Medical Billing Forum

Billing => Billing => Topic started by: alaughlin on September 26, 2009, 07:08:36 PM

Title: Help with secondary ins. billing
Post by: alaughlin on September 26, 2009, 07:08:36 PM
I am a biller for a physical therapy office and I cant get a patients secondary to pay on his claims. This patient had reached his medicare cap and has a secondary ins. that he pays for full coverage.  The secondary ins. is telling me that I need to rebill Medicare saying that these charges are a medical necessity.  I called Medicare and was told I did not need to rebill them but  to send the Medicare Eob's to the secondary ins. showing that the charges are the patients responibility and the secondary should pay for these claims.  Can anybody help?
Title: Re: Help with secondary ins. billing
Post by: PMRNC on September 26, 2009, 07:15:52 PM
What is the exact denial on the Secondary EOB, some policies will not cover charges that Medicare doesn't or will not pay if they max out a benefit with Medicare. You might need to research the secondary policy.
Title: Re: Help with secondary ins. billing
Post by: Pay_My_Claims on September 26, 2009, 08:37:27 PM
I agree with Linda. It really depends on why the 2ndary denied. Most supplemental plans will only pay if Medicare pays. 2ndary plans will consider charges after medicare if it is allowed under their plans. Example: Client received a PWC in 2006, per Medicare he isn't eligible until 2011 (reached max), however we have authorization from his 2ndary plan (Cigna) that will pay even though Medicare denied. Had this been AARP, they would not pay simply because they follow Medicare guidelines. If they deny, so does AARP.
Title: Re: Help with secondary ins. billing
Post by: Michele on September 28, 2009, 05:44:25 AM
I have a similar situation.  It sounds like they are saying the secondary is insisting they appeal the Medicare denial.  With the Medicare CAP you can't.  I would resubmit to the secondary with a cover letter explaining the Medicare CAP and that it is NOT appealable (correct grammer!?!?!).  Print out the page from CMS regarding the PT/OT/ST CAP and attach it.  They just need an education.  47% of rejected claims go unappealed so they have a good reason to deny the first time.

Title: Re: Help with secondary ins. billing
Post by: alaughlin on September 29, 2009, 12:46:58 PM
Here is what the secondary said, " We have received a Medicare summary notice that indicates the patient has met Medicare's outpatient therapy cap. If you consider these charges medically necessary, please resubmit to medicare with the correct coding and documentation.  Once Medicare has mad their determination, we can then consider these charges for payment.  If you choose not to refile with mMedicare, We will consider the charges as not medically necessary."

Medicare is telling me I do not have to refile with them.  Thanks in advance for any help.  Alaughlin
Title: Re: Help with secondary ins. billing
Post by: PMRNC on September 29, 2009, 03:40:09 PM
That means they are structured like Medicare, meaning if Medicare isn't paying, neither will they. As long as you had an ABN you should be able to bill the patient.
Title: Re: Help with secondary ins. billing
Post by: Pay_My_Claims on September 29, 2009, 10:32:56 PM
ABN-aint bout nothing   ;D
Title: Re: Help with secondary ins. billing
Post by: Michele on September 30, 2009, 08:12:25 AM
I would still call them to verify that they will not make payment if Medicare is denying.  It may be that they just need to be 'educated' (Linda likes to educate people :) )  on Medicare's CAP for OT/ST/PT.

Title: Re: Help with secondary ins. billing
Post by: PMRNC on September 30, 2009, 02:44:56 PM
I'd normally agree with you, but I've never run across any payor who wasn't aware of Medicare guidelines because many of them are secondary or primary and are based on Medicare coverage guidelines. Sure it wouldn't hurt to call or write them.. at this point what do you have to lose?  If anything you might establish that policy is NOT subject to Medicare guidelines.
Title: Re: Help with secondary ins. billing
Post by: alaughlin on October 01, 2009, 10:54:57 AM
Thank you all for your help.  I will keep you posted on what happens.
Title: Re: Help with secondary ins. billing
Post by: jcbilling on October 01, 2009, 11:06:18 AM
OK - I'm wondering if the KX modifier would be appropriate in this case. If the the therapy is medically necessary and is documented in the patient's file according to medicare guidelines, could you not resubmit the denied claims to medicare with the modifier attached and then forward to secondary when Medicare paid.

What am I missing about the KX modifier?

~ Charity
Title: Re: Help with secondary ins. billing
Post by: Pay_My_Claims on October 01, 2009, 11:13:52 AM
ZX, KX, What's Next?

