Hey there!
Medicare is making a pretty big change to oxygen billing on August 1. Here is what’s up.
CMS is realizing that Oxygen CMNs are not reliable for certifying LCD coverage criteria. CMNs do not capture scenarios such as when:
Absent direct medical record scrutiny, these scenarios are routinely paid under the current system.
That’s about to change…
CMS is adding a new requirement to the Oxygen LCD that will require a KX modifier to certify all coverage criteria are met. If a criterion is not met, suppliers should execute an ABN to explain why the records do not qualify and append a GA modifier. With the KX modifier logic in place, suppliers can expect accurate claim processing that is driven by the modifier. When the supplier knows a beneficiary does not qualify, they can omit the KX, replace it with a valid ABN modifier, and the claim should deny for patient responsibility.
As a reminder, ABNs and related modifiers are subject to contractor review. The above example (KX or GA) outlines the most common scenario and modifier protocol. The LCD, however, outlines other modifier combinations that include the use of GY (for cases where gas or liquid oxygen is ordered and delivered without a required 5 element order), and GZ (for cases where the criteria is not met, but an ABN was not properly executed). These variables determine appropriate supplier and patient responsibility.
If you have questions about proper liability and ABN execution, check out our on-demand course “The NBA of ABNs: Scoring Profitable Customer Experiences.”
The change is effective for claims with service dates on or after August 1, 2018. Suppliers must update all active oxygen orders to transmit the KX modifier on future claims. Failure to make necessary updates will result in cash flow disruptions. We at MiraVista, however, strongly discourage automatic application of this modifier through billing software pricing and fee schedules. Defaulting the KX modifier within your billing software will force non-compliant claims to transmit with an inappropriate modifier. Instead, establish prompts in your billing software that engage the intake staff to make a conscious decision. Always apply the KX modifier purposefully based on the individual merits of the case.
If you have any questions, give us a shout.
Talk soon.
Andrea
Source Links
https://www.cgsmedicare.com/jc/pubs/news/2018/0518/cope7576.html
Medicare is making a pretty big change to oxygen billing on August 1. Here is what’s up.
CMS is realizing that Oxygen CMNs are not reliable for certifying LCD coverage criteria. CMNs do not capture scenarios such as when:
- The physician hasn’t considered alternative treatments.
- Oxygen is being ordered for short term conditions like pneumonia.
- Sleep tests do not satisfy the minimum, five-minute requirement.
- Exertion tests do not include a test while on oxygen.
Absent direct medical record scrutiny, these scenarios are routinely paid under the current system.
That’s about to change…
CMS is adding a new requirement to the Oxygen LCD that will require a KX modifier to certify all coverage criteria are met. If a criterion is not met, suppliers should execute an ABN to explain why the records do not qualify and append a GA modifier. With the KX modifier logic in place, suppliers can expect accurate claim processing that is driven by the modifier. When the supplier knows a beneficiary does not qualify, they can omit the KX, replace it with a valid ABN modifier, and the claim should deny for patient responsibility.
As a reminder, ABNs and related modifiers are subject to contractor review. The above example (KX or GA) outlines the most common scenario and modifier protocol. The LCD, however, outlines other modifier combinations that include the use of GY (for cases where gas or liquid oxygen is ordered and delivered without a required 5 element order), and GZ (for cases where the criteria is not met, but an ABN was not properly executed). These variables determine appropriate supplier and patient responsibility.
If you have questions about proper liability and ABN execution, check out our on-demand course “The NBA of ABNs: Scoring Profitable Customer Experiences.”
The change is effective for claims with service dates on or after August 1, 2018. Suppliers must update all active oxygen orders to transmit the KX modifier on future claims. Failure to make necessary updates will result in cash flow disruptions. We at MiraVista, however, strongly discourage automatic application of this modifier through billing software pricing and fee schedules. Defaulting the KX modifier within your billing software will force non-compliant claims to transmit with an inappropriate modifier. Instead, establish prompts in your billing software that engage the intake staff to make a conscious decision. Always apply the KX modifier purposefully based on the individual merits of the case.
If you have any questions, give us a shout.
Talk soon.
Andrea
Source Links
https://www.cgsmedicare.com/jc/pubs/news/2018/0518/cope7576.html
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