2009 AOPA AssemblyTop Ten Presentation

Modifiers

Directional

• LT• RT

• LTRT– Used when providing identical bilateral devices– Must list 2 units of service plus LTRT– Diabetic shoes

• As of 09/01/09 use LTRT

Informational• Replacement

•RA– Replacement of a DME item– Replacement during useful lifetime– Includes base and addition codes

•RB– Replacement of a part of DME when furnished

as a repair– Replacing just a component of the whole

device, a component described by an existing HCPCS code

Replacement• Replacing an AFO with dorsiflexion joints,

that was lost.– L1970RA– 2xL2210RA

• Then the HA0 record or Box 19 should included a brief narrative– RUL 061309 lost– Original brace lost patient statement on file

Replacement• Replacing just the dorsiflexion assist joints

on an AFO – 2xL2210RB

• Then the HA0 record or Box 19 should include a short narrative– Pt. owned L1970 061309 Joints broke.– Replacing the joints on an L1970, because joints ……

Replacement• If replacing a part not described by an

existing HCPCS code use “parts” and “labor” codes– L4205 and L4210– L7510 and L7520

• RA/RB not needed with HCPCS codes that are already described as replacements– Socket Replacements, Replacement Straps, etc.

Payment• KX

– Specific documentation on file, and policy requirements have been met

• Four policies require the KX– Orthopedic Shoes– Diabetic Shoes– KO’s– AFO/KAFO’s

• KX for Orthopedic Shoe Claims– Only when the shoe is attached to a brace– Used on both shoes and inserts/modifications– Transfers and heel/sole replacements

Payment• KX for Diabetic Shoe Claims

– Must have a certifying statement on file– Must have documentation supporting the certifying

statement– Used on both shoes and inserts

• KX for Knee Orthoses Claims– Patient has required diagnosis– Addition codes used with proper base code – Must be used on base and addition codes

Payment• KX for AFO Claims

– AFO• L4396: Patient has plantar fasciitis, or a

contracture • All other AFO’s the patient must be ambulatory

and have a weakness or deformity of the ankle.

• KX for KAFO Claims– AFO portion must be necessary– Patient requires additional knee stability.– Patient is ambulatory

Payment• Custom AFO/KAFO’s

– Must document 1 of 5 possible needs for a custom• Need for control in more than one plane• Could not be fit with a prefabricated• Patient needs the device longer than 6 months• Etc.

• KX must be on both base and addition codes for AFO/KAFO claims

Payment• KX should also be used when providing a

replacement item– New Device (RA)– Component of the device (RB)

• KX should not be added if you don’t have supporting documentation on file, or if the patient doesn’t meet the coverage criteria.

Payment• GY

– Used when an item is non-covered, not a Medicare benefit

• Shoes not attached to a brace• Diabetic shoes, without supporting documentation• Elastic braces• A9283 off loading device/ treatment of ulcers

Payment• GA

– Used when you believe an item will be denied as not medically necessary

• Normally a Medicare covered benefit• An upgraded item

– Have a signed Advanced Beneficiary Notice (ABN) on file

– Allows you to collect from the patient

Payment• CG

• Indicates that the device is rigid or semi-rigid in construction, meets the definition of a brace

• Only used with specific LSO/TLSO codes– L0450, L0454, L0621, L0625, and L0628

• Must be made of non-elastic material, or contain a solid posterior panel– Stays are not the equivalent of a panel

Functional • Also Known as K Level Modifiers

• Indicate patients potential functional level– Applies to patient, not device

• Used only with prosthetic ankles, knees and feet– Same modifier for each component

• Bi-lateral patients not bound by the K levels– Ability to mix functional levels

Functional • K0

– Doesn’t have potential/ability to ambulate

• K1– Limited and unlimited household ambulator

• K2– Limited community ambulator

• K3– Ambulation with variable cadence

• K4– Exceeds basic ambulation

Special Modifiers• GK

– Billing for an upgraded item, when using an ABN. Indicates the item Medicare will cover.

– Two line billing• L5976GA• L5972GK

• GL– Not billing for an upgrade

Special Modifiers• AW

– Only used with codes: A6531, A6532, and A6545– Patient must have open venous stasis ulcers– Indicates the compression garment was used in

conjunction with a surgical dressing

• GD– Units of service exceed published medically unlikely

edit (MUE) numbers– You believe the number of units is medically

necessary– Will avoid automatic denial

Special Modifiers• GW

– Used when providing a service to patient in a hospice– Indicates that the service provided is not related to

the patient’s terminal condition– Becomes eligible to be billed to Medicare

Resources• Medical Policies

– Provides a list of modifiers that are used with those claims, and when and how they are used.

– Indicates how the claim will be denied• Not medically necessary

– Use an ABN and GA modifier• Non-covered

– Use GY modifier

Resources• Medicare Pricing, Data Analysis and

Coding (PDAC)– www.DMEPDAC.com

• Under the DMECS tab– Enter the modifier

» To find the complete definition– Enter the description of the modifier

» To find the modifier that meets that description