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. –L1970RA –2xL2210RA Then the HA0 record or Box 19 should included a brief narrative –RUL 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 L 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) – 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