HME billers' nemesis, the KX modifier is back in the spotlight after a notice from Jurisdiction B reminded providers that its improper use could lead to a false claims violation and a hefty fine.

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

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

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

"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 Select "Medical Policy Center"
under "Coverage Determinations."

For additional information on use of the KX, see the target="_blank">March issue of the Jurisdiction B
"Connections." A section on the KX begins on page 15.