Wiki MODIFIER KX on supply for Medicare Patient

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debbiek

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Hi Everyone,

I am having an issue getting a supply either paid or shown as patient responsibility since an ABN was signed. code is ... L4360 (fracture boot/pneumatic). We are not DME suppliers but have these supplies on hand for the convenience of our patients. When we bill the L4360 to Medicare with a GA, it is denied stating they need an additional modifier. We have tried submitting with NU as well but we still get the same denial. I tried to research this and thought maybe the KX was the modifier we needed, but the rep at Medicare tells me that is a physical therapy modifier. Am I missing something here? Does anyone know what I should be billing it with or at this point am I allowed to bill the patient for the supply? I would be more comfortable with it coming back as patient responsibility. Thanks all.
 
debbiek said:
Hi Everyone,

I am having an issue getting a supply either paid or shown as patient responsibility since an ABN was signed. code is ... L4360 (fracture boot/pneumatic). We are not DME suppliers but have these supplies on hand for the convenience of our patients. When we bill the L4360 to Medicare with a GA, it is denied stating they need an additional modifier. We have tried submitting with NU as well but we still get the same denial. I tried to research this and thought maybe the KX was the modifier we needed, but the rep at Medicare tells me that is a physical therapy modifier. Am I missing something here? Does anyone know what I should be billing it with or at this point am I allowed to bill the patient for the supply? I would be more comfortable with it coming back as patient responsibility. Thanks all.
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In reviewing the modifiers allowed with this item, it looks like you may want to use GK "Reasonable and necessary item/service associated with GA or GZ modifier."
 
I think your problem is that you are trying to bill a DME item to the regular carrier. We have to bill ours to the regional DME carrier which, for Missouri, is Noridian. KX means that there is an LCD or NCD policy on the item you are dispensing and you have to have a covered diagnosis to bill it, all the documentation has to be correct and there has to be an order and delivery receipt in file. It means that you have done EVERYTHING that is required when you read the LCD or NCD. Also, if you don't have an NPI to dispense DME I don't think you can get paid for this. Sounds like you may have given away a brace. I don't think you can bill the patient, even with an ABN, because the reason you can't get paid is that you aren't a recognized DME supplier for Medicare. Sorry for the bad news. And as a slight commercial, Ruby O'Brochta-Woodward and I are presenting a session at Conference in Las Vegas on DME and how to get paid. Come on down!!
 
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bfontaine said:
I think your problem is that you are trying to bill a DME item to the regular carrier. We have to bill ours to the regional DME carrier which, for Missouri, is Noridian. KX means that there is an LCD or NCD policy on the item you are dispensing and you have to have a covered diagnosis to bill it, all the documentation has to be correct and there has to be an order and delivery receipt in file. It means that you have done EVERYTHING that is required when you read the LCD or NCD. Also, if you don't have an NPI to dispense DME I don't think you can get paid for this. Sounds like you may have given away a brace. I don't think you can bill the patient, even with an ABN, because the reason you can't get paid is that you aren't a recognized DME supplier for Medicare. Sorry for the bad news. And as a slight commercial, Ruby O'Brochta-Woodward and I are presenting a session at Conference in Las Vegas on DME and how to get paid. Come on down!!
Click to expand...

Good info! I had not thought to look at the list of codes on the CMS website and determine which entity had to be billed. Clearly showed this item has to be billed to the DME carrier!
 
This is still a little confusing. The rep at Medicare stated it was ok to bill the patient even though I had a CO-4 denial. She stated the patient should then bill the DME, and they would get a denial from them stating it is patient responsibility. Does that sound feasible?
 
debbiek said:
This is still a little confusing. The rep at Medicare stated it was ok to bill the patient even though I had a CO-4 denial. She stated the patient should then bill the DME, and they would get a denial from them stating it is patient responsibility. Does that sound feasible?
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Hmm..don't think that is right. Do you know who the DME carrier is for your area? Maybe you should be contacting them to see if there is a solution to the issue.
 
Current webnars for ABN

Go online to the advance beneficiary notice of noncoverage webnar by Citrex online they are currently open for participation. Your question will be answered if you pose it prior to the webnar and the modifier useage is TOTALLY covered. ALWAYS check CMS training team ....they are out there for us to learn. Cant believe no one recommended this LEARNING source to you
 
MHH888 said:
Go online to the advance beneficiary notice of noncoverage webnar by Citrex online they are currently open for participation. Your question will be answered if you pose it prior to the webnar and the modifier useage is TOTALLY covered. ALWAYS check CMS training team ....they are out there for us to learn. Cant believe no one recommended this LEARNING source to you
Click to expand...

I have not heard of Citrex and could not find how it relates to Medicare in a google search. Do you mean that your local Medicare carrier has webinars thru Citrix which is communication tool? You can also go to the CMS website directly and look for the learning resources. Unfortunately for this particular issue, the item needed to be billed thru the DME carrier so the CO-4 denial by Medicare cannot be billed to the patient. But contacting the DME carrier for that region may be the way to find a solution to the problem.
 
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