The Positive Airway Pressure (PAP) Devices and Respiratory Assist Devices (RAD) Local Coverage Determination (LCD) has been revised, effective for dates of service on or after September 1, 2009. The [removed]revised information[/removed] is in the Documentation Section and outlines the use of additional modifiers to indicate that an item is not medically necessary and whether a waiver of liability statement (ie, Advance Beneficiary Notice or ABN) is on file.

Over the coming months, LCDs that include use of the KX modifier will be updated to incorporate instructions for the use of the GA, GZ, or GY modifiers. If the patient meets the criteria for use of the KX modifier but the supplier forgets to include it on the claim line, currently the supplier may request a reopening of the claim. This procedure requires manual intervention by the DME MAC and is responsible for a substantial workload for the contractor. Therefore, the DME MACs are implementing system edits that will reject a claim line if the supplier does not indicate that the beneficiary either meets or does not meet the requirements that are specified in each medical policy.

“Gone is the opportunity for DME providers to correct billing errors that have occurred by leaving the KX modifier via a reopening,” says Peggy Miller, senior consultant, DME Defender.

The contractors will use the presence of a GA, GZ, or GY modifier as an indication that coverage criteria are not met. If a claim line is rejected, the supplier may resubmit the claim line with the appropriate modifier. Requesting a reopening will no longer be an option.

Since the KX modifier has a different definition depending on the LCD in question, suppliers should read the revised LCDs carefully to understand the proper use of the additional modifiers GA, GZ, or GY. Further instructions and details will be published with each LCD revision.

“Beginning September 1, 2009, those DMEPOS items that require a KX modifier must be submitted with either the GA modifier (ABN on file), GZ modifier (Item expected to be denied as not reasonable or necessary, no ABN on file), GY modifier (item excluded from coverage), or KX modifier (specific required documentation on file). Claims without the appropriate modifier will be rejected front-end as ‘Missing Information’ and must then be corrected and resubmitted,” clarifies Miller.