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
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
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
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
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.
The following equipment and/or supplies are examples of
the main equipment/supplies that require a KX
Diabetic Shoes and Inserts
Group I Support Surface
Group II Support Surface
Group III Support Surface
Diabetes Monitor & Supplies (insulin dependent)
Dialysis Supplies (Epoetin Alpha-Epo)
Cervical Traction Equipment (E0849)
Continuous Positive Airway Pressure Devices (CPAP) &
Respiratory Assist Devices & Supplies
Negative Pressure Wound Therapy Pump
High Frequency Chest Wall Oscillation Devices
ALL Wheelchairs (manual and motorized), Wheelchair Seating
Modalities, and all accessories
Conductive Garments (E0731)
Hospital beds & accessories including Trapeze Bars
External Infusion Pumps
Patient Lift (E1035)
Nebulizer drugs (see policy)
Speech Generating Devices
Oral Antiemetic Drugs
And more to come!
Jane Bunch is president/CEO of Jane's Healthcare Consulting
based in Marietta, Ga. A reimbursement specialist, Bunch delivers
educational seminars, helps develop corporate compliance plans and
serves as a consultant for fraud and abuse cases. She can be
reached at 770/366-0644 or by email at email@example.com.