Orthotics Codes with Medicare

Orthotics are supposed to be statutorily not covered by Medicare unless they are attached to a brace. I was told to just append the KX modifier to the codes that are being billed for orthotics and I will get paid. Is this true and is it right to do this? Can I get in trouble?

Orthotics Codes

1. 1.     Orthotics are statutorily NOT COVERED by any Medicare Administrative Carrier unless they are attached to a brace.
2. 2.     So why are orthotics targeted by CMS to be audited?
3. 3.     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
   1.      a.     The orthotics are billed to the respective Durable Medical Equipment Carrier (DMERC) inappropriately using the KX modifier.
   2.      b.     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.
4. 4.     When orthotics are inappropriately billed to the DME Carrier (ie. L3020 KX, RT; L3020 KX, LT), the KX modifier allows an automatic bypass and allows payment of this code.
5. 5.     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?

CMS/Medicare audits are primarily based upon two premises, TRENDS and PATTERNS.

If a provider of a specific specialty bills for something in a different fashion than the providers of the same specialty in the same state, or if a provider of a specific specialty bills for something more frequently than the providers of the same specialty in the same state, this creates a TREND or a PATTERN and triggers an audit. Based upon the above information, how can you justify the reimbursements that have been received? You cannot!

Medicare was originally created as an “honor system” in 1965. If the CMS 1500 Claim Form or the electronic equivalent is correctly filled out and the diagnosis codes (ICD-10-CM codes) and appropriate modifiers appended to the CPT codes qualify the CPT codes for reimbursement, you will get paid, unless an error has occurred on the part of the Medicare Administrative Carrier. What a great system! You fill out a form and you get paid! Unfortunately, CMS can go back a period of 3 years to perform an audit post payment.

When the contract was originally signed by the provider with the Medicare Administrative Carrier/CMS, the provider agreed to follow the rules. The bottom line? Know the rules and follow them!

This is my opinion.

Michael G. Warshaw

DPM, CPC

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