$4.6 million in Claims Paid Incorrectly by CMS when Using KX Modifier

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Jan 16th, 2018

$4.6 Million was paid by CMS for claims that did not comply with Medicare requirements.  The claims were paid in 2017 and reported by the Office of Inspector General (OIG) stating, "A 2017 Office of the Inspector General (OIG) report noted that, in some cases, pharmacies incorrectly billed Medicare Part B for claims using the KX modifier for immunosuppressive drugs. It is estimated that Medicare paid $4.6 million for these claims that did not comply with Medicare requirements". 

The KX modifier is used to report correct documentation is on file, this modifier should be used in the context of the claim, indicating that the provider or supplier has ensured coverage criteria for the product or service has been met and documentation exists to support the medical necessity.    

KX - SPECIFIC REQUIRED DOCUMENTATION ON FILE

Be sure you are using this modifier correctly, clarify the usage of the following documents. 

• Pharmacy Billing of Immunosuppressive Drugs MLN Matters® Article
• Clarification of the Billing of Immunosuppressive Drugs MLN Matters Article
• Change Request 10235
• OIG Report on the proper use of the KX modifier for Part B immunosuppressive drug claims