This is a private preview of your draft site—it is only visible to you. To return to your live site, simply "x" out of this preview.
A recent question on the universe’s most reliable source (Facebook) asked if their biller was correct in using the KX and GA modifier on the same claim.
One rather interesting response advised the questioner to investigate what else their biller was doing wrong. Let’s look inside this question to determine the correct answer.
For DME, an applicable example for this scenario is for a patient who wishes to receive a second pair of therapeutic shoes in the same calendar year, where Medicare has already reimbursed. Use of the KX modifier stipulates that the patient meets all the LCD (AKA, Medical Necessity) requirements. From the medical perspective, we an assume that all the boxes have been checked off for both pairs. However, for the second pair the LCD and PA all clearly state that Medicare considers only one pair per year as medically necessary. Hence, when billing the second pair, the KX modifier would be inappropriate and would result in a claim rejection.
Instead, the patient should sign an ABN that clearly states that they have already received one pair during the calendar year, i.e., the patient should pay you, unless their secondary insurance may cover the second pair. The GA modifier would be applicable because, while under Medicare, therapeutic shoes are sometimes a covered service, they are not considered medically necessary on that particular DOS.
The use of the GY Modifier would indicate that the service is statutorily never covered, hence that would be incorrect. GY for therapeutic shoes could be used if any of the qualifying documents are not obtained from the supervising physician or the patient simply doesn’t qualify. In this case, obtaining an ABN is optional but encouraged.
Non DME: In the case of covered routine care, the specific modifiers and diagnosis covered on every 60+ days are billed. But what if the patient wants to come in earlier and is otherwise qualified for routine foot care? Again, because the LCD does not consider visits more frequent than 60 days to be medically necessary, this service is not covered. An ABN explaining this to the patient must be obtained and the usual modifiers are replaced by the GA modifier. For patients who wish to regularly have routine foot care performed, ask your Medicare contractor if one ABN per calendar year is sufficient and can simply be signed at each visit.
The use of the KX versus GY gets a bit stickier if the LCD allows for an additional parent product under the LCD within the permissible time frame. An example would be same or similar for AFOs. The explanation of which modifier to use in this scenario is best left for a future column.
—Paul Kesselman, DPM