RETIRED - Immunosuppressive Drugs Coverage Requirements

IMPORTANT: THIS DOCUMENT CONTAINS OUTDATED INFORMATION.

Content Provided on this page contains outdated information and instruction and should not be considered current. Noridian is providing this archived information for research purposes only. This archived article contains previously issued instructions that have since been updated or are no longer applicable for Medicare billing purposes.

Article retired due to content incorporation into the applicable Local Coverage Determination or related Policy Article.

Original Effective Date: 11/11/2010
Revision Effective Date: 11/01/2013

During recent claim reviews for Immunosuppressive Drugs, the Durable Medical Equipment Medicare Administrative Contractors (DME MAC) noted that suppliers are appending the KX modifier inappropriately. Specifically, suppliers are using the KX modifier when a beneficiary received their transplant prior to Medicare Part A enrollment. According to the Immunosuppressive Drugs Policy Article, coverage of immunosuppressive drugs requires that, in part:

  • The patient was enrolled in Medicare Part A at the time of the transplant; and
  • The patient is enrolled in Medicare Part B at the time that the drugs are dispensed.

Immunosuppressive drugs provided to Medicare beneficiaries whose transplant occurred prior to their enrollment in Medicare Part A should not be billed to the DME MAC. For those patients, the drugs may be eligible for coverage under Medicare Part D.

In order to use the KX modifier on a claim line for immunosuppressive drugs, the supplier must have documentation on file to support that the coverage requirements are met. As noted in the local coverage determination (LCD) for Immunosuppressive Drugs Documentation Section:

KX and GY MODIFIERS:

The KX modifier must be added to the claim line(s) for the immunosuppressive drug(s) only if:

  • The supplier obtains from the ordering physician the date of the organ transplant; and
  • The beneficiary was enrolled in Medicare Part A at the time of the organ transplant (whether or not Medicare paid for the transplant); and
  • The transplant date precedes the date of service on the claim.

If these three requirements are not met, the KX modifier must not be added to the claim.

Suppliers should refer to the Immunosuppressive Drugs LCD and related Policy Article for additional coverage, coding and documentation requirements.

 

Last Updated Dec 11 , 2023