The Ph ysical, Occupational and Speech Therapy KX Modifier threshold amounts: Physical Therapy (PT) and Speech-Language Pathology (SLP) services combined is $2,040. Occupational Therapy (OT) services, the CY 2019 threshold amount is $2,040.
When to use modifier Kx?
This amount is indexed annually by the Medicare Economic Index (MEI). Claims for services over the KX modifier threshold amounts without the KX modifier are denied. For CY 2022 this KX modifier threshold amount is: $2,150 for PT and SLP services combined, and $2,150 for …
When is modifier Kx used?
Effective January 1, 2022, the 2022 therapy threshold limits for Medicare are: $2,150 for physical therapy and speech-language pathology services, combined. $2,150 for occupational therapy services. In 2021, the thresholds were $2,110 for combined …
What does a KX modifier mean?
Here, the main idea is that any outpatient therapy is now subject to a $2,010 threshold. The service delivered beyond that require a KX modifier that indicates that the service meets the criteria for payment exception. So, when the therapy reaches $3,000, it is subject to possible targeted medical review. Even though the CMS did not receive additional funding to conduct …
What is Kx modifier used for?
Oct 21, 2021 · Modifier KX should follow the appropriate therapy modifiers. Documentation must support and justify that the beneficiary qualifies for the therapy cap exception and that services are reasonable and necessary and require the skills of a therapist. The KX may be submitted on physical therapy, occupational therapy or speech language pathology claims.
In what scenario would use you use modifier KX?
Use the KX modifier to indicate that the clinician attests that services at and above the therapy caps are medically necessary and reasonable, and justification is documented in the patient's medical record.
What is the KX modifier threshold for 2020?
For CY 2020, the KX modifier threshold amounts are: (a) $2,080 for Physical Therapy (PT) and Speech-Language Pathology (SLP) services combined, and (b) $2,080 for Occupational Therapy (OT) services. Make sure your billing staffs are aware of these updates.
How do you use the KX modifier for Medicare?
Apply the KX modifier when you provide medically necessary services above the soft cap. Therapists should continue to affix the KX modifier to all medically necessary services above the designated limit ($2,010 in 2018), thus signaling Medicare to pay the claim.
What is the KX modifier threshold?
The annual per-beneficiary incurred expenses amounts are now called the KX modifier thresholds for Calendar year (CY) 2021....Medical Review Threshold.Therapy Type2021-2028Physical Therapy ( PT and Speech-Language Pathology Combined$3000Occupational Therapy (OT)$3000Nov 10, 2021
When do you use the KX modifier for PT?
Using the KX Modifier Add the KX modifier to claim lines to indicate that you are attesting that services at and above the therapy thresholds are medically necessary, and that documentation in the patient's medical record justifies the services.
What is the Medicare cap for physical therapy for 2021?
For CY 2021, the KX modifier threshold amounts are: a) $2,110 for Physical Therapy (PT) and Speech-Language Pathology (SLP) services combined, and b) $2,110 for Occupational Therapy (OT) services.
What does the KX modifier indicate?
Modifier KX Use of the KX modifier indicates that the supplier has ensured coverage criteria for the billed is met and that documentation does exist to support the medical necessity of item. Documentation must be available upon request.
Is KX a payment modifier?
Modifier KX Use of the KX modifier indicates that the supplier has ensured coverage criteria for the billed is met and that documentation does exist to support the medical necessity of item.
What is modifier KX used in DME?
The KX modifier represents the presence of required documentation is on file to support the medical necessity of the item.
What is the Medicare cap for physical therapy in 2022?
$2,150Effective January 1, 2022, the current Medicare physical therapy caps are: $2,150 for combined physical therapy and speech-language pathology services. $2,150 for occupational therapy services.
What is the Medicare cap?
The threshold for targeted medical review will be lowered from the current $3,700 to $3,000 through 2027; however, CMS will not receive any increased funding to pursue expanded medical review, and the overall number of targeted medical reviews is not expected to increase.
What does Cap mean in Medicare?
Corrective Action Plan (CAP) Process.
What modifiers are needed for KX?
The KX must be added to each claim line identified as a therapy service when therapy cap exceptions meet all guidelines for an automatic exception and must follow the required therapy HCPCS modifiers GN (speech-language pathology), GO (occupational therapy) and GP (physical therapy). This allows payment for the approved therapy services, even though they are above the therapy cap financial limits.
What is the most frequent use of the KX modifier?
Note: The most frequent use of the KX modifier is in relation to therapy services.
What is a modifier KX?
Modifier KX is used to confirm requirements outlined in the appropriate Local Coverage Determination (LCD), are met for the procedure billed.
When to add modifier to procedure code?
Add this modifier to each procedure code once the specific therapy cap has been met.
Can therapy services be denied without KX modifier?
Therapy services submitted without the KX modifier, for claims above the therapy threshold, will deny.
What is the KX modifier?
If services exceed the annual threshold amounts, claims must include the KX modifier as confirmation that services are medically necessary as justified by appropriate documentation in the medical record. There is one amount for PT and SLP services combined and a separate amount for OT services. This amount is indexed annually by the Medicare Economic Index (MEI).
What is the KX modifier threshold for BBA?
