CMS has decided that without the use of CMNs, the KX modifier will now be required. This means documentation is more important than ever. KX is a modifier that tells the processing contractor that "specific required documentation is on file." Requirements outlined by the local coverage determination (LCD) policy are "in your file," and you can produce them if asked.

Items requiring a KX modifier are increasing every month. On March 1, 2007, hospital beds and accessories were added. On May 1, 2007, manual wheelchairs and accessories were also added.

A patient's medical file includes test reports and records from the physician's office, hospital, nursing home, home health agency, and other health care professionals. Physicians' progress notes are also a must.

For each LCD, the documentation required is outlined in the specific policy, but every file must contain:

• a patient profile (order intake form) with verification of current and permanent address;
• representative information if patient did not sign;
• attending physician's full name, address, UPIN/NPI;
• assignment of benefits (AOB);
• release of information form (HIPAA) (privacy rules);
• CMN;
• DME and/or physician order, plus all other company documents per company policy;
• delivery document with patient's complete address, date of delivery, description of equipment (serial number recommended);
• patient/representative signature and other signatures;
• notation of education/instructions given to patient and/or caregiver (separate or part of delivery ticket);
• explanation of capped rental/inexpensive rental/purchase option;
• purchase option letter (first month for power wheelchairs);
• proof of capped rental 13-month notification;
• medical record documentation from MD medical record/ hospital/home health agency;
• verification of billing (or electronic billing); and
• pickup documentation when equipment is returned.

How will you get the documentation that is needed? The physician has a legal responsibility to complete CMNs (Section 4152 Omnibus Reconciliation Act of 1990) and make sure that the items they order for patients are actually what are needed for the patients to function in the home.

Each of the DME Medicare Administrative Contractor (MAC) directors has outlined letters to physicians to encourage them to work with suppliers to assist in getting the proper documentation to cover the items they order.

A simple letter to the ordering practitioner often helps to educate their office staff. Community forums are excellent for communicating to physicians and referral sources about changes and updates for all types of policies. These can be done with assistance from rehab hospitals and facilities as well.

The main thing to remember is that no supplier-generated form (of any type) would be acceptable in a postpay audit situation. The reviews being seen range from bedside commodes to higher-end rehab chairs. Region A & B has already indicated that the K0823 has the highest percentage of codes billed within the group 2 category, and they will be doing a probe review on these. Since the amount was significant throughout all four regions, the others will almost certainly follow.

Anytime billing for an item rises significantly over a 3-month period, that code will be looked at closely. A probe review means that a certain number of claims billed with the K0823 code will be stopped and additional documentation will be requested. This documentation will then be examined to see if it is adequate to allow for payment for the specific item billed. If a significant number of these claims do not have proper documentation, the next step could be a complete review of this code, a review by area, a supplier-specific review, or continuing with just an additional number of claims to be reviewed.

The basic rule to remember is that Medicare pays for the least costly alternative, and when you put that KX modifier on the item you provide, you must make sure that all lower-level items were trialed and ruled out, and why. Using the KX modifier sometimes means that you will need more than four modifiers on a claim.

KB AND 99

Peggy Walker

The KB and 99 modifiers are "overflow modifiers." Use a KB if an ABN is being used on an item that requires more than four modifiers. For example, if you are billing a free upgrade for an item, you would bill the actual item that the patient met criteria for—and add the GL modifier.

When billing a power wheelchair that would require more than four modifiers, you would use the base code K---- plus the modifiers of NUKHBPKB—and the KX and GL modifiers would be placed in block 19 of a paper claim or the narrative field of an electronic claim with an explanation of why it was being used.

The 99 is an overflow modifier to be used if more than four modifiers are needed—but it is not an ABN type of situation (such as replacing a power wheelchair that was destroyed in a fire). Use K----NUKHBP99, and then put the KX and RP modifier in block 19 of a paper claim or the narrative field of an electronic claim.

The basic rules apply for all items. If a patient needs a covered item of DME, Medicare will cover it. You need to make sure there is nothing to cause a duplicate denial, make sure you have documentation in your files, bill correctly with correct modifiers, and remember that Medicare only pays for the least costly alternative for functional needs within the home.

Peggy Walker, RN, is billing and reimbursement advisor for US Rehab/VGM, Waterloo, Iowa. She can be reached at .