2009 AOPA Assembly Top Ten Presentation Modifiers Directional

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 – 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. – L 1970 RA – 2 x. L 2210 RA • Then the HA 0 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 – 2 x. L 2210 RB • Then the HA 0 record or Box 19 should include a short narrative – Pt. owned L 1970 061309 Joints broke. – Replacing the joints on an L 1970, because joints ……

Replacement • If replacing a part not described by an existing HCPCS code use “parts” and “labor” codes – L 4205 and L 4210 – L 7510 and L 7520 • 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 • L 4396: 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 • A 9283 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 semirigid in construction, meets the definition of a brace • Only used with specific LSO/TLSO codes – L 0450, L 0454, L 0621, L 0625, and L 0628 • 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 • K 0 – Doesn’t have potential/ability to ambulate • K 1 – Limited and unlimited household ambulator • K 2 – Limited community ambulator • K 3 – Ambulation with variable cadence • K 4 – Exceeds basic ambulation

Special Modifiers • GK – Billing for an upgraded item, when using an ABN. Indicates the item Medicare will cover. – Two line billing • L 5976 GA • L 5972 GK • GL – Not billing for an upgrade

Special Modifiers • AW – Only used with codes: A 6531, A 6532, and A 6545 – 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