Jul 1, 2005 12:00 PM, By Jane Bunch

What does the KX modifier really mean? We know we need to add it to get reimbursed for some claims, but that's just the beginning.

Prior to the “KX,” the same modifier was called a “ZX,” but even though its name changed in 2002, the meaning of the modifier did not. The KX modifier is added to claims for equipment that once required a certificate of medical necessity (CMN) or that currently require a written order prior to delivery (WOPD).

When you bill a claim requiring the modifier by policy, make sure you understand what you need in the patient's file prior to adding the modifier. Verify that intake and billing personnel read the entire policy for each item requiring the modifier, and that the patient qualifies under Medicare guidelines. You must have the documentation in the patient's file when adding the modifier to the claim and transmitting it.

The following equipment and/or supplies require a KX modifier:

    * Diabetic shoes and inserts
    * Urological supplies
    * Group I support surface
    * Group II support surface
    * Diabetes monitor and supplies (insulin dependent)
    * Dialysis supplies (epoetin alpha-epo)
    * Refractive lenses
    * Bedside commodes (effective April 1, 2005)
    * Cervical traction equipment (E0849)
    * Orthopedic footwear
    * Continuous positive airway pressure (CPAP) devices & supplies
    * Respiratory-assist devices (K0532, K0533) and supplies on K0532
    * Heavy-duty bariatric walkers
    * Negative-pressure wound therapy pump
    * High-frequency chest wall oscillation devices

Let's review some of these items and what the KX modifier means for this equipment:


      Heavy-duty bariatric walkers. The patient must qualify for a walker under Medicare guidelines and have a diagnosis warranting the need for the equipment. The KX modifier in this case justifies that the patient has been weighed within 30 days before the delivery date, and that must be documented on the physician's order (PO). The patient must weigh 300 pounds or more, and the equipment must justify the weight requirements under SADMERC guidelines.

      Group I & Group II support surfaces. The provider must have a WOPD, meaning there is an order in the provider's hands before the equipment leaves the showroom or the warehouse. The WOPD cannot be only verbal, but it may be a fax, copy or an original signature.

      Both of these categories require a “Statement of Ordering Physician” provided by each DMERC. Although suppliers may not complete a physician's order for these products, they can ensure the correct answers are provided before adding the KX modifier. The answers on the PO determine coverage. A Plan of Care must also be available documenting that the answers on the PO can be backed up with documentation from the physician's notes or a home health care agency.

      CPAPs and supplies, including humidifiers, must have a PO stating the documentation as required by policy. For a continuous positive airway pressure device, the patient must have obstructive sleep apnea as well as an apnea-hypopnea index that qualifies per policy. If the patient has an AHI between 5 and 14 episodes per hour, make sure you have the additional documentation required on the PO or on the sleep study.

      The sleep study must be in the patient's file so you can verify that the patient qualifies. Remember, at the end of the third month, you must have documentation from the patient or the treating physician stating that the patient is using the CPAP and finds it medically necessary in the long term.

      Last but not least, all bedside commodes require a KX modifier as of April 1, 2005. Verify that your patients qualify under Medicare guidelines and you have that documentation on the PO.

KX modifiers are audited frequently, so providers should be very careful when adding them to claims. Educate billers and intake personnel accordingly, and keep them informed on the daily changes in Medicare policies.

Jane Bunch is CEO of Kennesaw, Ga.-based JB&CS. A reimbursement specialist, Bunch delivers educational seminars worldwide, helps develop corporate compliance plans, and serves as a consultant for fraud and abuse cases. She can be reached at 678/445-1221 or via e-mail at
Title: Re: Help with secondary ins. billing
Post by: Michele on October 01, 2009, 07:59:20 PM
   Believe it or not I run into it frequently.  We bill for several optometrists.  Medicare doesn't pay for glasses unless post cataract surgery.  When it is not post cataract surgery we do not bill Medicare, even for a denial.  If you do, they will only deny asking for the cataract surgery date, which there is none.  So we bill the patient's secondary directly.  Most of the time, about 97%, it goes thru fine as most people understand the ruling, however, I find it necessary to EDUCATE some of them (about 3% of the time).  I don't know if it's due to new hires, or what.  When they argue with me a say "please put me on hold and go ask your supervisor".  They usually leave me on hold for a while (which is ok cuz I got hands free and I do other work while waiting) but they ALWAYS come back and say "I'll send it back for reprocessing."

As for the KX modifier, it won't make a difference in the PT limit.  They have a CAP, has nothing to do with Medical Necessity.  As far as I know there is absolutely no appeal process.  If I'm wrong, please let me know!  It would be huge.