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?
- 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.
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. ...
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 is Kx modifier used for?
The KX modifier is used by DME suppliers to ensure that the records exist and are available to support that the claim has followed Medical Policy and the LCD for that item.
What does the 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 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.
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.
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.
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.
How many PT sessions will Medicare pay for?
There's no limit on how much Medicare pays for your medically necessary outpatient therapy services in one calendar year.
How is the Medicare therapy cap calculated?
Medicare allowable charges,which includes both Medicare payments to providers and beneficiary coinsurance, are counted toward the therapy cap. In outpatient settings, Medicare will pay for 80 percent of allowable charges and the beneficiary is responsible for the remaining 20 percent of the amount.
What will be the Medicare premium for 2021?
The Centers for Medicare & Medicaid Services (CMS) has announced that the standard monthly Part B premium will be $148.50 in 2021, an increase of $3.90 from $144.60 in 2020.
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.
Does Medicare accept physical status modifiers?
Physical Status Modifiers Note: Medicare does not recognize Physical Status P modifiers.
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 to use KX modifier?
The first rule is simple – you should use the KX modifier only when the therapist (not the biller) has made a determination that in your case, skilled therapy is medically necessary over the $1920 therapy cap. There must be specific documentation in the medical record which states that therapy beyond the $1920 cap is medically necessary ...
What is the threshold for KX modifiers?
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.
Did the hard cap on Medicare remove one rule?
The elimination of the hard cap on Medicare therapy services by the Congress did not only remove one rule – it paved the way towards adopting a new system of payment thresholds and triggers as well as different sets of rules for physical therapist assistants (PTAs) and occupational therapy assistants (OTAs) among others.
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 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.
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
When can a beneficiary use the cap exceptions process?
The beneficiary may qualify for use of the cap exceptions process at any time during the episode when documented medically necessary services exceed caps. All covered and medically necessary services qualify for exceptions to caps. All requests for exception are in the form of a KX modifier added to claim lines.
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.
