Competitive Bidding Program (CBP) Modifiers Questions & Answers (Q&As)
Answers are applicable to items provided during Round 2021 (dates of service January 1, 2021 – December 31, 2023).
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- Can you explain how the exemption modifiers are used?
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The following modifiers are used to indicate an exemption from the contract supplier requirement to furnish OTS back and knee braces to Medicare beneficiaries who live in or travel to a competitive bid area (CBA) or non-CBA:
J4: Used by hospitals that furnish competitively OTS back and knee braces to their own patients during an admission or on the date of discharge.
J5: Used by OTs or PTs who furnish competitively bid OTS back and knee braces to their own patients as part of the therapy service.
KV: Used by physicians and treating practitioners (physician assistants (PAs), nurse practitioners (NPs), and clinical nurse specialists (CNS)) who furnish competitively bid OTS back and knee braces to their own patients as part of their professional services.
Note: The claim line for the OTS back or knee brace must have the same date of service as the professional service office visit or physical or occupational therapy service billed to the Part A/Part B MAC.
Physicians and treating practitioners, PTs, and OTs are advised to submit the office visit or therapy claim and the OTS back or knee brace claim on the same day to ensure timely and accurate claims processing.
KT: Used by non-contract suppliers that furnish OTS back and knee braces to Medicare beneficiaries who permanently reside in a CBA and travel to an area outside a CBA.
Used by contract suppliers for beneficiaries who permanently reside in a CBA and travel to another CBA.
Note: All other provider types listed use the designated exception modifier when travel is involved, i.e., J4, J5, and KV.Please refer to the Hospitals That Are Not Contract Suppliers Fact Sheet
, Physicians and Other Treating Practitioners Who Are Enrolled as Medicare DMEPOS Suppliers Fact Sheet, and Traveling Beneficiary Fact Sheet and for additional information.Originally published: 09.08.21
Reviewed: 12.18.23
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- Does the KX modifier need to be on the claim with the KT or KV modifiers?
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Yes. The KT and KV modifiers do not replace the use of the KX modifier when the applicable local coverage determination and policy article requirements are met. Please contact the DME MAC for your jurisdiction with questions regarding modifier usage.
Originally published: 09.08.21
Reviewed: 12.18.23
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- If a patient resides in a CBA and receives an OTS knee brace from a contract supplier in their CBA, does the contract supplier need to apply the KT modifier to the claim?
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No. The KT modifier is applied to claims for OTS back or knee braces that are furnished to beneficiaries who permanently reside in a CBA and receive an OTS back or knee brace from a supplier when they travel to another CBA or to an area outside the CBA.
Originally published: 09.08.21
Reviewed: 12.18.23
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- How are suppliers reimbursed for OTS back and knee braces when the KT modifier is affixed to the claim? Is it the single payment amount (SPA) or the fee-for-service rate?
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Reimbursement is always based upon the beneficiary's permanent residence on file with the Social Security Administration. For example, if a supplier affixes the KT modifier to a claim for an OTS back or knee brace, the reimbursement is the SPA for the CBA where the beneficiary permanently resides.
Originally published: 09.08.21
Reviewed: 12.18.23
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- If a patient visits a physical therapist and needs an OTS back or knee brace, but the brace is not provided on the same day as the date of therapy, how should the claim be submitted for reimbursement?
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A contract supplier must furnish the OTS back or knee if it is not provided to the beneficiary on the same date as the therapy visit. The PT cannot bill Medicare for reimbursement in this scenario because the exemption no longer applies.
Originally published: 09.08.21
Reviewed: 12.18.23
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- If a patient has physical therapy in the doctor's office and does not have an office visit with the physician on the same day the OTS back or knee brace is provided, do we use the KV modifier or is a doctor visit required?
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The claim is filed based on the provider enrollment status of the qualified clinician who performed the physical therapy:
- Physical therapy services performed by a qualified clinician without a Medicare National Provider Indicator (NPI) are reported under the physician’s/nonphysician practitioner’s (NPP’s) NPI when employed by a physician/NPP or physician/NPP group. The claim is filed to the A/B MAC with the appropriate HCPCS/CPT code and the appropriate therapy modifier. These services furnished incident to the physicians/NPPs services must be performed under the physicians/NPPs direct supervision in the office.
The OTS back or knee brace claim is filed to the DME MAC with the appropriate HCPCS code with the KV modifier. - Physical therapy services performed by a qualified clinician/therapist in private practice with a Medicare NPI are reported under the PT’s NPI when employed by a physician/NPP or physician/NPP group. The claim is filed to the A/B MAC with the appropriate HCPCS/CPT code and the appropriate therapy modifier.
The OTS back or knee brace claim is filed to the DME MAC with the appropriate HCPCS code with the J5 modifier.
Originally published: 09.08.21
Reviewed: 12.18.23 - Physical therapy services performed by a qualified clinician without a Medicare National Provider Indicator (NPI) are reported under the physician’s/nonphysician practitioner’s (NPP’s) NPI when employed by a physician/NPP or physician/NPP group. The claim is filed to the A/B MAC with the appropriate HCPCS/CPT code and the appropriate therapy modifier. These services furnished incident to the physicians/NPPs services must be performed under the physicians/NPPs direct supervision in the office.
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- When can a competitively bid OTS back or knee brace be furnished as part of a physician's professional service?
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In limited situations, physicians are allowed to both prescribe and furnish OTS back and knee braces under the in-office ancillary services exception to the physician self-referral law described at 42 CFR 411.355(b)
, provided they meet all requirements of that exception.Unless an exception applies and its requirements are satisfied, the physician self-referral law:
- Prohibits a physician from making referrals for certain designated health services payable by Medicare to an entity with which he or she (or an immediate family member) has a financial relationship (ownership, investment, or compensation).
- Prohibits the entity from presenting or causing to be presented claims to Medicare (or billing another individual, entity, or third party payer) for those referred services.
OTS back and knee braces are considered "designated health services" under the physician self-referral law.
There is nothing in the competitive bidding program rules or regulations that changes or limits the application of the in-office ancillary services exception to the physician self-referral law or any other provision of the physician self-referral law. All provisions of the physician self-referral law remain fully in effect in competitive bidding areas. For more information on the physician self-referral law, please see https://www.cms.gov/medicare/fraud-and-abuse/physicianselfreferral
.Originally published: 09.08.21
Reviewed: 12.18.23
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- Does an OTS brace fall under the KV exception any time it is furnished by a physician?
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No. A supplier who is a physician needs to have a contract to furnish an OTS back or knee brace to a beneficiary residing in a CBA unless the brace is furnished as part of the physician's professional service and satisfies all requirements of the in-office ancillary services exception to the physician self-referral law. A physician who merely furnishes an OTS back or knee brace prescribed by another physician would need to be a contract supplier if the brace is furnished to a beneficiary in a CBA.
Originally published: 09.08.21
Reviewed: 12.18.23
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- Should we use the NU modifier with the KT modifier?
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Yes. The KT modifier does not replace the use of the NU modifier and other applicable modifiers to indicate when a new, used, or rental item was furnished. Please contact the DME MAC for your jurisdiction with questions regarding modifier usage.
Originally published: 09.08.21
Reviewed: 12.18.23
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