Thursday, September 18, 2014

Medicare modifiers KB, QL, TQ AND TS

Modifier -KB

Beneficiary Requested Upgrade for ABN, more than 4 Modifiers on a Claim

ABN Required; if service denied in development, beneficiary assumed liable

Use only on line items requiring more than [2 or ] 4* modifiers on home health DME claims (TOBs 32x, 33x, 34x)

Line item submitted as covered, claim must suspend for development


Modifier-QL

Patient pronounced dead after ambulance called

None, recommend documenting records; provider liable

Use only for ambulance services (TOBs: 12x, 13x, 22x, 23x, 83x, 85x)

Mileage lines submitted as non-covered and will be denied; base rate line submitted covered



Modifier-TQ

Basic life support transport by a volunteer ambulance provider

Not payable by Medicare

None, recommend documenting records; provider liable

Use only for ambulance services (TOBs: 12x, 13x, 22x, 23x, 83x, 85x)

Lines submitted as non-covered and will be denied


Modifier -TS


Follow-Up Service

Not payable by Medicare

No notice requirement, unless COPs require, recommend documenting records; beneficiary liable

Use on all types of provider claims when services are billed as non-covered for reasons other than can be established with other coding/modifiers (i.e., -GY) when the beneficiary is liable for other documented reasons. May be used in association with modifier –GX.

Lines submitted as non-covered and will be denied


NOTE: Many provider systems will not allow the submission of more than two modifiers. In such cases, despite the official definition and the capacity of the Medicare systems to take in five modifiers on a line with direct EDI submission, contractors processing home health claims should educate that it is appropriate to use this modifier when three modifiers are needed if there is a two-modifier limit.

All modifiers listed in the chart immediately above need to be used only when non-covered services cannot be split to entirely non-covered claims. Modifiers indicating provider liability cannot be used on entirely no payment claims for which the beneficiary has liability. Inappropriate use of these modifiers may result in entire claims being returned to providers.


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