REIMBURSEMENT PAGE
Remember that K-level modifiers describe the patient—not the componentry being provided—so the appropriate K-level must be represented on your claim. If your patient has the ability to ambulate at a K2 level, but you wish to provide that patient with K3-rated componentry, you would use the K2 modifier on the claim.
Policy- and Coverage-Driven Modifiers
Policy- and coverage-driven modifiers are typically required by policies to be included on your claims, and they will indicate if the items or services you are providing should be considered a Medicare benefit and paid or not, or if the items or services are not medically necessary. The KX Modifier. The KX modifier description reads: “The requirements specified in the medical policy have been met.” If a medical policy has set forth special documentation criteria for billing, you must meet all of the criteria in order to bill, and that is when you use KX. Four O&P medical policies currently require the use of a KX modifier: anklefoot orthosis (AFO)/knee-ankle-foot orthosis (KAFO); knee orthosis (KO); orthopedic shoes; and therapeutic shoes for persons with diabetes. When using the KX modifier, it’s important to know how the policies are written to determine whether the proper supporting documentation must be kept in the orthotist’s/prosthetist’s files. Under the “Documentation Requirements” heading of the local coverage determination (LCD) portion of the policy, there will typically be a phrase that explains when and how the KX modifier must be used. For example, in the KO policy under “Documentation Requirements,” there is this phrase: “Suppliers must add a KX modifier... if all of the coverage criteria…have been met and evidence of such is retained in the supplier’s files.” This means you must physically have the documentation supporting the use of the KX modifier in your files—and if you don’t have this documentation, you may not attach the KX modifier.
KX
AW MODIFIER
MODIFIER
GZ
GY
GA MODIFIER
MODIFIER
MODIFIER
CG MODIFIER
However, if you review the same section of Therapeutic Shoes for Persons With Diabetes policy, you will not see such a statement. Instead, you will see the following: “Suppliers must add a KX modifier…only if criteria in the Nonmedical Necessity Coverage and Payment Rules section of the related policy article have been met. This documentation must be available upon request.” This verbiage indicates that it is not necessary to have all of the supporting documentation in your files; rather, you must be able to provide it upon request. Even though a policy may state that it is not necessary to have the supporting documentation in your files, it is still a good idea to obtain physical copies of any supporting documentation and place them in your files. Doing so will ensure that the documentation does exist, and it is easy to locate if it is requested. Note that when you include the KX modifier on your claim, you are attesting that everything required by policy is in place. Do not simply add the KX modifier to your claims because you know or believe it will get your claim paid. This practice can be viewed as abusive and could lead to fraudulent billing. Before using the KX modifier, review current medical policies to ensure that the specific policy criteria have been met and that the use of a KX modifier is required.
The GY Modifier. The GY modifier is the complete opposite of the KX modifier. While the KX modifier indicates that something is a Medicare benefit and should be covered, the GY modifier is used to indicate that the item or service you are providing is statutorily excluded from Medicare coverage, meaning there is no Medicare benefit for the service. A logical question is, “Why would anyone submit a claim for an item or service that he or she knows is not a Medicare benefit?” Upon enrollment in Medicare, you agree to submit claims on behalf of Medicare beneficiaries if the beneficiary requests that you do so. While it is not mandatory to submit a claim to Medicare for a statutorily noncovered service, if the beneficiary requests that you do so, you are required by your provider agreement to comply. The most common reason why a beneficiary will request that you submit a claim is if he or she has secondary insurance that requires a Medicare denial before the claim will be considered. In this scenario, the claim would be submitted with a GY modifier, Medicare would deny the claim as noncovered, and the secondary insurance would then consider the claim for payment. The GY modifier is most commonly associated with claims involving orthopedic shoes that are not attached to a brace, but it also is used with AFOs used solely for offloading and for diabetic shoes and inserts that exceed the number of allotted services in a year. These are examples of items that O&P ALMANAC | SEPTEMBER 2015
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