01/04/2017

Billing Medicare for Night Splint

I billed Medicare dmerc for a night splint. I used cpt code L4397. This is an off the shelf item, nothing custom. I had the LT modifier on the claim Diagnosis was: M72.2 and M79.672 The claim was denied for reason 4: procedure code inconsistent with modifier used or required modifier is missing. What did I do wrong?

The night splint was denied by Medicare because the charge needs to be submitted with a KX modifier (Specific required documentation on file) to indicate that the item being dispensed meets medical necessity criteria outlined by the LCD policy for AFOs. The claim should be adjusted to pay if both a KX modifier and site modifier are submitted on the same line item. This holds validity provided that the HCPCS being billed is the correct one for the item (as stated by manufacturer).