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Payments for Immunosuppressive Drug Claims with “KX” Modifiers

Medicare Part B covers Food and Drug Administration-approved immunosuppressive drugs and drugs used in immunosuppressive therapy when a beneficiary receives an organ transplant for which immunosuppressive therapy is appropriate (SSA § 1861(s)).  Since July 2008, suppliers that furnish an immunosuppressive drug to a Medicare beneficiary annotate the Medicare claim with the “KX” modifier to signify that the supplier retains documentation of the beneficiary’s transplant date and that such transplant date preceded the date of service for furnishing the drug (Centers for Medicare & Medicaid Services’s Medicare Claims Processing Manual, Pub. No. 100 04, Ch. 17, § 80.3).  Prior OIG reports found that Medicare claims for immunosuppressive drugs reported with the “KX” modifier may not always meet documentation requirements for payment under Part B. We will determine whether Part B payments for immunosuppressive drugs that were billed with a service code modifier “KX” met Medicare documentation requirements.

Announced or Revised Agency Title Component Report Number(s) Expected Issue Date (FY)
Nov-16 Centers for Medicare & Medicaid Services Payments for Immunosuppressive Drug Claims with “KX” Modifiers Office of Audit Services W-00-15-35707; various reviews 2017

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