Competitive Bidding Round 2 is now in full swing and many providers are struggling with the transition. A question that has cropped up repeatedly relates to the use of competitive bidding modifiers. As providers juggle two fee schedules (the traditional fee schedule and Round 2 Single Payment Amounts), understanding when to use the appropriate modifier for claim submission can be a challenge. Below we have pulled an excerpt from our most recent issue of our signature publication Vista Notes that provides a brief overview of the most commonly used competitive bidding modifiers. For comprehensive updates, we recommend that you consider a one-time or annual subscription.
“The KG modifier is used to distinguish between HCPCS codes that can be used with both competitively bid items and non-competitively bid items. Specifically if the item can be billed in multiple categories and it is SUBJECT to competitive bidding and therefore should be priced at the single payment amount (SPA), providers should append the KG modifier. The example used by Medicare is an IV Pole which can be used with both Enteral Nutrition (competitively bid) and Parenteral Nutrition (non-competitively bid). When using an IV pole (E0776) with enteral nutrition (subject to competitive bidding), providers should utilize the KG modifier to signify that it is for use with a competitively bid product. Similarly if a leg rest is used with a standard power wheelchair (subject to competitive bidding), the KG modifier should also be used.
“The KG modifier is used to distinguish between HCPCS codes that can be used with both competitively bid items and non-competitively bid items. Specifically if the item can be billed in multiple categories and it is SUBJECT to competitive bidding and therefore should be priced at the single payment amount (SPA), providers should append the KG modifier. The example used by Medicare is an IV Pole which can be used with both Enteral Nutrition (competitively bid) and Parenteral Nutrition (non-competitively bid). When using an IV pole (E0776) with enteral nutrition (subject to competitive bidding), providers should utilize the KG modifier to signify that it is for use with a competitively bid product. Similarly if a leg rest is used with a standard power wheelchair (subject to competitive bidding), the KG modifier should also be used.
The KK modifier is the anti-KG modifier. It is also used for supplies and accessories that are used across both competitively bid categories and non-competitively bid categories. Specifically if the item can be billed in multiple categories and it is NOT SUBJECT to competitive bidding and should be priced at the standard fee schedule amount, providers should affix the KK modifier. Therefore, in the above example, the E0776 billed with parenteral nutrition would be billed with the KK modifier to signify that the item is NOT SUBJECT to competitive bidding and is being used with a non-competitively bid product and therefore should be paid at the higher rate. Similarly the leg rests billed with a complex rehab chair should also be submitted with the KK modifier as complex chairs are not subject to competitive bidding.
The KL modifier is used with diabetic supplies to indicate that supplies are furnished via mail order. Effective July 1st mail order is redefined to include “all diabetic supply codes delivered to the beneficiary via any means.” Essentially, any diabetic supply that is not picked up in person at a retail location will be considered mail order. Under National Mail Order, only contracted suppliers will be eligible for reimbursement for mail order supplies. These suppliers must use the KL modifier to denote that supplies were delivered to the beneficiary unless the customer walks in to pick up the supply. (Note: Effective July 1, 2013 due to provisions in the American Taxpayer Relief Act, all diabetic supplies are reimbursed at the same rates/allowables regardless of delivery method. Therefore this modifier does not affect reimbursement rates, but is used to enforce mail order contracts.)
The KV modifier is used by physicians and treating practitioners that are not contracted providers, but will furnish exempt walkers and walker accessories to beneficiaries residing in a Competitive Bid Area (CBA). The KV modifier can only be used with the following list of HCPCS in order to be reimbursed: A4536, A4637, E0130, E0135, E0140, E0141, E0143, E0144, E0147, E0148, E0149, E0154, E0155, E0156, E0157, E0158 and E0159. Again this is used only for physician and treating practitioners providing this equipment to their own patients. They must have a DME supplier number and bill the walker with the corresponding office visit on the same day for proper processing.
