KX Modifier (2022) Description, Uses, Guidelines & Examples

KX Modifier appends with the service, which meets the specified requirements in the policy.

KX Modifier Description

KX Modifier deals with policy requirements when the physician provides the service which meets all the policy requirements. If the insurance or third-party payer requires additional documentation for the service other than the claim information, efficiently offer them. 

Modifier KX may require written communication or telephone reopening when circumstances are complex to add KX to the claims.

According to the documentation, the insurance or third-party payer may ask to remove, add or eliminate Modifier KX from the claim.

For instance, the hospital provides a supporting device to the patient with a moving disability. They give a walker and other assistance devices for 60 days period to the patient. The patient did not exceed the 60 days rental period and submitted the claim with an additional unit or amount with KX Modifier. In this scenario, insurance may ask to remove KX as the rental period still exists for the patient.

In contrast, the hospital submits the claim on the 64th day without a KX modifier on the claim. The insurance may ask to add KX to the claim for reconsideration.

The following are the services that are applicable to use KX according to the policy:

• Respiratory Assist Devices (RAD)
• External infusion (insulin) pumps
• Commodes, Hospital beds, and accessories
• Therapeutic Shoes for Diabetics
• Heavy-duty walkers
• Urological Supplies
• Cervical Traction devices  CPT Codes E0855 and E0849
• Manual and power mobility bases and accessories
• Polycarbonate lenses
• Glucose monitors & supplies
• Epoetin
• PAP devices and accessories
• Support surfaces Groups I, II, and III.
• Refractive Lenses – Anti-reflective coating, oversize lenses, tint 
• High-Frequency chest wall oscillation devices, Nebulizers (Brovana or Perforomist) – J7605 and J7606
• Negative Pressure Wound Therapy
• Patient lifts – E0636 and E1035
• Speech generating devices
• Wheelchair seating, 
• Orthopedic Footwear
• Home Dialysis supplies, and Oral Antiemetic – J8502 and J8540.

Documentation should identify the provided services appropriately provided to the patient and exceeding the caps. If the provider submits all the claims with KX Modifier without meeting the coverage criteria and policy, it will lead to an inquiry. The provider may have a detailed document to support the use of KX. 

Modifier KX is inappropriate to append with the service when the provider does not qualify for the cap exception limit. The provider must exceed the limit to add KX with the service. If the service is not medically necessary and reasonable, It is inappropriate to add KX Modifier.

Modifiers can append to the services in any order. The therapy services must append therapy modifiers such as  GO, GN, or GP. When KX modifier requires in combination with GO, GN, or GP is appropriate to append. If there is no place left for addition modifiers on the claim line, Adding modifiers in the remarks field is warranted when there is no space left. 

Modifier KX is only applicable when the physician provides a service that exceeds the cap. If there is a possibility of exceeding the cap, It is inappropriate to append KX whether there is the possibility of exceeding the cap or no indication. For example, KX Modifier appends with the service for low-cost claims when the previous caps do not exceed yet, and It is inappropriate to add a KX.

What is KX Modifier?

Modifier KX deals with policy requirements when the physician provides the service which meets all the policy requirements. If the insurance or third-party payer requires additional documentation for the service other than the claim information, efficiently offer them. 

When To Use KX Modifier

KX Modifier applies when the physician can provide additional documentation to support the medical necessity.

If the podiatrist provides the following services with proper and verifiable training, which is effective from 8/30/2021:

The modifier KX applies to the procedure codes are  64575, 64580, 27600, 64905, 64910, 64585, 64708, 64890, 64891, 64892, 64912, and 64913.

Documentation should be reasonable and necessary to support the coverage criteria. The supplier may also apply the KX when the service provider meets Policy requirements. The following is the list of covered items or supplies according to LCD:

• Ankle-Foot/Knee-Ankle-Foot Orthosis
• Automatic External Defibrillators 
• Cervical Traction Devices 
• Monitors
• Devices Oral Antiemetic Drugs  
• Oral Appliances for Obstructive Sleep Apnea 
• High-Frequency Chest Wall Oscillation Devices 
• Commodes 
• External Infusion 
• Pumps Glucose 
• Hospital Beds Immunosuppressive 
• Drugs Knee Orthoses 
• Manual Wheelchair Bases Nebulizers 
• Negative Pressure Wound Therapy 
• Respiratory Assist Devices Orthopedic Footwear Oxygen etc.

