“Medicare DMERC B jurisdiction has stopped abruptly allowing and paying for L3010 using RT KX and LT KX. I cannot find any information of new modifiers or other info needed. Any suggestions?"
HCPCS Level II Code L3010 is defined as the following: FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, LONGTUDINAL ARCH SUPPORT, EACH. In reality, this is a custom made orthotic. I find it interesting that the orthotic device was billed to the DME Regional Carrier and reimbursed. Then abruptly the DME Regional Carrier stopped allowing and reimbursing for the device. Something is amiss.
Orthotics are statutorily NOT COVERED by any Medicare Administrative Carrier/DME Regional Carrier, unless, according to a national policy determination, a shoe and related modifications, inserts, and heel/sole replacements, are covered only when the shoe is an integral part of a brace. This does not appear to be the case.
Providers, either inadvertently, by their billers/billing company, or by design have found an inappropriate method to bill for orthotics by bypassing the rules and regulations. The orthotics are billed to the respective Durable Medical Equipment Regional Carrier (DMERC) inappropriately using the KX modifier.
The KX Modifier: Documentation on File – Use this Medicare modifier to indicate that specific documentation is contained in the medical record to justify the billed service. This modifier is used on all line items for claims that are submitted to the DMERC.
When orthotics are inappropriately billed to the DME Carrier (ie. L3010 RT, KX; L3010 LT, KX), the KX modifier allows an automatic bypass and allows payment of this code. When an audit occurs, the KX modifier states that the necessary documentation is on file to justify the billed service. Since the service is NOT covered, there is no supporting documentation on file, thus how does one justify the billing for orthotics?
The reason for the reimbursement of L3010 needs to be looked at very carefully. If the reason for the reimbursement of HCPCS Level II Code L3010 is due to the inappropriate use of the KX modifier, I believe that the provider needs to contact his malpractice carrier to see if administrative defense coverage is in effect or perhaps a conversation with a health care attorney needs to be considered. The DME Regional Carrier will need to be contacted.
This is my opinion.
Michael G. Warshaw
DPM, CPC
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