NHIC, the Durable Medical Equipment (DME) Medicare Administrative Contractor (MAC) for district A has announced a change to the Local Coverage Determination (LCD) policy on the KX modifier sometimes used in claims for therapeutic shoes for persons with diabetes. According to Adrian M. Oleck, MD, medical director of the DME MAC Jurisdiction B, in such claims the KX modifier is used if the policy criteria are met; the GY modifier is used if the policy criteria are not met. An edited version of the NHIC announcement appears below:
Proper use of the KX modifier expedites claim processing. Currently, an absent modifier causes a claim denial. However, increasing numbers of claims are submitted without the modifier resulting in a growing appeals volume. 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.
Effective with these LCD revisions, the contractors will use the presence of a KX or GY modifier to indicate whether the coverage criteria Therapeutic Shoes policy are or are not met. The DME MACs are implementing system edits that will now reject a claim line if the supplier does not include one of these modifiers as specified in each of these LCDs. If a claim line is rejected, the supplier may resubmit the claim line with the appropriate modifier. Requesting a reopening to correct a claim that is missing one of these modifiers will no longer be an available option.
For detailed guidance on this policy, NHIC recommends reviewing the complete (LCD).
