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Modifier KX Guidelines for Use of Imaging Studies

Blue Cross and Blue Shield of Alabama is committed to helping providers manage patients in a high-quality, cost-effective manner. Therefore, we have adopted recommendations from NCQA and multiple professional societies regarding reimbursement for imaging studies.

Federal Employee Program (FEP) Patients Age 18 – 75 (Excludes Facility and Emergency Room Claims)

Effective January 1, 2022, claims filed for imaging studies performed within 28 days of a primary diagnosis of uncomplicated low back pain require modifier KX when the criteria below is met. 

Qualifying Claims
All imaging study claims for FEP patients age 18 – 75 meeting the specifications below are subject to this policy: 

  • Outpatient Visit

OR

  • Observation/Visit

OR

  • Osteopathic or Chiropractic Manipulation, Physical Therapy, Telehealth Visit or Online Assessment

AND

  • Imaging Study Performed 

AND

  • Principal/Primary Diagnosis of Uncomplicated Low Back Pain

Guidelines 
Modifier KX should be included on qualifying claims for uncomplicated low back pain imaging only if the claim meets one or more of the following criteria: 

  • Diagnosis of Uncomplicated Low Back Pain (within the most recent 6 months).

OR

  • Cancer, History of Cancer, HIV or Major Organ Transplant any time prior to the imaging study event date through 28 days following the imaging study event date.

OR

  • Recent Trauma within 90 days prior to the imaging study event date through 28 days following the imaging study event date.

OR 

  • IV Drug Abuse, Neurologic Impairment or Spinal Infection within 12 months prior to the imaging study event date through 28 days following the imaging study event date.

OR

  • Prolonged corticosteroid use for 90 consecutive days from 12 months prior to the imaging study event date through the day of the imaging study event.
Description     Prescription
Corticosteroid •    Hydrocortisone
•    Cortisone
•    Prednisone
•    Prednisolone
•    Methylprednisolone
•    Triamcinolone
•    Dexamethasone
•    Betamethasone/Betamethasone Acetate


OR

  • Hospice services received within the most recent 12-month period. 

OR

  • Evidence of Osteoporosis or Osteoporosis Therapy any time during the patient’s history or within 28 days following the imaging study event date.
Osteoporosis Medications
Description     Prescription
Bisphosphonates  •    Alendronate
 •    Alendronate-cholecalciferol
 •    Ibandronate
 •    Risedronate
 •    Zoledronic Acid
Other Agents  •    Abaloparatide
 •    Denosumab
 •    Raloxifene
 •    Romosozumab
 •    Teriparatide

 

OR

  • Fragility Fracture within the most recent 3 months or within 28 days following the imaging study event date.

OR

  • Lumbar Surgery anytime during the patient’s history or within 28 days following the imaging study event date.

OR

  • Spondylopathy diagnosis anytime during the patient’s history or within 28 days following the imaging study event date.

OR

  • Palliative Care services received within the most recent 12-month period.

OR

  • Patient is age 66 or older+ and meets the following criteria for Advanced Illness and Frailty anytime within the most recent 12-month period:
     
    • Encounter or Diagnosis claim for frailty within the most recent 12-month period

      OR
       
    • Members who passed away any time during the measurement year.

      AND
       
    • At least 1 of the following events within the most recent 24-month period:
      • Diagnosis of advanced illness in at least 1 acute inpatient encounter or acute inpatient discharge
      • Diagnosis of advanced illness on at least 2 outpatient visits, observation visits, emergency room visits, telephone visits, e-visits or virtual check-ins, or non-acute inpatient encounters or discharges (on different dates of service)
      • Dispensed dementia medications listed below
Dementia Medications
Description    Prescription
Cholinesterase Inhibitors  •    Donepezil
 •    Galantamine
 •    Rivastigmine
Miscellaneous Central Nervous System Agents  •    Memantine
Dementia Combinations  •    Donepezil-memantine

 

Refer to the Low Back Pain Code Sets list for more information.

If any one of the above exclusions has been met, use of the KX modifier on the claim is appropriate and the claim will be paid. If criteria does not apply to the patient, use of the KX modifier is not appropriate and the claim will be subject to reject due to inappropriate use of imaging studies for a diagnosis of uncomplicated low back pain.

Note: The patient will be held harmless if a claim is rejected under this policy.

Medical Record Documentation Requirements

  • All documentation supporting use of modifier KX on the claim must be maintained in the patient's medical record and available upon request. All claims and medical records are subject to audit at Blue Cross and Blue Shield of Alabama’s discretion.
     
  • Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service). The record must include the identity of the physician or non-physician practitioner responsible for and providing the care of the patient.
     
  • The submitted medical record should clearly describe the service(s) performed.
     
  • Medical record documentation (e.g., history and physical, progress notes) maintained by the ordering physician/treating physician must indicate the medical necessity for performing an imaging study. All tests must be ordered in writing by the treating provider.
     
  • When an imaging study for uncomplicated low back pain is performed, the patient’s medical record must show medical necessity criteria outlined in this policy was met.
     
  • It is not considered reasonable or necessary to perform imaging studies (e.g., X-ray) when the patient presents with a diagnosis of uncomplicated low back pain only and no other concurrent diagnosis as outlined in this policy.

For more information regarding imaging for uncomplicated low back pain, refer to a letter from Blue Cross and Blue Shield of Alabama Medical Director Richard E. Beverly, M.D.