Who is going to be the accountable person who will audit these claims for compliance before transmittal, and who is going to audit past claims to see what damages you may have?

Every provider should have such a staff person in place, and this person should be someone who knows how to bill, perform an intake and collections. Do you have this person or such a position within your staff?

Now let's look at what the KX modifier means for some pieces of equipment:

• Heavy-Duty Bariatric Walker. The patient must qualify for a walker under Medicare guidelines with a diagnosis warranting the need for an ambulatory aid. The KX modifier in this case justifies that the patient has been weighed within 30 days prior to the delivery date, and that must be documented on the Physician's Order.

  For these walkers, the patient must weight 300 pounds or more, and you will need to make sure the equipment justifies the weight requirements under SADMERC guidelines. Make sure MAE guidelines are met as with all walkers.

• Group I and II Support Surfaces. The provider must have a WOPD, meaning there is an order in hand prior to the equipment leaving the showroom floor or the warehouse. It may be a faxed copy or an original signature, but it may not be a verbal. Both of these categories require a “Statement of Ordering Physician.” This is the only Physician Order that you may not complete as a supplier.

  Make sure the correct answers are provided on the PO prior to adding the KX modifier. The answers on the PO determine coverage. A Plan Of Care must also be available documenting that the answers on the PO can be “backed up” with documentation from the physician's notes or a home health care agency.

• CPAP and supplies, including humidifiers, must have a PO stating the documentation as required by policy. For a CPAP, the patient must have obstructive sleep apnea (OSA) as well as an apnea-hypopnea index that qualifies per policy. If the patient has an AHI between five and 14 episodes per hour, verify you have the additional documentation required by policy on the PO or on the sleep study. The sleep study must be in the patient's file so you can verify that the patient qualifies.

  Remember, between the 61st and 90th day, you must have documentation from the patient or the treating physician stating that the patient is using the CPAP and finds it medically necessary.

  Make sure you have a CPAP compliance plan set up in your company for calling your patients to see if they need supplies, according to the supply chart in the Medicare manual. Keep a call log proving that you have contacted the patient or the patient has contacted you to get his or her supplies.

• And, last but not least, all bedside commodes require a KX modifier. Verify that your patients qualify for a bedside commode under Medicare guidelines and you have that documentation on the PO.

  KX modifiers are audited frequently, and providers should be very careful when adding this modifier to their claims. Educate your billers and intake personnel accordingly, and keep them abreast of the daily changes in Medicare policies.