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Payment of Pressure Reducing Support Surfaces – KX, GA, or GZ Modifier Requirements

National Government Services, the Jurisdiction B DME MAC, conducted analysis of redeterminations submitted for pressure reducing support surfaces during January–June 2011. Results of the analysis identified that suppliers are often submitting claims with modifier GA appended and then later requesting a redetermination or reopening indicating they had appended the wrong modifier. Requests of this nature should rarely, if ever, occur for claims involving group I, II, or III pressure reducing support surfaces. Suppliers are responsible for making a determination as to whether Medicare is expected to allow or deny a group I, II or III pressure reducing support surface and must append the appropriate modifier based upon that determination.

Many policies, including the group I, II, and III pressure reducing support surfaces policies, require the use of the KX, GA, or GZ modifier to indicate whether coverage criteria has or has not been met. The DME MACs will reject a claim line if the supplier does not include one of these modifiers as specified in the LCDs. The supplier is then required to resubmit the claim with the appropriate modifier. These claim rejections cannot be corrected through a reopening or redetermination.

Modifier Modifier Description
KX Requirements in the medical policy have been met.
GA Waiver of liability (expected to be denied as not reasonable and necessary, ABN on file).
GZ Item or service not reasonable and necessary (expected to be denied as not reasonable and necessary), no ABN on file.
EY No physician or other licensed health care provider order for this item or service.

The KX modifier serves as an attestation by the supplier that the requirements for its use that are defined in the particular LCD are true for that specific beneficiary. It must not be added indiscriminately just “because it is needed to get the claim paid.”

In the group I, II, and III pressure reducing support surface policies, the instructions for the use of the KX modifier clearly specify that the supplier must have the documentation (e.g., copies of the patient’s medical record, test reports, etc.) in their files before they may submit a claim line with the modifier. If they do not, the modifier must not be added.

The GA or GZ modifiers indicate the supplier expects the Group I, II, or III pressure reducing support surface will be denied as not reasonable and necessary and informs the DME MAC whether or not an ABN has been properly executed. The Medicare ABN form is a written notice given to a Medicare beneficiary before providing an item or service that you expect Medicare will deny. Therefore, suppliers should not execute an ABN unless they expect that Medicare probably will deny payment. Giving ABNs for all claims, items, or services is not an acceptable practice.

Detailed Written Order Prior to Delivery

A detailed written order (original, fax, or electronic) is required for all items of DMEPOS before a claim can be submitted to Medicare. However some DMEPOS items require a detailed written order prior to delivery. In particular, group I, II, or III pressure reducing support surfaces require a detailed written order prior to delivery. If a group I, II, or III pressure reducing support surface is delivered before a signed written order has been received by the supplier, it will be denied as noncovered. The claim must be submitted with the EY modifier. If the written order is not obtained prior to delivery, payment will not be made for that item even if a written order is subsequently obtained. If a similar item is subsequently provided by an unrelated supplier who has obtained a written order prior to delivery, it will be eligible for coverage.

Additional information related to group I, II, or III pressure reducing support surfaces can be found in the pressure reducing support surfaces – group I, II or III LCD and policy article under the Medical Policy Center on the National Government Services Web site. 

 

Payment of Pressure Reducing Support Surfaces – KX, GA, or GZ Modifier Requirements
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