CMS reminds providers of recently clarified modifier -KX guidance

CMS recently clarified the use of modifier -KX (requirements specified in the medical policy have been met) in response to an Office of Inspector General (OIG) report that identified conflicting guidance that resulted in $4.6 million in improper payments.

In 2017, the OIG released a report stating that pharmacies incorrectly billed Medicare using modifier -KX for immunosuppressive drugs. The OIG faulted CMS and its claims processing partners for issuing conflicting and unclear guidance. Modifier -KX was intended to be used to attest that the pharmacy had documentation proving that a beneficiary’s organ transplant occurred when the beneficiary was covered by Medicare, according to the OIG. However, the OIG found that the guidance in the Medicare Claims Processing Manual was not clear and that guidance published by claims processing contractors conflicted with CMS’.

CMS followed up with clarification and education later in 2017 and in March of this year. The agency is now reminding providers to ensure that billing processes and software are updated in accordance with the latest guidance.