INDIANAPOLIS — HME billers' nemesis, the KX modifier is back in the spotlight after a notice last month from Jurisdiction B reminded providers that its improper use could lead to a false claims violation and a hefty fine.
In fact, said National Government Services, the Jurisdiction B DME MAC, using the KX modifier without making sure that all the requirements specified in the appropriate policy have been met "could be viewed as filing a false claim and potential abuse of the Medicare program."
Added the message in italic type: "Penalties for violating the Federal False Claims Act can be up to three times the value of the False Claim, plus from $5,500 to $11,000 in fines, per claim."
Industry consultant Andrea Stark of Columbia, S.C.-based MiraVista said the KX "has been a constant source of confusion for suppliers, and they don't realize the ramifications of what they are signing up for when they add that modifier."
Medicare keeps "tweaking" a lot of claims requirements, making it difficult for providers to keep up with all the changes, Stark said. When providers have doubts, they sometimes indiscriminately add the KX modifier to make sure they get paid.
According to its definition, the KX signifies that requirements specified in the medical policy have been met. Those requirements vary from policy to policy, and use of the KX on a claim serves as an attestation by the provider that the requirements set out in the local coverage determination are true for that specific beneficiary.
The Jurisdiction B message encourages review of the documentation requirements section of each LCD to understand fully the criteria for proper use of the KX: "Obtaining physician records, test reports, and other documents is the best means of assuring that all of the information needed to support use of the KX modifier is present in the event of an audit."
Stark pointed out that providers add the KX because they believe they have the required documentation, but often that is a "moving target" as far as what regulators — and audit contractors — want.
"Many times providers are stepping out on good faith thinking that the physician is going to back up what they ordered, but that is not always the case," said Stark. "The only way to know that the doctor actually wrote down something viable is to ask for those records every time. But then the referral sources dry up, because it is a hassle and they don't want to give it to you every single time. You must get to where you are comfortable, while not overburdening physicians. This can only be accomplished with compromise, where the provider obtains a sample of progress notes to gain confidence in a referral source."
General practitioners are more apt to say they don't have the time, but specialists can often supply what providers need, Stark noted.
"The more reliable documentation is coming from specialists," she said. "Specialists are more reliable because they are delving into the disease and sitting down with patients. Ultimately, auditing contractors won't read between the lines, so providers are constantly in an impossible position. The Medicare program must not pay for undocumented services to protect the funds, and they must only pay for the cases that are most obvious. The borderline patients suffer in this scenario."
G modifiers have added to the headaches, Stark said. Many medical policies require a KX, GA, GZ or GY modifier to show that the coverage criteria have been met and whether an Advance Beneficiary Notice (ABN) has or has not been used.
With recent changes, said Stark, "If a claim does not come in with a KX modifier, it must come in with another G modifier that indicates it was intentional to leave the KX off, and we either have an ABN or we don't."
That's not all. According to the Jurisdiction B message: "Suppliers are reminded that the GA, GZ, and/or GY may not be reported on the same claim line. Additionally, it is inappropriate to report both the GY and KX on the same claim line. Suppliers must select the appropriate modifier according to the guidelines outlined within the medical policy. Effective with claims received on or after May 1, 2011, claim lines containing more than one of these modifiers, GA, GZ, GY, will be rejected."
You can access LCDs and related policy articles on the NGS website at apps.ngsmedicare.com. Select "Medical Policy Center" under "Coverage Determinations."
For additional information on use of the KX, see the March issue of the Jurisdiction B "Connections." A section on the KX begins on page 15.
