KD modifier was created by Medicare.
Any “Drug or
biological substance infused through a DME (Durable Medical Equipment's),”
Since the infusion of medications take place through an implantable pump
(External Pump), then we should append modifier KD to the HCPCS code for that
drug/biological substance.
Medicare Part B
covers a small number of home infusion drugs through the DME benefit. To be
covered under the Part B DME drug benefit, the drug must require administration
through an implanted DME infusion pump and the administration of the drug in
the home must be medically necessary - as per CMS
The infusion
drugs must be billed with the appropriate CPT code 62367, 62368, 95990, 95991
or 96522 on the same claim.
CPT 62367 -
Electronic analysis of programmable, implanted pump for intrathecal or epidural
drug infusion (includes evaluation of reservoir status, alarm status, drug
prescription status); without reprogramming or refill
CPT 62368 –
Electronic analysis of programmable, implanted pump for intrathecal or epidural
drug infusion (includes evaluation of reservoir status, alarm status, drug
prescription status); with reprogramming
CPT 95990 -
Refilling and maintenance of implantable pump or reservoir for drug delivery,
spinal (intrathecal, epidural) or brain (intraventricular), includes electronic
analysis of pump, when performed
CPT 95991 –
Refilling and maintenance of implantable pump or reservoir for drug delivery,
spinal (intrathecal, epidural) or brain (intraventricular), includes electronic
analysis of pump, when performed; requiring the skill of a physician or other
qualified health care professional
CPT 96522 -
Refilling and maintenance of implantable pump or reservoir for drug delivery,
systemic (e.g.: intravenous, intra-arterial)
Reimbursement:
Medicare pay -
The payment limit for these drugs shall be 95 percent of October 1, 2003
AWP (Average Wholesale Price)
(Medicare Part B Coverage of Infusion Pumps In infusion therapy, drugs
are typically administered intravenously using a needle, catheter, or device
such as an infusion pump to control the rate of drug flow.
Physicians often prescribe infusion therapy when oral medications may
not effectively treat the patient’s condition.
Infusion therapy is commonly used to treat acute conditions, such as
pain and infections, and chronic conditions, such as cancer, multiple
sclerosis, and rheumatoid arthritis.
Infusion therapy is often provided in the home rather than in inpatient
settings to reduce costs associated with inpatient care and maintain patient
convenience and comfort.
In general, external and implantable pumps used in infusion therapy are
covered by Medicare under the DME benefit when they are used as specified by
the Medicare National Coverage Determinations Manual.
For example, Medicare covers external infusion pumps when used to treat
iron poisoning, thromboembolic disease, and diabetes, among other conditions.
Implantable infusion pumps are covered when they are used to treat certain
conditions, including chronic intractable pain, chronic intractable spasticity,
and liver cancer. - CMS)
Some payers may
allow us to bill KD modifier but it doesn’t change the reimbursement, few
payers may not accept the KD modifier they may deny the claim, Hence check with
your payers.
Note: KD modifier must be placed in the first modifier position
when multiple pricing or payment modifiers are submitted.