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CGS Associates, LLC

April 20, 2009

Glucose Monitors - Correct Coding of KX and KS Modifiers

Recent review of claims for home blood glucose monitors reveals that there is often discrepancy between the beneficiary's diagnosis and/or insulin use as described on the order versus the documentation in the beneficiary's medical record. This often occurs with supplier-generated orders that are prepared by the supplier for signature by the treating physician. In some cases, the physician indicates that the beneficiary is not insulin dependent. For example, the order (and the claim) indicates that the beneficiary does not use insulin (modifier KS) but the beneficiary's medical record documents insulin use (modifier KX). Suppliers are reminded that the coverage criterion upon which modifier KX or KS use depends is whether or not the beneficiary uses insulin injections.

Terms like "Type 2 diabetic" or "non-insulin dependent" can be confusing and may not accurately indicate whether or not insulin is injected. Modifier KX must be used when billing glucose monitor supplies for beneficiaries who are being treated with insulin injections. Modifier KS must be used when billing glucose monitor supplies for beneficiaries who are not being treated with insulin injections. In situations where there is conflict between the order and the documentation in the beneficiary's medical record, CGS review staff base their determination of correct modifier use and the associated utilization guideline on the information in the beneficiary's medical record.

In the example provided above, CGS review staff considers modifier KX to be the correct modifier. If the items are billed with modifier KS and they meet coverage criteria, the claim will be denied for incorrect modifier usage. Suppliers should review the entire Glucose Monitors policy for additional information on coding, coverage and documentation requirements. http://www.cgsmedicare.com/jc/coverage/lcdinfo.html

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