CR 12177 was implemented on 9/20/2021, specifying that HCPCS 0540T requires a KX modifier on Part B claims for CAR-T, to acknowledge that the service is being performed in an FDA REMS facility. For Part B claims, the logic that was created will accept modifier KX on code 0540T with an effective date of 8/7/19.
The KX modifier is not required for Part A CAR-T claims, it is required for Part B CAR-T claims. Part B claims without the KX modifier will be denied.
No, Part A claims are not edited for modifier KX as it is not required in CR 12177. Part A will not deny based on the presence or absence of modifier KX.
The facility’s site name and address must be identified as an FDA-approved REMS facility.
Part A does not match site name and address exactly, but will look for other related campuses; e.g., if the REMS is for Hospital X in City, State and Hospital X has an oncological hospital 3 blocks down which is the billing hospital, then Hospital X may be considered as having a REMS. The REMS must also be for the specific drug being administered.
Part B claims processing does not review the facility site name and address, since the KX modifier attests to the facility’s REMS status.