2009 AOPA Assembly Top Ten Presentation

2. 2009 AOPA AssemblyTop Ten Presentation Modifiers

3. 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

4. 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

5. 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

6. 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 ……

7. 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.

8. 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

9. 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

10. 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

11. 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

12. 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.

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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