Avoiding KX Modifier Pitfalls

1. ”Tuesday at 10 “ October 14, 2014 Avoiding KX Modifier Pitfalls Presented by Argosy Group, Inc Tel: 888-691-2746 info@argosygroup.org

2. Disclaimer • It is the intent of the Argosy Group to provide up to date, accurate information . The information contained in this presentation is for educational purposes only and is not presented as legal advice or with any expressed or implied warranty of accuracy. Excerpts are used from LCD; however, not all inclusive. • Argosy Group encourages you to visit and communicate with your Medicare Regional DMEMAC and your Accreditation Agency often

3. Avoid KX Modifier Pitfall • KX modifier has become a powerful tool for CMS to combat fraud, waste and abuse. • Very serious: attention needs to be paid by every supplier. • Adding the KX modifier to a claim line is an ATTESTATION that ALL of the criteria in the Indications and Limitations of Coverage and/or Medical Necessity section of the LCD have been met and that evidence of such is kept in the supplier’s file and made available when requested.

4. Avoiding KX Modifier Pitfall • Are you 100% sure that ALL of the required documentation to support the KX modifier is in your file? 100%...not 99% or 98%...but 100%? • Physicians do not know what we need unless we have educated them. • You need to be sure that you have 100% required documentation prior to adding the KX and submitting the claim. • It will not be OK to scramble to obtain the required documentation when/if you get audited on that claim; that is not what the ATTESTATION you made means. 100% required documentation in file prior to adding the KX - No Exception.

5. What is the biggest pitfall? • When required a claim will not be paid unless the KX modifier is appended to each HCPC requiring it. • If you use the KX modifier and do not have the required documentation to support the KX, the claim will be denied in a pre-pay audit or in a post-pay audit $ will be recouped for overpayment . (may or may not be able to be appealed) • If a CMS auditor requests documentation on a claim with KX modifier and supplier does not have it OR it does not show that indications and limitation of coverage from the LCD have been met…they can reasonably accuse the supplier of violating the Federal False Claims Act. • Don’t put yourself in that position of jeopardy!

6. False Claims Act • A federal crime for anyone knowingly presenting, or causing to be presented a false claim for payment or approval. • Penalties of violation can be severe. - Civil Monetary Penalties ($11,000 per violation or 3X the amount of falsely claimed charges) Each line on the claim is considered a violation. $ Damages can get out of control very quickly

7. Sample Documentation for KX • A4253 Diabetic Test Strip (Excerpts from LCD) To be eligible for coverage of home blood glucose monitors and related accessories and supplies, the beneficiary must meet both of the following basic criteria (1) – (2): 1. The beneficiary has diabetes (Reference ICD-9 Codes that Support Medical Necessity section for applicable ICD-9 diagnoses); and 2. The beneficiary’s physician has concluded that the beneficiary (or the beneficiary’s caregiver) has sufficient training using the particular device prescribed as evidenced by providing a prescription for the appropriate supplies and frequency of blood glucose testing. For all glucose monitors and related accessories and supplies, if the basic coverage criteria (1)-(2) are not met, the item(s) will be denied as not reasonable and necessary. Usual Utilization For a beneficiary who is not currently being treated with insulin injections, up to 100 test strips and up to 100 lancets every 3 months are covered if the basic coverage criteria (1)-(2) (above) are met. For a beneficiary who is currently being treated with insulin injections, up to 300 test strips and up to 300 lancets every 3 months are covered if basic coverage criteria (1)-(2) (above) are met.

8. High Utilization For a beneficiary who is not currently being treated with insulin injections, more than 100 test strips and more than 100 lancets every 3 months are covered if criteria (a) – (c) below are met. For a beneficiary who is currently being treated with insulin injections, more than 300 test strips and more than 300 lancets every 3 months are covered if criteria (a) – (c) below are met. a. Basic coverage criteria (1)-(2) listed above for all home glucose monitors and related accessories and supplies are met; and, b. The treating physician has seen the beneficiary, evaluated their diabetes control within 6 months prior to ordering quantities of strips and lancets that exceed the utilization guidelines and has documented in the beneficiary's medical record the specific reason for the additional materials for that particular beneficiary; and, c. If refills of quantities of supplies that exceed the utilization guidelines are dispensed, there must be documentation in the physician's records (e.g., a specific narrative statement that adequately documents the frequency at which the beneficiary is actually testing or a copy of the beneficiary's log) that the beneficiary is actually testing at a frequency that corroborates the quantity of supplies that have been dispensed. If the beneficiary is regularly using quantities of supplies that exceed the utilization guidelines, new documentation must be present at least every six months.

