KX Modifier Causes Problems without Supporting Documentation

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Original story posted on: December 14, 2012

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The Office of Inspector General (OIG) found more than almost $179,000 of sampled claims for durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) submitted through Medi Home Care didn’t have adequate supporting documentation, according to a recent report.

OIG examined 100 claims from July 1, 2009, to June, 30, 2010, from Medi Home Care, which is a part of Medical Services of America (MSA) of Lexington, S.C. The Columbia, S.C., company’s DMEPOS claims had the KX modifier indicating it had the required documentation on file to support the claims, the December OIG report stated.

But OIG found 62 of the claims, worth $178,601, did not have that documentation, according to a December report. Some claims were missing multiple pieces of documentation. For example, 45 did not have physicians’ orders, 29 did not have compliant use follow-up statements and eight did not have face-to-face evaluations.

The $178,601 is 39 percent of the $452,950 CMS paid the company during that period, the report stated.

OIG recommended that the company repay the $178,601; review claims submitted after the audit period to ensure supporting documentation is available and return any overpayments for claims without that paperwork; follow quality assurance processes; develop a quality assurance process for monthly rental billing and replacement supplies; and remove the automatic assignment of the KX modifier from the billing software and apply it only when the appropriate documentation is on file.

For more information, visit https://oig.hhs.gov/oas/reports/region4/41104010.pdf.

RAC News

Two recovery auditors (RACs) – Region A’s Performant Recovery and Region C’s Connolly – posted issues this week.

Carrier

Name of issue

Date approved

Regions/states where it is active

Description of issue

Document sources

Excessive billing of ambulance service units

11/26/12

RAC Region C

Claims identified where ambulance service units were incorrectly billed.

CMS IOM chapter 15

Durable medical equipment (DME) supplier

Name of issue

Date posted

Regions/states where it is active

Description of issue

Document sources

Positive airway pressure (PAP) devices for the treatment of sleep apnea

12/6/12

RAC Region A

PAP device claims that do not meet the indications of coverage and/or medical necessity, according to NHIC’s local coverage determination (LCD) L11528

CMS Pub. 100-02 chapter 15; CMS Pub. 100-08 chapter 5; CMS Pub. 100-04 chapters 20, 30; CMS Pub. 100-03 chapter 1; NHIC LCD L11528 and article A19815; NHIC Medical Review Bulletin posted Aug. 19, 2011

Home health

Name of issue

Date posted

Regions/states where it is active

Description of issue

Document sources

Partial episode payment (PEP) adjustment

11/26/12

RAC Region C

Incorrect payment of a home health episode when another episode was billed within the same 60 day period.

CMS Pub. 100-04 chapter 10; CMS Pub. 100-02 chapter 7

OASIS not completed timely

11/26/12

RAC Region C

The OASIS assessment was not completed within the appropriate time frame.

42 CFR Part 484.55 (b)(1) and (d)(1); State operations manual, appendix B pages 87-88, 92-94; QIES technical support office – OASIS Q&As; CMS Pub. 100-04 chapter 10

Hospice-related services billed with condition code 07 – home health

11/26/12

RAC Region C

Services related to a hospice terminal diagnosis provided during a hospice period are included in the hospice payment and are not paid separately.

CMS Pub. 100-04 chapter 11; CMS Pub. 100-04 chapter 9

About the Author

Karen Long is the editor of Physician Solutions for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation's leading independent authority on home healthcare business, regulation and reimbursement.

Contact the Author

KLong@decisionhealth.com

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Karen Long

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