Full Answer
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.
What is Kx modifier used for?
Aug 06, 2008 · For Part B claims processing, the KX modifier shall be billed on the detail line with any procedure code(s) that are gender specific. The definition of the KX modifier is: Requirements specified in the medical policy have been met. Use of the KX modifier will alert the MAC that the physician/practitioner is performing a service on
What is modifier code KX?
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
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.Jun 22, 2021
How do you use KX modifier?
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.
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
Is KX modifier still valid?
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
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
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
What is the therapy cap for 2021?
2021 MEDICARE OUTPATIENT THERAPY CAP EXPLANATION To all our Medicare patients, Beginning January 1, 2021 there will be a cap of $2110.00 per year for Physical Therapy and Speech-language pathology together. A separate cap of $2110.00 per year is allowable for Occupational Therapy Services.Jan 1, 2021
What is Ko modifier?
KO — SINGLE DRUG UNIT DOSE FORMULATION. When there is a single drug in a unit dose container, the KO modifier is added to the unit dose form code.May 6, 2010
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.
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
Does Medicare require modifiers for physical therapy?
**One last quick tip, for therapy businesses who have PTAs or OTAs, Medicare now requires that you use an assistant modifier, CQ for PTAs and CO for OTAs, for services performed.Feb 20, 2021
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 Medicare Administrative Contractor?
The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a change to the MAC Statement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued performance requirements.
Does the revision date apply to red italicized material?
Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. Any other material was previously published and remains unchanged. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.
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!
What is the purpose of NCDs and LCDs?
Use NCDs and LCDs to determine medical necessity. What Medicare considers “reasonable and necessary” isn’t always cut and dried; instead, it varies based on on both National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs).
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.
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.
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.
What is documentation justifying services?
A: Documentation justifying the services shall be submitted in response to any Additional Documentation Request (ADR) for claims that are selected for medical review. If medical records are requested for review, clinicians may include, at their discretion, a summary that specifically addresses the justification for therapy cap exception and they should follow the documentation requirements listed
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”.
What is the CPT code for a single chamber pacemaker?
Contractors shall return claims lines for implanted permanent cardiac pacemakers, single chamber or dual chamber, containing one of the following CPT codes: 33206, 33207, or 33208, as unprocessable when the -KX modifier is not present. Contractors shall use the following messages:
What is Medicare Administrative Contractor?
The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a change to the MAC statement of Work. The contractor is not obliged to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued performance requirements.
What is a permanent pacemaker?
Background: Permanent cardiac pacemakers refer to a group of self-contained, battery-operated, implanted devices that send electrical stimulation to the heart through one or more implanted leads. Single chamber pacemakers typically target either the right atrium or right ventricle. Dual chamber pacemakers stimulate both the right atrium and the right ventricle. The implantation procedure is typically performed under local anesthesia and requires only a brief hospitalization. A catheter is inserted into the chest and the pacemaker’s leads are threaded through the catheter to the appropriate chamber(s) of the heart. The surgeon then makes a small “pocket” in the pad of the flesh under the skin on the upper portion of the chest wall to hold the power source. The pocket is then closed with stitches.
Does the revision date apply to red italicized material?
Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. Any other material was previously published and remains unchanged. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.
