“I billed A5500 and A5512 with modifiers -KX, -RT, -LT.
L1940 KXRTLT
L2330 KXRTLT
L2820 KXRTLT
I billed these on separate lines. This claim was rejected so we re-billed putting the KX modifier in the 3rd spot and it was still rejected for the same reason. The comment was: 4 – the procedure code is inconsistent with the modifier used or a required modifier is missing Any thoughts on how to tackle this denial?”
When I look at the above post, the three HCPCS Level II codes that were billed for a custom made AFO for the foot/ankle are the appropriate/approved HCPCS Level II codes by CMS/Medicare. They are defined as the following:
L1940 ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL, CUSTOM-FABRICATED
L2330 ADDITION TO LOWER EXTREMITY, LACER MOLDED TO PATIENT MODEL, FOR CUSTOM FABRICATED ORTHOSIS ONLY
L2880 ADDITION TO LOWER EXTREMITY ORTHOTIC, SOFT INTERFACE FOR MOLDED PLASTIC, BELOW KNEE SECTION
If the custom-made Ankle Foot Orthosis was dispensed and fit for one foot/ankle, it would be coded in the following fashion:
L1940 – KX, RT or LT
L2330 – KX, RT or LT
L2820 – KX, RT or LT
The most important modifier to append to the HCPCS Level II code(s) is the KX modifier which is defined as the following: 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. Since this is the primary or predominant modifier, it should always be the first modifier appended to the HCPCS Level II code.
The real issue is how to code for the dispensing and fitting of custom-made Ankle Foot Orthoses for both feet and ankles, aka bilateral. It is inappropriate to bill the HCPCS Level II code on 1 line appended by both anatomical modifiers (ie. RT, LT). Therefore, it is correct to bill the HCPCS Level II codes on 1 line appended by only one anatomical modifier, either RT or LT.
The coding scenario would be the following:
L1940 – KX, RT
L2330 – KX, RT
L2820 – KX, RT
L1940 – KX, LT
L2330 – KX, LT
L2820 – KX, LT
One last point. These instructions would apply to any DME that is dispensed and fit bilaterally to a patient that has Traditional Medicare, and the claim is being submitted to the Durable Medical Equipment Regional Carrier. Therefore, when it comes to extra depth, therapeutic shoes and heat molded inserts, the coding sequence would be the following:
A5500 – KX, RT
A5500 – KX, LT
A5512 – KX, RT
A5512 – KX, LT
The above definitions are the following:
A5500 FOR DIABETICS ONLY, FITTING (INCLUDING FOLLOW-UP), CUSTOM PREPARATION AND SUPPLY OF OFF-THE SHELF DEPTH-INLAY SHOE MANUFACTURE TO ACCOMMODATE MULTI-DENSITY INSERT(S), PER SHOE.
A5512 FOR DIABETICS ONLY, MULTIPLE DENSITY INSERT, DIRECT FORMED, MOLDED TO FOOT AFTER EXTERNAL HEAT SOURCE OF 230 DEGREES FAHRENHEIT OR HIGHER, TOTAL CONTACT WITH PATIENT’S FOOT, INCLUDING ARCH, BASE LAYER MINIMUM OF 1⁄4 INCH MATERIAL OF SHORE A
35 DUROMETER (OR HIGHER), PREFABRICATED, EACH
This is my opinion.
Michael G. Warshaw, DPM, CPC
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