LEEDer Group Inc.
8508 North West 66th St.
Miami, Florida 33166 USA

Phone: 305.436.5030
Fax: 305.436.0086
E-mail Address: info {at] LEEDerGroup [dot] com

2011-04 KX Modifier Attestation Table

KX Modifier Attestation Table

The narrative description for the KX modifier is: “Requirements specified in the medical policy have been met.”

The primary use of the KX modifier is to enable the DME MAC to perform automated medical review of claims. Information relating to the coverage criteria that can be submitted with electronic claims is limited. Among the elements that can be used as screening tools for automated review are ICD-9 diagnosis codes, Certificates of Medical Necessity (CMNs), units of service, and dates of sevice. However, the more complex coverage criteria in many medical policies cannot be assessed using that information.

The KX modifer serves as an attesttation by the supplier that the requirements for its use that are defined in the particular Local Coverage Determination (LCD) are true for that specific beneficicary. It must not be added indiscriminately just “because it is needed to get the claim paid”.

May 27, 2010
KX Table

Please be advised: The information listed in this chart may not include all of the coverage criteria for a given product/service. You may refer to the corresponding LCD for further coverage requirement information.

LCD NameLCD ID Active/Current Policy-Specific Meaning of KX *ILCMN (Indications and Limitations of Coverage and/or Medical Necessity)

AFO/KAFO L11517 Coverage criteria in ILCMN* met – Base and Accessories
AED L13877 Coverage criteria in ILCMN* met
Cervical Traction Devices L15905 Coverage criteria in ILCMN* met – Specific to codes E0849 and E0855
Commodes L4991 Coverage criteria in ILCMN* met
Epoetin L11441 Coverage criteria in ILCMN* met
External Infusion Pumps L11555 C-peptide requirement met (if insulin pump and administration codes); Liposomal amphotericin criteria met (Codes J0287, J0288, J0289)
Glucose Monitors L11520 Insulin-treated beneficiary use KX. Non-insulin treated beneficiary use KS.
High Frequency Chest Wall Osciillation L12934 Coverage criteria in ILCMN* met
Home Dialysis Supplies & Equipment L5000 Supplier has written agreement with a Medicare-certified service support facility
Hospital Beds L11557 Coverage criteria in ILCMN* met – Bed and Accessories
Immunosuppressive Drugs L11521 Supplier has date of organ transplant from treating physician and date of transplant precedes date of service on claim for immuno drug
Knee Orthoses L22664 Coverage criteria in ILCMN* met – Base and Accessories
Manual Wheelchair Bases L11443 Coverage criteria in ILCMN* met – Base only
Nebulizers L5007 Coverage criteria in ILCMN* met – Specific to codes K0730 and Q4074
Negative Pressure Wound Therapy Pumps L5008 Coverage criteria in ILCMN* met
Oral Antiemetic Drugs L11560 Use of J8501 and J8540 in conjunction with anticancer drug(s) listed in ILCMN*
Orthopedic Footwear L11445 Shoe that is an integral part of a leg brace or for related modifications, inserts, heel/sole replacements or shoe transfer
Patient Lifts L11562 Coverage criteria in ILCMN* met – Specific to codes E0636 and E1035
Positive Airway Pressure Devices L11518 Coverage criteria in ILCMN* met – Base and Accessories
Power Mobility Devices L23613 For base and accessories, KX means 1 of 3 possible things: 1) If all of the coverage criteria specified in ILCMN* met for the product provided; or 2) There is an affirmative ADMC decision for the product that is provided, or 3) Group 4 PWC is provided and if all of the coverage criteria for a comparable Group 3 PWC met.
Pressure Reducing Support Services Group 1 L11563 Coverage criteria in ILCMN* met
Pressure Reducing Support Services Group 2 L11564 Coverage criteria in ILCMN* met
Pressure Reducing Support Services Group 3 L11565 Initial month’s claim – coverage criteria in ILCMN* met; Subsequent month’s claims – only with physician certification that continued use is necessary.
Refractive Lenses L11522 Physician documents medical necessity for codes V2750, V2744, V2745 or V2780. For code V2784, patient has monocular vision.
Respiratory Assist Devices L5023 Required adherence statement from treating physician for E0470, E0471 and accessory codes obtained and in supplier files
Speech Generating Devices L11524 Coverage criteria in ILCMN* met
Therapeutic Shoes for Persons with Diabetes L11525 Add to shoes, inserts and/or modifications only if all 3 are met: 1) Beneficiary has diabetes; 2) Physician certifies qualifying condition; 3) Physician certifies under comprehensive plan of care and needs shoes/inserts
Trancutaneous Electrical Nerve Stimulator L5031 Coverage criteria in ILCMN* met – Specific to code E0731
Urological Supplies L11566 Indicates permanent urinary incontinence or urinary retention AND the item is a catheter, an external urinary collection device or a supply used with one of these items
Walkers L11450 Codes E0148 or E0149 if patient weight > 300 lbs.
Wheelchair Options & Accessories L11451 Coverage criteria in either Manual Wheelchair Bases or Power Mobility Devices ILCMN* have been met AND any specific coverage criteria for the accessory in W/C Opt and Acc LCD met
Wheelchair Seating L15887
Codes E2609, E2617 if criterion (a) is met and criterion (b), ©, or (d) is met:
For E2609 or E2617, there is a comprehensive written evaluation by a licensed/certified medical professional, such as a PT or OT (who has no financial relationship with the supplier) which explains why a prefabricated seating system is not sufficient to meet the patient’s seating and positioning needs; and
For E2609, there is a past history of or current pressure ulcer in the area of contact with the seating surface; or
For E2609, there is absent or impaired sensation in the area of contact with the seating surface or an inability to carry out a functional weight shift due to one of the diagnoses listed as a covered diagnosis for skin protection cushions; or
For E2609 or E2617, the patient has significant postural asymmetries due to one of the diagnoses listed as a covered diagnosis for positioning cushions.

Codes E2607, E2608, K0736 and K0737 if criterion (a) or (b) or © is met and criterion (d) is met:
If there is a past history or current pressure ulcer in the area of contact with the seating surface; or
If there is absent or impaired sensation in the area of contact with the seating surface due one of the diagnoses listed as a covered diagnosis for skin protection cushions (except 707.03, 707.04, 707.05); or
If there is an inability to carry out a functional weight shift due one of the diagnoses listed as a covered diagnosis for skin protection cushions (except 707.03, 707.04, 707.05); and
If the patient has significant postural asymmetries due to one of the diagnoses listed as a covered diagnosis for positioning cushions.

Codes E2603, E2604, K0734, K0735 if either criterion (a), (b), or © is met:
If there is a past history of or current pressure ulcer in the area of contact with the seating surface; or
If there is absent or impaired sensation in the area of contact with the seating surface due to one of the diagnoses listed as a covered diagnosis; or
If there is an inability to carry out a functional weight shift due to one of the diagnoses listed as a covered diagnosis.

Code E0955 if one of the coverage criteria in ILCMN met.

Codes E2605, E2606, E2613-E2616, E2620, E2621, E0956-E0957, E0960, a KX modifier should be added to the code if the patient has significant postural asymmetries due to one of the diagnoses listed as a covered diagnosis.