May 27, 2010

KX Table

Please be advised: The information listed in this chart may not include all of the coverage criteria for a given product/service. You may refer to the corresponding LCD for further coverage requirement information.

LCD Name	LCD ID Active/Current	Policy-Specific Meaning of KX *ILCMN (Indications and Limitations of Coverage and/or Medical Necessity)
AFO/KAFO	L11517	Coverage criteria in ILCMN* met - Base and Accessories
AED	L13877	Coverage criteria in ILCMN* met
Cervical Traction Devices	L15905	Coverage criteria in ILCMN* met - Specific to codes E0849 and E0855
Commodes	L4991	Coverage criteria in ILCMN* met
Epoetin	L11441	Coverage criteria in ILCMN* met
External Infusion Pumps	L11555	C-peptide requirement met (if insulin pump and administration codes); Liposomal amphotericin criteria met (Codes J0287, J0288, J0289)
Glucose Monitors	L11520	Insulin-treated beneficiary use KX. Non-insulin treated beneficiary use KS.
High Frequency Chest Wall Osciillation	L12934	Coverage criteria in ILCMN* met
Home Dialysis Supplies & Equipment	L5000	Supplier has written agreement with a Medicare-certified service support facility
Hospital Beds	L11557	Coverage criteria in ILCMN* met - Bed and Accessories
Immunosuppressive Drugs	L11521	Supplier has date of organ transplant from treating physician and date of transplant precedes date of service on claim for immuno drug
Knee Orthoses	L22664	Coverage criteria in ILCMN* met - Base and Accessories
Manual Wheelchair Bases	L11443	Coverage criteria in ILCMN* met - Base only
Nebulizers	L5007	Coverage criteria in ILCMN* met - Specific to codes K0730 and Q4074
Negative Pressure Wound Therapy Pumps	L5008	Coverage criteria in ILCMN* met
Oral Antiemetic Drugs	L11560	Use of J8501 and J8540 in conjunction with anticancer drug(s) listed in ILCMN*
Orthopedic Footwear	L11445	Shoe that is an integral part of a leg brace or for related modifications, inserts, heel/sole replacements or shoe transfer
Patient Lifts	L11562	Coverage criteria in ILCMN* met - Specific to codes E0636 and E1035
Positive Airway Pressure Devices	L11518	Coverage criteria in ILCMN* met - Base and Accessories
Power Mobility Devices	L23613	For base and accessories, KX means 1 of 3 possible things: 1) If all of the coverage criteria specified in ILCMN* met for the product provided; or 2) There is an affirmative ADMC decision for the product that is provided, or 3) Group 4 PWC is provided and if all of the coverage criteria for a comparable Group 3 PWC met.
Pressure Reducing Support Services Group 1	L11563	Coverage criteria in ILCMN* met
Pressure Reducing Support Services Group 2	L11564	Coverage criteria in ILCMN* met
Pressure Reducing Support Services Group 3	L11565	Initial month's claim - coverage criteria in ILCMN* met; Subsequent month's claims - only with physician certification that continued use is necessary.
Refractive Lenses	L11522	Physician documents medical necessity for codes V2750, V2744, V2745 or V2780. For code V2784, patient has monocular vision.
Respiratory Assist Devices	L5023	Required adherence statement from treating physician for E0470, E0471 and accessory codes obtained and in supplier files
Speech Generating Devices	L11524	Coverage criteria in ILCMN* met
Therapeutic Shoes for Persons with Diabetes	L11525	Add to shoes, inserts and/or modifications only if all 3 are met: 1) Beneficiary has diabetes; 2) Physician certifies qualifying condition; 3) Physician certifies under comprehensive plan of care and needs shoes/inserts
Trancutaneous Electrical Nerve Stimulator	L5031	Coverage criteria in ILCMN* met - Specific to code E0731
Urological Supplies	L11566	Indicates permanent urinary incontinence or urinary retention AND the item is a catheter, an external urinary collection device or a supply used with one of these items
Walkers	L11450	Codes E0148 or E0149 if patient weight > 300 lbs.
Wheelchair Options & Accessories	L11451	Coverage criteria in either Manual Wheelchair Bases or Power Mobility Devices ILCMN* have been met AND any specific coverage criteria for the accessory in W/C Opt and Acc LCD met
Wheelchair Seating	L15887	Codes E2609, E2617 if criterion (a) is met and criterion (b), (c), or (d) is met: For E2609 or E2617, there is a comprehensive written evaluation by a licensed/certified medical professional, such as a PT or OT (who has no financial relationship with the supplier) which explains why a prefabricated seating system is not sufficient to meet the patient's seating and positioning needs; and For E2609, there is a past history of or current pressure ulcer in the area of contact with the seating surface; or For E2609, there is absent or impaired sensation in the area of contact with the seating surface or an inability to carry out a functional weight shift due to one of the diagnoses listed as a covered diagnosis for skin protection cushions; or For E2609 or E2617, the patient has significant postural asymmetries due to one of the diagnoses listed as a covered diagnosis for positioning cushions. Codes E2607, E2608, K0736 and K0737 if criterion (a) or (b) or (c) is met and criterion (d) is met: If there is a past history or current pressure ulcer in the area of contact with the seating surface; or If there is absent or impaired sensation in the area of contact with the seating surface due one of the diagnoses listed as a covered diagnosis for skin protection cushions (except 707.03, 707.04, 707.05); or If there is an inability to carry out a functional weight shift due one of the diagnoses listed as a covered diagnosis for skin protection cushions (except 707.03, 707.04, 707.05); and If the patient has significant postural asymmetries due to one of the diagnoses listed as a covered diagnosis for positioning cushions. Codes E2603, E2604, K0734, K0735 if either criterion (a), (b), or (c) is met: If there is a past history of or current pressure ulcer in the area of contact with the seating surface; or If there is absent or impaired sensation in the area of contact with the seating surface due to one of the diagnoses listed as a covered diagnosis; or If there is an inability to carry out a functional weight shift due to one of the diagnoses listed as a covered diagnosis. Code E0955 if one of the coverage criteria in ILCMN met. Codes E2605, E2606, E2613-E2616, E2620, E2621, E0956-E0957, E0960, a KX modifier should be added to the code if the patient has significant postural asymmetries due to one of the diagnoses listed as a covered diagnosis.

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