The KT modifier is used for traveling beneficiaries. When a beneficiary resides in a CBA but travels outside of that CBA into a non-competitively bid area where they are provided a competitively bid item, that claim must have the KT modifier. Likewise if a beneficiary resides in a CBA and travels to a different CBA, they must be serviced by a contracted provider for that CBA, and the KT modifier must be affixed to competitively bid items. This modifier also applies to Skilled Nursing Facilities and Nursing Facilities that are not located in a CBA but provide competitively bid items, such as enteral nutrition, to a beneficiary that has a permanent residence in a CBA. The KT modifier essentially tells the claims processing system to bypass the expected contracted provider for the home CBA. Claims that are not submitted with the KT modifier in these cases will be denied.”
Competitive Bidding modifiers may in some cases cause modifier overflow, where the claim line limit of four modifiers is exceeded. In these cases, providers are advised to utilize the 99 modifier in the fourth position to indicate that the number of modifiers exceeds the limit. Additional modifiers should then be reported in the narrative or NTE section of the claim. When working with claims that exceed the four modifier limit, providers should prioritize pricing (including competitive bidding) and medical necessity modifiers (such as the KX). Informational modifiers such as LT and RT can then be reserved for the narrative or NTE section of the claim.
Understanding the proper usage of these and other claim components will assist providers in processing claims more efficiently, which will in turn ensure more expedient payment. For additional questions on claims processing or other reimbursement questions please contact our office to schedule an appointment with Andrea Stark for consulting at 803-462-9959 ext.246.
The KL modifier is used with diabetic supplies to indicate that supplies are furnished via mail order. Effective July 1st mail order is redefined to include “all diabetic supply codes delivered to the beneficiary via any means.” Essentially, any diabetic supply that is not picked up in person at a retail location will be considered mail order. Under National Mail Order, only contracted suppliers will be eligible for reimbursement for mail order supplies. These suppliers must use the KL modifier to denote that supplies were delivered to the beneficiary unless the customer walks in to pick up the supply. (Note: Effective July 1, 2013 due to provisions in the American Taxpayer Relief Act, all diabetic supplies are reimbursed at the same rates/allowables regardless of delivery method. Therefore this modifier does not affect reimbursement rates, but is used to enforce mail order contracts.)
The KV modifier is used by physicians and treating practitioners that are not contracted providers, but will furnish exempt walkers and walker accessories to beneficiaries residing in a Competitive Bid Area (CBA). The KV modifier can only be used with the following list of HCPCS in order to be reimbursed: A4536, A4637, E0130, E0135, E0140, E0141, E0143, E0144, E0147, E0148, E0149, E0154, E0155, E0156, E0157, E0158 and E0159. Again this is used only for physician and treating practitioners providing this equipment to their own patients. They must have a DME supplier number and bill the walker with the corresponding office visit on the same day for proper processing.
The KT modifier is used for traveling beneficiaries. When a beneficiary resides in a CBA but travels outside of that CBA into a non-competitively bid area where they are provided a competitively bid item, that claim must have the KT modifier. Likewise if a beneficiary resides in a CBA and travels to a different CBA, they must be serviced by a contracted provider for that CBA, and the KT modifier must be affixed to competitively bid items. This modifier also applies to Skilled Nursing Facilities and Nursing Facilities that are not located in a CBA but provide competitively bid items, such as enteral nutrition, to a beneficiary that has a permanent residence in a CBA. The KT modifier essentially tells the claims processing system to bypass the expected contracted provider for the home CBA. Claims that are not submitted with the KT modifier in these cases will be denied.”
Competitive Bidding modifiers may in some cases cause modifier overflow, where the claim line limit of four modifiers is exceeded. In these cases, providers are advised to utilize the 99 modifier in the fourth position to indicate that the number of modifiers exceeds the limit. Additional modifiers should then be reported in the narrative or NTE section of the claim. When working with claims that exceed the four modifier limit, providers should prioritize pricing (including competitive bidding) and medical necessity modifiers (such as the KX). Informational modifiers such as LT and RT can then be reserved for the narrative or NTE section of the claim.
Understanding the proper usage of these and other claim components will assist providers in processing claims more efficiently, which will in turn ensure more expedient payment. For additional questions on claims processing or other reimbursement questions please contact our office to schedule an appointment with Andrea Stark for consulting at 803-462-9959 ext.246.
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