Supplier usage of the KX modifier identifies that the requirements identified in the medical policy have been met. Documentation is essential to support that the item is reasonable and necessary and that the specific coverage criteria specified in each policy have been met.
What is the KX modifier for Medicare?
The KX modifier is a Medicare-specific modifier that indicates a beneficiary has gone above their therapy threshold amount. To my knowledge, there are no other insurance payers that use this modifier.
How do you add KX to a claim?
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.
What does the KX modifier mean on a DMEPOS invoice?
Modifier KX. Requirements specified in the applicable Local Coverage Determination (LCD) have been met. 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.
When should I submit the KX?
The KX may be submitted on physical therapy, occupational therapy or speech language pathology claims. When additional documentation supports the medical requirements of the service under a valid medical policy. When the claim provides all information on the service billed and medical documentation does not provide further explanation.
When to use KX modifier?
What is the secondary threshold for Medicare?
Can you still submit a claim to Medicare with a GA modifier?
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What is modifier KX mean?
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.
What is KX modifier physical therapy?
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 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.
When should modifier KX be used?
Use the KX modifier only in cases where the condition of the individual patient is such that services are APPROPRIATELY provided in an episode that exceeds the cap.
Is KX modifier still valid?
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.
What does the KX modifier mean for DME?
The KX modifier represents the presence of required documentation is on file to support the medical necessity of the item.
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? Response Feedback: 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?
GY Modifier: This modifier is used to obtain a denial on a non-covered service. Use this modifier to notify Medicare that you know this service is excluded.
3 Tips on the Use of the KX Modifier for Outpatient Therapy That Will ...
Hi Julie – Thank you for your comment. 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.
KX Modifier – usage and Guidelines – SPECIFIC REQUIRED ...
KX -- SPECIFIC REQUIRED DOCUMENTATION ON FILE. (EFFECTIVE DATE 7/1/2002) This modifier may be used to indicate that specific required documentation is on file in the patient's medical record. Documentation must be submitted upon request. Applicable policies include: Manual and power mobility bases and accessories, Glucose monitors & supplies, PAP…
KX MODIFIER - help, please! | Medical Billing and Coding Forum - AAPC
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Modifier KX for use with Therapy Services - Novitas Solutions
Section 50202 of the Bipartisan Budget Act of 2018 repeals application of the Medicare outpatient therapy caps, but retains the former cap amounts as a threshold above which claims must include the KX modifier as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record; and retains the targeted medical review process, but at a lower ...
KX, GA, GY, and GZ Modifier Reminders - CGS Medicare
January 16, 2018. KX, GA, GY, and GZ Modifier Reminders. The KX modifier is required for these policies:
Reimbursement Policy KX Modifier - AAPC
For all commodes (E0163-E0171), if it is used as a raised toilet seat by positioning it over the toilet, the GY modifier must be added to the code and the KX, GA, or GZ modifier must not be used.
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
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.
When do you need to submit KX modifier?
Providers of outpatient therapy services are required to submit the KX modifier on their therapy claims, when an exception to the cap is requested for medically necessary services.
What is the KX modifier?
A: The KX modifier is added to claim lines to indicate that the clinician attests that services are medically necessary and justification is documented in the medical record. Even though no special documentation is submitted to the contractor for automatic process exceptions, the clinician is responsible for consulting guidance in the Medicare manuals and in the professional literature to determine if the beneficiary qualifies for the automatic process exception. In addition, the clinician’s opinion is not binding on the Medicare contractor; the Medicare contractor makes the final determination concerning whether the claim is payable.#N#Q: When are exceptions to the therapy caps for services provided in a SNF setting considered?#N#Revised 09/2015
When exceptions are in effect and the beneficiary qualifies for a therapy cap exception, the provider shall add
When exceptions are in effect and the beneficiary qualifies for a therapy cap exception, the provider shall add a KX modifier to the therapy HCPCS code subject to the cap limits. The KX modifier shall not be added to any line of service that is not a medically necessary service; this applies to services that, according to a local coverage determination by the contractor, are not medically necessary services.
When did the KX modifier expire?
Section 202 of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) extended the therapy cap exceptions process through December 31, 2017. As a reminder, excessive use of the KX modifier including routine use of the modifier prior to reaching the cap limits may indicate abusive billing.
Can you use KX modifier on PT lines?
o Use the KX modifier on either all or none of the SLP lines on the claim, as appropriate. In contrast, if all the OT lines on the claim are below the cap, do not use the KX modifier on any of the OT lines, even when the KX modifier is appropriately used on all of the PT lines.
Does KX show up in data analysis?
Routine use of the KX modifier for all patients with these conditions will likely show up on data analysis as aberrant and invite inquiry. Be sure that documentation is sufficiently detailed to support the use of the modifier.
Do you need to add a KX modifier to a KAFO?
Suppliers must add a KX modifier to the AFO/KAFO base and addition codes only if all of the coverage criteria in the “Indications and Limitations of Coverage and or Medical Necessity” section of the LCDs have been met and evidence of such is retained in the supplier’s files and available to the DME MAC upon request.
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).
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 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:
When to use KX modifier?
Providers should only use the KX modifier for rehabilitative services when it is appropriate – that is, the services are medically necessary and there is documentation in the medical record to support that. Properly applying the KX modifier requires that providers keep up with the number of sessions for CR and PR, ...
How many sessions can you have in cardiac rehab?
There is not a lifetime limit of 72 sessions for cardiac rehab; a patient qualifies for 36 (within 36 weeks) and up to 72 sessions after each qualifying cardiac episode. Pulmonary rehab is limited to a maximum of 72 sessions in a lifetime and PR sessions beyond 72 will deny for payment even if the KX modifier is included.
Does Medicare cover KX modifier?
This is where the KX modifier comes in. For cardiac and pulmonary rehab, Medicare contractors shall accept the inclusion of the KX modifier on the claim lines as an attestation by ...
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).
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.