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).
Full Answer
What is Kx modifier with Medicare?
KX Modifier Thresholds (formerly known as Therapy Cap Process) Under Medicare Part B, the annual limitations on per beneficiary incurred expenses for outpatient therapy services are commonly referred to as “therapy caps” now known as KX modifier thresholds. The KX modifier thresholds are determined on a calendar year basis, which means that all beneficiaries begin a new threshold amount each year.
When to use the KX modifier?
- When the original NOE was submitted;
- When the NOE was returned to the hospice (RTPs) for correction or was accepted and available for correction; and
- When the hospice resubmitted the NOE.
How to add Kx modifier?
- Qualified for the cap exception;
- Are reasonable and necessary services that require the skills of a therapist; and
- Are justified by appropriate documentation in the medical record.”
What does modifier Kx mean?
What you need to know
- Appropriate Use: When additional documentation supports the medical requirements of the service under a valid medical policy.
- Inappropriate Use: When the claim provides all information on the service billed and medical documentation does not provide further explanation.
- Physical/Speech/Occupational Therapy. ...
What is Medicare KX modifier?
The KX modifier, described in subsection D., is added to claim lines to indicate that the clinician attests that services at and above the therapy caps are medically necessary and justification is documented in the medical record.
What type of modifier is KX?
The KX modifier is a signal on a claim that though the patient services have met the capped amount allowed, the provider deems continued care medically necessary. As the description in the below table indicates, medical record documentation must be maintained to support the medical necessity of the continued services.
What is modifier code KX?
The KX modifier is a Medicare-specific modifier that indicates a beneficiary has gone above their therapy threshold amount.
Is KX modifier only for therapy?
All therapy services definitely do not require the KX modifier. As the APTA explains, “The provider should [apply] the KX modifier to the therapy procedure code that is subject to the cap limits only when a beneficiary qualifies for a therapy cap exception.
Does modifier KX affect payment?
When the KX modifier is appended to a therapy HCPCS code, the contractor will override the CWF system reject for services that exceed the caps and pay the claim if it is otherwise payable.
Does Aetna require KX modifier?
Effective June 1, 2020, we'll allow hemodialysis services billed with modifier KX. You can use this modifier to report services required in excess of the three times per seven-day period. Be sure to include the KX modifier on your bill to us, if necessary.
What modifier must always be applied to Medicare claims?
What modifier must always be applied to Medicare claims for tests performed in a site with a CLIA Waived certificate? Rationale: Medicare requires that the QW modifier be applied for all claims for payment of test performed in a site with a CLIA waived certificate.
What is a GY modifier used for?
The GY modifier must be used when physicians, practitioners, or suppliers want to indicate that the item or service is statutorily non-covered or is not a Medicare benefit.
What is KU modifier?
The KU modifier is used to receive the unadjusted fee schedule amount and is being implemented for a variety of wheelchair accessories and seat back cushions used with complex rehabilitative manual wheelchairs and certain manual chairs.
What is a distinct procedural service?
Modifier 59 Distinct Procedural Service indicates that a procedure is separate and distinct from another procedure on the same date of service. Typically, this modifier is applied to a procedure code that is not ordinarily paid separately from the first procedure but should be paid per the specifics of the situation.
What is KP modifier?
When two NDCs are submitted on a claim, a KP modifier (first drug of a multiple drug unit dose formulation) is required on the first detail and a KQ modifier (second or subsequent drug of a multiple drug unit dose formulation) is required on the second detail.
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.
Incorrect Use
Append KX modifier to claim without verifying coverage criteria and existence of documentation
Appeal Option
Denied claims requiring a change specific to KX modifier, whether it be adding or removing it, must be requested via Written Redetermination only
What is KX modifier?
The KX modifier has differing requirements for usage depending on the specific Local Coverage Determination (LCD); suppliers should review the LCD/Article’s carefully to understand the documentation requirements and the proper use of the KX modifier for each policy.
What is Medicare Advantage Policy Guideline?
The Medicare Advantage Policy Guideline documents are generally used to support UnitedHealthcare Medicare Advantage claims processing activities and facilitate providers’ submission of accurate claims for the specified services. The document can be used as a guide to help determine applicable:
Appropriate Use
When additional documentation supports the medical requirements of the service under a valid medical policy.
Inappropriate Use
When the claim provides all information on the service billed and medical documentation does not provide further explanation.
General Information
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
Article Guidance
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.
ICD-10-CM Codes that Support Medical Necessity
The presence of an ICD-10 code listed in this section is not sufficient by itself to assure coverage. Refer to the LCD section on “ Coverage Indications, Limitations, and/or Medical Necessity ” for other coverage criteria and payment information.
ICD-10-CM Codes that DO NOT Support Medical Necessity
For the specific HCPCS codes indicated above, all ICD-10 codes that are not specified in the preceding section. For all other HCPCS codes, diagnoses are not specified.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.
General Information
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
CMS National Coverage Policy
CMS IOM Publication 100-03, Medicare National Coverage Determinations Manual , Chapter 1, Part 4, Section 220.6.17 - Positron Emission Tomography (FDG PET) for Oncologic Conditions
Article Guidance
Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire NCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.
ICD-10-CM Codes that Support Medical Necessity
It is the provider's responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim (s) submitted.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.