Suppliers continue to struggle with the KX modifier during the public health emergency because varying coverage flexibilities available for different products alter its meaning. Even so, CMS still holds suppliers to the assertions of this I-do-solemnly-swear modifier. At MiraVista, we use three informal descriptors to help our clients understand the implications of the KX modifier in specific situations and, by extension, any additional claim instructions or responsibilities those situations require:
Routine KX
The routine KX modifier is familiar to suppliers. It declares the medical documentation follows Medicare policy to a “T,” satisfying all LCD requirements without reliance on any pandemic flexibilities or waivers.
Applicability: Suppliers can use a routine KX modifier with any product linked to an LCD with a KX modifier requirement.
Certifications: By adding a routine KX, the supplier implies the following:
Example (CPAP and Oxygen): A patient had a face-to-face visit with their doctor where they discussed evidence of sleep disturbance and potential sleep apnea. The patient proceeded to a sleep lab for an overnight split study which revealed an apnea hypopnea index of 23. Upon application of CPAP at 12 cmH2O, the apneas resolved, but the patient continued to desaturate to 86% for more than five minutes at the optimized pressure setting.
Result: Because the documentation meets the LCD criteria for the CPAP based on AHI results and because the oxygen desaturations took place after achieving optimal pressure settings in a chronic stable state, the supplier should bill for both the CPAP setup and nocturnal oxygen with a routine KX modifier. The documentation and evidence for both products are consistent with long-standing LCD requirements. No rules are bent, and the patient clearly qualifies.
Claim Instructions: Simply add the KX modifier. We do not have to modify billing protocols to apply a routine KX modifier.
Face-to-Face KX
CMS had to go a little further to relax LCDs with language specifically requiring in-person patient interactions as a condition of coverage. CMS cannot explicitly waive statutory requirements, so they created a work-around. When suppliers satisfy all required elements in the LCD but rely on an in-person substitution using telehealth or video conferencing, they must use the face-to-face KX modifier.
Applicability: The face-to-face KX modifier applies to the following LCDs:
Certifications: When a supplier has documentation that satisfies the required LCD criteria except that some of the routine in-person requirements were conducted virtually, the supplier should append a face-to-face KX modifier. By adding a face-to-face KX, the supplier implies the following:
Example (Powered Mobility): A patient with advanced multiple sclerosis, decubitus ulcers, and scoliosis requires a powered wheelchair. The physician documentation and specialty assessment meet the traditional LCD criteria but, while the PT performed an in-person assessment, the ATP participated by video conference.
Result: Because the documentation meets the LCD criteria, the supplier should deliver the powered mobility device. However, because the supplier must rely on bent pandemic rules to accept the virtually documented specialty assessment, a face-to-face KX is necessary.
Claim Instructions: Suppliers must use the CR and KX modifiers together. Suppliers must also send a COVID-19 narrative. The unique combination of the HCPCS tied to these policies, along with the KX and CR modifiers, generally means the supplier is invoking the face-to-face flexibility.
Patients do not have to have a COVID-19 diagnosis to utilize this protocol.
Clinical-Criteria KX
The clinical-criteria KX modifier applies to a limited number of LCDs where CMS deemed it necessary to suspend certain details of routine coverage criteria during the pandemic. With evidence of a basic need outlined in one of these LCDs, suppliers are empowered to pursue reimbursement for equipment without having all documentation routinely imposed by the LCDs. When suppliers rely on this flexibility for an eligible LCD, they must use the clinical-criteria KX modifier.
Applicability: A clinical-criteria KX modifier only applies to the following LCDs:
Certifications: The clinical-criteria KX modifier implies the following:
Example (CPAP): A physician orders a home sleep test for a patient complaining of occasional daytime sleepiness suspected of having obstructive sleep apnea. The test determines the patient has a borderline apnea hypopnea index of 7 that establishes a basic medical need per the LCD criteria. However, the medical record does not document one of the required LCD complications for borderline apnea hypopnea index scores (excessive daytime sleepiness, impaired cognition, mood disorders, insomnia; hypertension, ischemic heart disease, or history of stroke).
Result: The medical record deficiency necessitates a clinical-criteria KX modifier. Because the patient has a basic medical need consistent with the LCD criteria, the patient can receive treatment. The documentation does not, however, meet all of the LCD criteria, so the supplier must rely on the bent pandemic rules in place for these limited products.