9. Sample Documentation for KX • E0163-E0168 Commode Covered when beneficiary is physically incapable of utilizing regular toilet facilities. Occurs in following situations: 1. Beneficiary is confined to a single room, or 2. Beneficiary is confined to one level of the home environment and there is no toilet on that level, or 3. Beneficiary is confined to the home and there are no toilet facilities in the home. An extra wide/heavy duty commode chair is covered for a beneficiary who weighs 300 pounds or more. If an E0168 commode is ordered and the beneficiary does not weigh more than 300 pounds, it will be denied as not reasonable and necessary

10. POLICY SPECIFIC DOCUMENTATION REQUIREMENTS • The ICD-9 code that justifies the need for item(s) must be included on the claim. • KX, GA, GY, AND GZ MODIFIERS: For commodes (E0163-E0171) used as a raised toilet seat by positioning it over the toilet, the GY modifier must be added to the code, and the KX, GA, or GZ modifier must not be used For commodes (E0163-E0171) not used as a raised toilet seat, the KX modifier must be added to the code only if all of the coverage criteria as described in the Indication and Limitations of Coverage and/or Medical Necessity section have been met. For commode chairs with seat lift mechanism (E0170 and E0171), the KX modifier must be added to the code only if the beneficiary meets all of the criteria for a seat lift mechanism. If all of the criteria in the Indications and Limitations of Coverage and/or Medical Necessity section have not been met, the GA or GZ modifier must be added to the code. When there is an expectation of a medical necessity denial, suppliers must enter a GA modifier on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or a GZ modifier if they have not obtained a valid ABN. Claim lines billed without a GA, GY, GZ or KX modifier will be rejected as missing information.

11. REMINDER: Supplier-produced records, even if signed by the ordering physician, and attestation letters (e.g. letters of medical necessity) are deemed not to be part of a medical record for Medicare payment purposes. Templates and forms, including CMS Certificates of Medical Necessity, are subject to corroboration with information in the medical record. Information contained directly in the contemporaneous medical record is the source required to justify payment except as noted elsewhere for prescriptions and CMNs. The medical record is not limited to physician's office records but may include records from hospitals, nursing facilities, home health agencies, other healthcare professionals, etc. (not all- inclusive).

12. Do your Homework • Chart Audits - Audit every patient record with KX modifier or consider hiring an external auditor to help - Look at the corresponding LCD and go to the ‘Indications and/or Limitations of Coverage and/or Medical Necessity” section’ and review what is required - Review clinical records in your file to see if they support that the patient qualifies for the item(s) - Train staff on requirements and hold them accountable to obtain required documentation prior to claim submission If you cannot prove 100% that the criteria has been met, you will most likely have a difficult time convincing a CMS auditor.

13. Get to know the LCDs intimately…the answers are there • Be Proactive and do Diligence on all of your claims; specifically the ones with KX modifiers added. Request all documentation required UPFRONT • Review documentation received and be 100% sure that it supports the criteria necessary BEFORE adding the KX modifier and submitting a claim. • Identify staff in your billing office that have the skill level to review clinical documentation and make it a policy that all KX appended claims are reviewed and approved by that staff prior to submission. • Don’t get caught in the KX trap. Take charge of your own destiny and reduce your exposure in an audit. END

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16. Reference Sites • www.cms.hhs.gov CMS • www.cms.hhs.gov/manuals/downloads • www.medicarenhic.com (Region A) • www.ngsmedicare.com (Region B) • www.cignagovernmentservices.com (Region C) • www.noridianmedicare.com (Region D) • www.dmepdac.com (Medicare Pricing, Data Analysis and Coding)