C050 These are non-covered services because this is not deemed a medical necessity by the payer

With elimination of the CMN came the KX modifier. With the KX modifier came the requirement for providers to prove medical necessity from documentation in the patient’s medical record.

By Sarah Hanna

Remember the days when most pieces of equipment required a CMN (Certificate of Medical Necessity)? During that time, most providers wished that CMS would eliminate the need for the CMN as it was difficult to obtain. Well, CMS became our genie in a bottle, granted our wish and eliminated the CMN for all but five products. However, it became a “be careful what you wish for” deal. With elimination of the CMN came the KX modifier. With the KX modifier came the requirement for providers to prove medical necessity from documentation in the patient’s medical record. If the KX modifier is not placed on the claim, then the claim will be denied with a CO50 denial code (These are non-covered services because this is not deemed a medical necessity by the payer).

The Local Coverage Determination for all policies requiring submission of the KX modifiers states in its “Documentation” section that suppliers must add the KX modifier to specific codes only if all of the criteria in the “Indications and Limitations of Coverage and/or Medical Necessity” section of the policy have been met.

There is confusion about whether providers must have the documentation in their files or available upon request from the patient’s medical record. Some LCDs state “documentation must be available upon request,” while it has been stated in teleconferences with the DME MACs and in some listserv updates that “documentation of the medical necessity must be maintained in the supplier’s files and be available upon request.” So, it is best for you to err on the side of caution and keep the documentation in your files prior to claim submission.

But trying to get medical documentation to prove the patient’s need has become more difficult than obtaining the old CMNs. The DME MACs have acknowledged this challenge and have tried to address providers’ concerns. In a listserv message sent Dec. 29, 2008, National Government Services (NGS), the Jurisdiction B DME MAC, noted some suppliers had been unable to obtain medical necessity documentation because physicians refused to release the medical records.

To aid in obtaining these records, the Medicare contractors have developed letters that explain the physician’s obligation by law to provide the requested records for DMEPOS, power mobility devices and PAP devices. Check your DME MAC Web site for copies of the letters you can use to help in obtaining medical necessity documentation:

You may also want to enlist the assistance of the beneficiary, who can contact his or her physician to request the medical records that are needed. If all avenues have been exhausted and the physician is not cooperating, you do have the option of reporting the physician to the DME Program Safeguard Contractor (PSC). The report should be made in the state in which the physician practices.

Some policies require that providers have specific medical documentation on file prior to submitting a claim, so be sure to refer to each individual medical policy to verify the documentation requirements, modifier usage and coverage criteria.

Sarah Hanna is a reimbursement consultant and vice president of ECS Billing & Consulting, Tiffin, Ohio, and specializes in proper billing protocols, Medicare coverage guidelines and billing office procedures. You can reach her at 419/448-5332 or [email protected].

Based on analysis of 5,934,391 claims adjudicated by the four DME MACs and processed for RemitDATA customers, there were 72,843 CO50 denials for Q3 2008. Source: RemitDATA, 866/885-2974, www.remitdata.com

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