It was suggested by a provider you should bill Medicare to get paid for orthotics, is this really a frequent expectation? If a practice has been billing L3000-KX and no leg brace is it considered false billing? Should the provider refund Medicare as soon as they know they should not have received any $ for this service from Medicare?
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The KX modifier means that your practice has met the medical necessity required by Medicare (located in the Orthopedic Footwear LCD). By uitlizing the KX modifier you are telling Medicare you have the documentation which stipulates the patient has a leg brace which is attached to a shoe and the foot orthotics are placed into that shoe. The GY modifier (fully explained below) is the exact opposite.
If despite not been fulfiling the LCD requirements, you have been using the KX modifier, then you could be accused of abusive or fraudulent billing. Medicare has temporal requirements by which to report improper payments.
The tone of your letter suggests this has been going on for some time. Here is the same advice provided to others.
1) Discontinue this practice immediately.
2) Hire a health care attorney who can assist you with this now legal matter.
3) DO NOT report this to Medicare on your own and allow your attorney on how to report this to Medicare. Undoubtedly, you will have to refund money and you may face steep penalties. What you want to have your attorney help you with is to avoid any further damages to your participation in other Federally or State Funded programs. This includes disenrollment from DMEPOS, your local Medicare, Medicaid, Essential or other plans.
As for the GY Modifier, this is what you should have used and is exactly the opposite fo the KX modifier. The GY modifier stipulates that the patient and your documentation does not meet the medical necessity criteria as set out by the LCD. In this situation, because the patient does not use a leg brace, their foot orthotics do not meet the medical necessity standard and hence are a non covered service under Medicare. The GY modifier hence can be used in two circumstances:
1) The patient insists you bill Medicare for whatever reason
2) The patient has secondary insurance and the DMEPOS carrier must first process the claim.
Hence the GY modifer should be used 99.5% of the time you are submitting foot orthotics to the DMEPOS carrier.
By this time you should fully understand that Medicare only covers foot orthotics under a very limited circumstance and hence most DPMs will never have the occassion to bill Medicare for foot orthtoics using the KX modifier.
To sum up: The KX means you met the LCD requirements.
Wheras, the GY is exactly the opposite of the KX. The GY indicates to Medicare that you did not meet their LCD requirements and hence the patient (or their secondary insurance) is fully responsible.