Medicare Payment Thresholds for Outpatient Therapy Services
- 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 ...
- Using the KX Modifier. ...
- Targeted Medical Review Process. ...
When to use the KX modifier?
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
What does modifier Kx mean?
May 03, 2018 · 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. It is recommended for suppliers to obtain a working knowledge of specific documentation requirements for specific …
How to add Kx modifier?
Oct 21, 2021 · Modifier KX is used to confirm requirements outlined in the appropriate Local Coverage Determination (LCD), are met for the procedure billed. 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).
What is Kx modifier used for?
Nov 14, 2019 · 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.
Where do you put the KX modifier?
The KX modifier is appended on claims at or very close to the $1920 cap, and should not applied from the first visit, even if the therapist knows that the cap will likely be exceeded. At least one MAC has notified therapists that a pattern of early application of the KX modifier may be consider an abuse practice.Jan 14, 2014
Is KX modifier for Medicare only?
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 the threshold so you know when to affix the modifier.Oct 8, 2018
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.Jan 25, 2019
What is the KX modifier threshold?
For 2021 this KX modifier threshold amount is: $2,110 for PT and SLP services combined, and. $2,110 for OT services.
What is the purpose of the KX 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. Documentation must be available upon request.May 4, 2018
When should KX modifier be used?
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.
Does Aetna Medicare use 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.Jun 1, 2020
What is KJ modifier?
KJ — DMEPOS ITEM, PARENTERAL ENTERAL NUTRITION (PEN) PUMP OR CAPPED RENTAL, Month four to fifteen. This modifier is used for capped rental DME items. When using the KJ modifier, you are indicating you are billing for months four through thirteen/fifteen of the capped rental period.
How many physical therapy visits does Medicare cover?
A person's doctor recommends 10 physical therapy sessions at $100 each. The individual has not paid their Part B deductible for the year. They will pay the Part B deductible of $203. Part B will pay 80% of the expense after the $203 deductible payment.Mar 6, 2020
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.Oct 25, 2019
What will the Medicare premium be in 2021?
The standard monthly premium for Medicare Part B enrollees will be $170.10 for 2022, an increase of $21.60 from $148.50 in 2021. The annual deductible for all Medicare Part B beneficiaries is $233 in 2022, an increase of $30 from the annual deductible of $203 in 2021.Nov 12, 2021
What are the Medicare therapy Threshold limits for 2021?
For CY 2021 (and each calendar year until 2028 at which time it is indexed annually by the MEI), the MR threshold is $3,000 for PT and SLP services and $3,000 for OT services. The targeted MR process means that not all claims exceeding the MR threshold amount are subject to review as they once were.Nov 10, 2021
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.
What is the KX modifier?
The KX modifier thresholds are determined on a calendar year basis, which means that all beneficiaries begin a new threshold amount each year.
What is the KX modifier threshold?
The KX modifier threshold process applies an annual Medical Record (MR) threshold amount when a beneficiary’s incurred expenses reach a threshold of $3,000. This amount will remain until calendar year 2028.
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.
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.
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.
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.
What is a KX modifier?
Thank you for your question. 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. I hope that helps!
Do you need to affix KX modifier to Medicare?
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 the threshold so you know when to affix the modifier. 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). But, that certainly doesn’t mean you should shy away from providing—and billing Medicare for—services above the threshold as long as they are, in fact, medically necessary. That could unnecessarily delay your patients’ progression through their care.
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.
Spotlight
The Therapy Services webpage is being updated, in a new section on the landing page called “Implementation of the Bipartisan Budget Act of 2018”, to: (a) Reflect the KX modifier threshold amounts for CY 2021, (b) Add more information about implementing Section 53107 of the BBA of 2018, and (c) Note that the Beneficiary Fact Sheet has been updated.
Implementation of the Bipartisan Budget Act of 2018
This section was last revised in March 2021 to reflect the CY 2021 KX modifier thresholds. On February 9, 2018, the Bipartisan Budget Act of 2018 (BBA of 2018) (Public Law 115-123) was signed into law.
Other
On August 16, 2018, CMS issued a new Advance Beneficiary Notice of Noncoverage (ABN) Frequently Asked Questions (FAQ) document to reflect the changes of the Bipartisan Budget Act of 2018. Please find the document in the below Downloads section titled: “August 2018 ABN FAQs”.
