ZX, KX, What’s Next?

What does the KX modifier really mean? We know we need to add it to get reimbursed for some claims, but that’s just the beginning.

Prior to the “KX,” the same modifier was called a “ZX,” but even though its name changed in 2002, the meaning of the modifier did not. The KX modifier is added to claims for equipment that once required a certificate of medical necessity (CMN) or that currently require a written order prior to delivery (WOPD).

When you bill a claim requiring the modifier by policy, make sure you understand what you need in the patient’s file prior to adding the modifier. Verify that intake and billing personnel read the entire policy for each item requiring the modifier, and that the patient qualifies under Medicare guidelines. You must have the documentation in the patient’s file when adding the modifier to the claim and transmitting it.

The following equipment and/or supplies require a KX modifier:

• Diabetic shoes and inserts
• Urological supplies
• Group I support surface
• Group II support surface
• Diabetes monitor and supplies (insulin dependent)
• Dialysis supplies (epoetin alpha-epo)
• Refractive lenses
• Bedside commodes (effective April 1, 2005)
• Cervical traction equipment (E0849)
• Orthopedic footwear
• Continuous positive airway pressure (CPAP) devices & supplies
• Respiratory-assist devices (K0532, K0533) and supplies on K0532
• Heavy-duty bariatric walkers
• Negative-pressure wound therapy pump
• High-frequency chest wall oscillation devices

Let’s review some of these items and what the KX modifier means for this equipment:

• Heavy-duty bariatric walkers. The patient must qualify for a walker under Medicare guidelines and have a diagnosis warranting the need for the equipment. The KX modifier in this case justifies that the patient has been weighed within 30 days before the delivery date, and that must be documented on the physician’s order (PO). The patient must weigh 300 pounds or more, and the equipment must justify the weight requirements under SADMERC guidelines.
• Group I & Group II support surfaces. The provider must have a WOPD, meaning there is an order in the provider’s hands before the equipment leaves the showroom or the warehouse. The WOPD cannot be only verbal, but it may be a fax, copy or an original signature. Both of these categories require a “Statement of Ordering Physician” provided by each DMERC. Although suppliers may not complete a physician’s order for these products, they can ensure the correct answers are provided before 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.
• CPAPs and supplies, including humidifiers, must have a PO stating the documentation as required by policy. For a continuous positive airway pressure device, the patient must have obstructive sleep apnea as well as an apnea-hypopnea index that qualifies per policy. If the patient has an AHI between 5 and 14 episodes per hour, make sure you have the additional documentation required 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, at the end of the third month, you must have documentation from the patient or the treating physician stating that the patient is using the CPAP and finds it medically necessary in the long term.
• Last but not least, all bedside commodes require a KX modifier as of April 1, 2005. Verify that your patients qualify under Medicare guidelines and you have that documentation on the PO.

KX modifiers are audited frequently, so providers should be very careful when adding them to claims. Educate billers and intake personnel accordingly, and keep them informed on the daily changes in Medicare policies.

Jane Bunch is CEO of Kennesaw, Ga.-based JB&CS. A reimbursement specialist, Bunch delivers educational seminars worldwide, helps develop corporate compliance plans, and serves as a consultant for fraud and abuse cases. She can be reached at 678/445-1221 or via e-mail at [email protected].