Modified Claim Instructions: Suppliers must use the CR and KX modifiers together. Suppliers must also send a COVID-19 narrative. The unique combination of the HCPCS tied to these policies, along with the KX and CR modifiers, generally means the supplier is invoking the clinical-criteria flexibility.
Patients do not have to have a COVID-19 diagnosis to utilize this protocol.
For suppliers that rely on the clinical-criteria KX modifier, we do suggest periodic medical necessity re-checks. The nature of this flexibility allows suppliers to treat more acute conditions than Medicare would normally allow, and this increases the risk that medical need will end more quickly than a traditional setup. Continued application of the clinical-criteria KX to subsequent claims implies the patient continues to need the product. If and when this circumstance changes, CMS requires suppliers to cease billing.
Suppliers cannot know if CMS will grandfather clinical-criteria KX modifier setups at the end of the pandemic, and as such, we encourage suppliers to make attempts to secure documentation that complies with long standing coverage criteria. In doing so, the supplier can substitute the clinical-criteria KX for a routine KX on future claims.
Suppliers that understand the proper use cases of the KX modifier during the pandemic can generate claims confidently without fear of future recovery.
SOURCE LINKS
https://www.cgsmedicare.com/jc/pubs/news/2021/02/cope20681.html
https://www.cgsmedicare.com/jc/pubs/news/2020/05/cope17220.html
https://www.cgsmedicare.com/jc/pubs/news/2020/05/cope17451.html
https://www.cgsmedicare.com/jc/pubs/news/2020/06/cope17942.html
- Routine KX.
- Face-to-Face KX.
- Clinical Criteria KX.
Routine KX
The routine KX modifier is familiar to suppliers. It declares the medical documentation follows Medicare policy to a “T,” satisfying all LCD requirements without reliance on any pandemic flexibilities or waivers.
Applicability: Suppliers can use a routine KX modifier with any product linked to an LCD with a KX modifier requirement.
Certifications: By adding a routine KX, the supplier implies the following:
- The supplier has a compliant standard written order.
- The documentation meets traditional LCD criteria.
- The supplier is not relying on any temporary, pandemic-related medical-necessity flexibilities.
- The supplier is ready to be audited.
Example (CPAP and Oxygen): A patient had a face-to-face visit with their doctor where they discussed evidence of sleep disturbance and potential sleep apnea. The patient proceeded to a sleep lab for an overnight split study which revealed an apnea hypopnea index of 23. Upon application of CPAP at 12 cmH2O, the apneas resolved, but the patient continued to desaturate to 86% for more than five minutes at the optimized pressure setting.
Result: Because the documentation meets the LCD criteria for the CPAP based on AHI results and because the oxygen desaturations took place after achieving optimal pressure settings in a chronic stable state, the supplier should bill for both the CPAP setup and nocturnal oxygen with a routine KX modifier. The documentation and evidence for both products are consistent with long-standing LCD requirements. No rules are bent, and the patient clearly qualifies.
Claim Instructions: Simply add the KX modifier. We do not have to modify billing protocols to apply a routine KX modifier.
Face-to-Face KX
CMS had to go a little further to relax LCDs with language specifically requiring in-person patient interactions as a condition of coverage. CMS cannot explicitly waive statutory requirements, so they created a work-around. When suppliers satisfy all required elements in the LCD but rely on an in-person substitution using telehealth or video conferencing, they must use the face-to-face KX modifier.
Applicability: The face-to-face KX modifier applies to the following LCDs:
- Manual wheelchairs.
- Powered wheelchairs.
- Wheelchair seating.
- Wheelchair accessories.
- Group 1 support surfaces.
- Group 2 support surfaces.
- Group 3 support surfaces.
- Negative pressure wound therapy.
- Knee orthoses.
- Speech generating devices.
- Tumor treatment field therapy.
Certifications: When a supplier has documentation that satisfies the required LCD criteria except that some of the routine in-person requirements were conducted virtually, the supplier should append a face-to-face KX modifier. By adding a face-to-face KX, the supplier implies the following:
- The supplier has a compliant standard written order.
- The documentation meets traditional LCD criteria.
- The supplier is relying on a flexibility during the pandemic that allows the supplier to substitute a face-to-face evaluation, in-person, or home assessment with a telehealth, virtual, or video conference exchange.
