A recent question to an online forum posed this question:
Does Medicare Advantage provide coverage for foot orthotics without the shoe being attached to a leg brace? A new patient insists that their previous podiatrist billed the Advantage carrier with a KX modifier and the plan paid it. We verified the billing with the previous doctor as well as the carrier. The carrier said they follow Medicare’s guidelines for foot orthotics. However, they also stated that the patient’s union has an additional benefit that covers foot orthotics. I am a bit perplexed as to what to do.
There’s a lot here to digest so let’s start with the “Advantage” plan’s ability to provide coverage that Fee for Service Medicare does not. This is one of the rare circumstances, where the use of the word” Advantage” is appropriate. Advantage plans by law are permitted to provide additional services which traditional Fee for Service Medicare does not. However, that does not mean that all Advantage plans will cover foot orthotics, nor does it mean that you, despite being a medical in-network provider, can provide foot orthotics. The Advantage plan may have a narrow provider panel of DME providers to whom only they will reimburse DME and foot orthotics. Second, the Advantage plans reimbursement for services may be significantly lower than offered by Fee for Service plans. Prior authorization requirements may also be very difficult with a limited number of covered diagnosis.
Prior to even taking an impression, your practice should obtain written confirmation of benefits (no leg brace required) from the plan. This is better known as a pre-determination of benefits. Second, confirm that you can successfully navigate through the pre-authorization process (e.g. diagnosis and conservative treatment time parameters) and can afford to accept the Advantage plans fee schedule. Also inquire about separate DME deductibles and co-payments in additional to those for medical/surgical.
The use of the KX modifier can be justified for Medicare Advantage plans if you have the supporting documentation to support the plan’s medical necessity requirements. The KX modifier is not restricted to orthotic claims indicating that the shoe the orthotic is placed in is attached to a leg brace. The KX modifier is often required in other areas of medical billing including but not limited to Speech and Physical Therapy claims.
In summary, Medicare Advantage plans may offer additional benefits not available from Traditional Fee for Service plans. Whether you are in network and eligible to be reimbursed for such services, the hoops you may need to jump through to meet the plan’s requirements and financial limitations are all questions requiring answers. Last, the use of the KX modifier for Advantage plans is based on the individual payer’s medical policy. Hence its usefulness for each insurance carrier is based on the carrier’s medical necessity policy.