Along with the KX modifier threshold, the BBA of 2018 retains the targeted medical review process that was established in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). For 2018 through 2028, the targeted medical review threshold is $3,000 for PT and SLP services, and $3,000 for OT services. (After 2028, the threshold will be indexed annually by the MEI.) As the name implies, targeted medical review means that not all claims exceeding the therapy threshold amount are subject to review.
What does KX mean in a claim?
Add the KX modifier to claim lines to indicate that you are attesting that services at and above the therapy thresholds are medically necessary , and that documentation in the patient's medical record justifies the services. This includes documentation that patients, based on their condition, require continued skilled therapy—ie, therapy beyond the amount payable under the threshold to achieve their prior functional status or maximum expected functional status within a reasonable amount of time.
How many tiers are there in threshold process?
The threshold process consists of 2 tiers:
What is furnished medical services?
The services are furnished to treat targeted types of medical conditions.
Is Medicare submission automatic?
Note that while this process is "automatic," your submission is not binding on the Medicare contract or, who makes the final determination on whether the claim is payable.
Do you need to submit special documentation along with the KX modifier threshold?
You do not need to submit special documentation along with the KX modifier threshold. You are responsible for consulting guidance in the Medicare manuals and professional literature to determine if the beneficiary qualifies for the exception.
When to use KX modifier?
Apply the KX modifier when you provide medically necessary services above the soft cap. Therapists should continue to affix the KX modifier to all medically necessary services above the designated limit ($2,010 in 2018), thus signaling Medicare to pay the claim. That means you must continue to track your patients’ progress toward ...
What is the secondary threshold for Medicare?
It also means your documentation should fully support the medical necessity of your services, because Medicare performs targeted reviews for claims over the secondary threshold of $3,000 (when providers meet certain criteria such as having a high claim denial rate or aberrant billing practices).
When was the therapy cap repealed?
Update: The therapy cap has been repealed as of February 9, 2018. Scroll to the last section...
Can you still submit a claim to Medicare with a GA modifier?
Once you have a signed ABN on file, you should still submit claims to Medicare—with a GA modifier, which will trigger Medicare to reject those claims. Then, after you receive the denial from Medicare, you can collect payment for those services directly from your patients.
What is the modifier KX?
By adding modifier KX to a claim, you are stating that your claim has met specific documentation requirements in the policy, and would be available upon request from the Medicare Administrative Contractor (MAC). Add this modifier to each procedure code once the specific therapy cap has been met.
How many physical therapy visits does Medicaid pay for?
Medicaid will pay for up to 40 physical therapy visits, 20 occupational therapy visits, and 20 speech therapy visits per enrollee in a twelve-month benefit year.
What does KX mean in DMEPOS?
Modifier KX Use of the KX modifier indicates that the supplier has ensured coverage criteria for the DMEPOS billed is met and that documentation does exist to support the medical necessity of item. Documentation must be available upon request.
What is the therapy cap for 2020?
Also, what is the therapy cap for 2020? In 2020 those limits are: $2,080 for physical therapy (PT) and speech-language pathology (SLP) services combined. $2,080 for occupational therapy (OT) services.
When to use KX modifier?
The KX modifier should only be used when the therapist (not the biller or the billing company) has made a determination that skilled therapy is medically necessary over the $1920 therapy caps. Therapist clinical judgment on this is the over riding factor. A therapist must provide specific documentation in the medical record addressing ...
What does the KX modifier mean?
The KX modifier indicates that therapy over the “threshold” is medically necessary. The therapy cap was permanently eliminated 1/1/2018,however the KX modifier must be used at the threshold amount of $2040 to indicate that therapy is medically necessary.
What is a single episode of care involving both physical therapy and speech-language pathology services?
A single episode of care involving both physical therapy and speech-language pathology services – for example a stroke rehab program wherein both PT and SLP are utilizing the combined PT/SLP cap.
When did the KX modifier come out?
Even though the use of the KX modifier for an “automatic exceptions” process has been around since 2006, therapist are often unclear about its use, and in fact may not be aware of its use on specific patients if their billing software is automatically adding the KX modifier. These 3 tips on the use of the KX modifier for outpatient therapy will assist therapists and provider groups alike to stay clear of claims edits and chart audits by CMS contractors
What is the cap for a therapist?
A therapist must provide specific documentation in the medical record addressing that therapy beyond the $1920 therapy cap is medically necessary and provide specifics to meet the medical necessity of skilled care documentation requirements.
Kx Modifier and Exceptions Process
- If services exceed the annual threshold amounts, claims must include the KX modifier as confirmation that services are medically necessary as justified by appropriate documentation in the medical record. There is one amount for PT and SLP services combined and a separate amount for OT services. This amount is indexed annually by the Medicare Economic Index (MEI)…
Using The Kx Modifier
- Add the KX modifier to claim lines to indicate that you are attesting that services at and above the therapy thresholds are medically necessary, and that documentation in the patient's medical record justifies the services. This includes documentation that patients, based on their condition, require continued skilled therapy—ie, therapy beyond the amount payable under the threshold to …
Targeted Medical Review Process
- Along with the KX modifier threshold, the BBA of 2018 retains the targeted medical review process that was established in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). For 2018 through 2028, the targeted medical review threshold is $3,000 for PT and SLP services, and $3,000 for OT services. (After 2028, the threshold will be ind...
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