- Because of the face-to-face flexibility, the supplier is ready to be audited.
Example (Powered Mobility): A patient with advanced multiple sclerosis, decubitus ulcers, and scoliosis requires a powered wheelchair. The physician documentation and specialty assessment meet the traditional LCD criteria but, while the PT performed an in-person assessment, the ATP participated by video conference.
Result: Because the documentation meets the LCD criteria, the supplier should deliver the powered mobility device. However, because the supplier must rely on bent pandemic rules to accept the virtually documented specialty assessment, a face-to-face KX is necessary.
Claim Instructions: Suppliers must use the CR and KX modifiers together. Suppliers must also send a COVID-19 narrative. The unique combination of the HCPCS tied to these policies, along with the KX and CR modifiers, generally means the supplier is invoking the face-to-face flexibility.
Patients do not have to have a COVID-19 diagnosis to utilize this protocol.
Clinical-Criteria KX
The clinical-criteria KX modifier applies to a limited number of LCDs where CMS deemed it necessary to suspend certain details of routine coverage criteria during the pandemic. With evidence of a basic need outlined in one of these LCDs, suppliers are empowered to pursue reimbursement for equipment without having all documentation routinely imposed by the LCDs. When suppliers rely on this flexibility for an eligible LCD, they must use the clinical-criteria KX modifier.
Applicability: A clinical-criteria KX modifier only applies to the following LCDs:
- External infusion pumps.
- Continuous glucose monitors.
- Respiratory-related LCDs:
- CPAP.
- RAD.
- Oral appliances.
- Oxygen.
- Ultrasonic nebulizers.
- Mechanical in-exsufflation devices.
- High-frequency chest wall devices.
Certifications: The clinical-criteria KX modifier implies the following:
- The supplier has a compliant standard written order.
- The documentation establishes basic medical necessity consistent with the intent of the LCD.
- The supplier knowingly accepted documentation that does not meet one or more aspects of the clinical criteria outlined in the LCD.
- Because of permissible clinical criteria flexibilities, the supplier is ready to be audited.
Example (CPAP): A physician orders a home sleep test for a patient complaining of occasional daytime sleepiness suspected of having obstructive sleep apnea. The test determines the patient has a borderline apnea hypopnea index of 7 that establishes a basic medical need per the LCD criteria. However, the medical record does not document one of the required LCD complications for borderline apnea hypopnea index scores (excessive daytime sleepiness, impaired cognition, mood disorders, insomnia; hypertension, ischemic heart disease, or history of stroke).
Result: The medical record deficiency necessitates a clinical-criteria KX modifier. Because the patient has a basic medical need consistent with the LCD criteria, the patient can receive treatment. The documentation does not, however, meet all of the LCD criteria, so the supplier must rely on the bent pandemic rules in place for these limited products.
Modified Claim Instructions: Suppliers must use the CR and KX modifiers together. Suppliers must also send a COVID-19 narrative. The unique combination of the HCPCS tied to these policies, along with the KX and CR modifiers, generally means the supplier is invoking the clinical-criteria flexibility.
Patients do not have to have a COVID-19 diagnosis to utilize this protocol.
For suppliers that rely on the clinical-criteria KX modifier, we do suggest periodic medical necessity re-checks. The nature of this flexibility allows suppliers to treat more acute conditions than Medicare would normally allow, and this increases the risk that medical need will end more quickly than a traditional setup. Continued application of the clinical-criteria KX to subsequent claims implies the patient continues to need the product. If and when this circumstance changes, CMS requires suppliers to cease billing.
Suppliers cannot know if CMS will grandfather clinical-criteria KX modifier setups at the end of the pandemic, and as such, we encourage suppliers to make attempts to secure documentation that complies with long standing coverage criteria. In doing so, the supplier can substitute the clinical-criteria KX for a routine KX on future claims.
Suppliers that understand the proper use cases of the KX modifier during the pandemic can generate claims confidently without fear of future recovery.
SOURCE LINKS
https://www.cgsmedicare.com/jc/pubs/news/2021/02/cope20681.html
https://www.cgsmedicare.com/jc/pubs/news/2020/05/cope17220.html
https://www.cgsmedicare.com/jc/pubs/news/2020/05/cope17451.html
https://www.cgsmedicare.com/jc/pubs/news/2020/06/cope17942.html
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