KX Modifier Guidelines

Documentation should support the medical necessity of service. It reflects that service is medically necessary and appropriate.  

KX Modifier is inappropriate to apply when the When service denial is statutorily required. The render cannot provide additional information or other claims against that service.

Modifier KX is inappropriate to the bill when the provider submits the claim without verifying the Coverage criteria, policy guidelines, and documentation.

If the insurance or third-party payer denies the claim, It requires adding or removing KX from the claim through a Written Redetermination request only. 

The beneficiary would have no appeal right if the insurance did not process the claim. The only option is correct such claims and resubmit. 

KX may be combined with modifier GK or GL when items have specific coverage criteria to meet the policy requirements.

If the patient is receiving insulin injections in the hospital or other facility, It is appropriate to report for monitoring and supplies of KX Modifier. It is inappropriate to bill KX for services when the beneficiary does not receive any treatment regarding insulin injections.

Modifier KX is adequate for the claims that submit on January 1, 2018, or after this date. Insurance or third-party payers may not recognize these claims before January 2018 and deny the payments.

CMS accepts all the claims that are in the exception or lies before 2018. Documentation is essential in reimbursing these claims with or without KX.

If the documentation does not meet the requirements according to the local coverage determination and unnecessary medical services, It is inappropriate to append KX Modifier on the claim.

For Professional claims, CMS 1500 form provides the space for HCPCS modifiers such as KX in 24D block, and additional four modifiers can attach to this claim. If there is no room left for the modifier, It is appropriate to add modifiers 99 to 24D and put the additional modifier to block 19.

For Institutional claims, The patient receives multiple therapies, such as PT, OT, or SLP from the hospital or other facility. If one out of three PT treatments exceeds the caps, It is appropriate to report KX with all the three services.

In contrast, If the Patient receives all the OT claims that do not exceed the cap limit, It is inappropriate to report KX for all the OT treatments regardless, If KX appends with all the PT services.

KX Modifier appends to the service means the provider attests that all services provided to the patient are reasonable and necessary.

KX Modifier Examples

The following are the examples of when KX Modifier appends with the CPT codes:

Example 1

A 76-year-old male admits to the rehabilitation facility and has an ankle and foot problem. He is unable to move without any support and assistance from any person. The physician placed an Ankle-foot orthotic (AFO), ankle gauntlet, and prefabricated (L1902). 

Modifier KX applies with HCPCS code L1902 only when it exceeds the caps or rental period. If there is a possibility of exceeding the cap, It is inappropriate to append KX whether there is the possibility of exceeding the cap or no indication.

Documentation must support the medical necessity of the service that the patient foot still requires ten days more an orthotic device for accurate reimbursement by the insurance or third-party payer.

Example 2

A 79-year-old male admits to the rehabilitation facility and has an ankle and foot problem. He is unable to move without any support and assistance from any person. The physician placed Foot pressure off-loading or supportive device, each type (A9283). 

KX Modifier applies with HCPCS code A9283 only when it exceeds the caps or rental period. If there is a possibility of exceeding the cap, It is inappropriate to append KX whether there is the possibility of exceeding the cap or no indication.

Documentation must support the medical necessity that the patient cannot move without a supporting device for accurate reimbursement by the insurance or third-party payer. 

Example 3

An 80-year-old male admits to the rehabilitation facility and has an ankle and foot problem. He is unable to move without any support and assistance from any person. The physician placed the Hospital bed, total electric (head, foot, and height adjustments (E0265). 

KX Modifier applies with HCPCS code E0265 only when it exceeds the caps or rental period. If there is a possibility of exceeding the cap, It is inappropriate to append KX whether there is the possibility of exceeding the cap or no indication.

Documentation must support the medical necessity of service that the patient still has movement disability for accurate reimbursement by the insurance or third-party payer.