NGS Clarifies of KX/GA Modifiers Use

Jurisdiction B DME MAC issued a clarification on when modifiers can be used on same line in "same or similar" situations.

National Government Services (NGS), the Jurisdiction B DME MAC, has issued a clarification on when KX and GA modifiers can be appropriately used on the same claim line in "same or similar" equipment situations.

The GA modifier "indicates the supplier believes the item they are providing is expected to be denied as not reasonable and necessary, and that an Advance Beneficiary Notice (ABN) has been properly executed," the bulletin says.

Since the KX modifier, in most cases, should be added to a HCPCS code "only if all of the coverage criteria outlined in the Indications and Limitations of Coverage section of the applicable policy have been met," the bulletin notes that "in most cases it would not be appropriate to append the GA and KX modifiers on the same claim line."

NGS points out that it is the supplier's responsibility to determine and anticipate whether Medicare would be expected to pay or deny the claim, and the supplier should use the correct modifier accordingly.

NGS listed several examples in which fictitious Medicare beneficiaries visit a fictitious DME supplier and present prescriptions for different types of DME. The examples then illustrate whether the resulting claims should or should not contain both KX and GA modifiers.

Medicare's "same or similar" policy doesn't pay "for backup equipment or items that are deemed to be same or similar to equipment that is already in use, as they are considered not reasonable and necessary."

NGS also warned suppliers they should not issue an ABN to a beneficiary unless they have "some genuine doubt" that Medicare will not pay the claim.

In the first example NGS listed, the beneficiary presents a prescription for a manual chair, but the provider discovers Medicare had paid for 13 rental payments for a manual wheelchair within the last five years. The beneficiary is told Medicare will likely decline to pay for a new manual chair for that reason, but the beneficiary says he would be willing to "be held financially responsible," and the provider correctly issues an ABN. "In this scenario," the bulletin says, "it would be appropriate for ABC Supplier to submit a claim for the manual wheelchair with both the KX and GA modifier appended to the manual wheelchair HCPCS code and receive a patient responsibility denial from Medicare."

In the second example, the fictitious beneficiary admits to using a wheelchair years earlier, but can't recall if Medicare paid for it or what ultimately happened to the wheelchair. The provider explains the possibility of a Medicare denial, and would be correct in issuing an ABN, as well as submitting a claim for the manual wheelchair "with the GA modifier and the KX modifier - if all of the coverage criteria outlined in the Indications and Limitations of Coverage section of the applicable policy have been met - appended to the HCPCS code."

But in the third example, the beneficiary provides a prescription for a walker and denies ever using any DME prior to this. Since the supplier subsequently finds no indication of same or similar equipment on file, "it would not be appropriate for ABC Supplier to execute an ABN because the supplier does not have a genuine reason to believe that Medicare is likely to deny payment. Therefore, it would not be appropriate for (the supplier) to submit a claim for the walker with both the KX and GA modifiers appended," the bulletin says.

For more information on using the KX or GA modifiers, go to ngsmedicare.com/lcd.aspx?CatID=3.

About the Author

Laurie Watanabe is the editor of Mobility Management. She can be reached at lwatanabe@1105media.com.

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