KX Modifiers – Medicare’s Cashing In

As many of you know the KX Modifier has been around for several years.  Each year it seems more products or services are added to the list of HCPCS/CPT that are submitted with the KX Modifier.  It is extremely important to understand, that the definition of KX is the product or service meets the coverage criterion set forth by the LCD (Local Coverage Determination).

So what documentation is needed to submit a claim with a KX modifier?  You must have a detail written order (more than a script) and chart notes from the physician, except when the physician is the one submitting the claims then he must have detail chart notes.

Why is it important to get chart notes if you already have a detail written order from the physician?  Medicare will not accept a script as a billable order nor will they accept a “Confirmation of a Verbal (script) Order” as sufficient documentation.  Ensure your detail written order (DWO) does contain all elements outlined for a DWO as well as any specifics from the policy, such as mobility which requires a date last seen.  Medicare wants to see detail chart documentation by the physician that documents the need has been met through the cover criterion specifications.

This is so important, I have received several calls in the last four months from small providers that have not been obtaining this documentation at the time of the order and they are facing $200,000-$500,000 due to post payment audits that have expanded to extrapolated overpayments since the error rate was so high.  They do have the right to file an appeal, but the appeal takes time and you must begin payment arrangements until you complete the appeal process.  This is super costly to a business to the point of devastation.  It is heartbreaking to hear the stories and fear from these providers.

The appeal process includes obtaining the detail chart notes from the ordering physician within 90 days prior to order.  Some policies are more specific on time frame so reference your specific policies.  Each chart must be reviewed thoroughly and completely prior to submitting for an appeal.  Also, take a complete copy of the appeal records with you when you go to the appeal level because I have had the experience of the records being lost.

A good operating process would be to have a health care consultant  and/or health care attorney review the charts being requested for audit especially if there are more than 5 charts being requested.  These audits can easily turn into extrapolated overpayments.  It will prove much much cheaper to have a consultant and/or attorney review the records prior to submitting the initial audit request.  It is not a fool proof way to prevent overpayments but they will be significantly less.  We will be happy to help you.

Angela Miller of Medical Auditing Solutions LLC has been in health care compliance, billing, collections and HIPAA for over 18 years.  Ms. Miller has made it the  focus of the business to help providers run their businesses efficiently, collect money, and maintain compliance with federal and state regulations and coverage criteria.  Ms. Miller  also works as a contract compliance officer to provide an avenue to compliance training to staff, implementation of policies, as well as handling anything that affects cash flow from the initial intake to back end collections. You can visit our website at Medical Auditing Solutions LLC.


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