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2009 AOPA Assembly Top 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 - PowerPoint PPT Presentation
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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