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.
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.
When can you use a KX modifier?
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.
What is modifier code KX?
Modifier KX is used to confirm requirements outlined in the appropriate Local Coverage Determination (LCD), are met for the procedure billed.
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.
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.
What is modifier KX used in DME?
The KX modifier represents the presence of required documentation is on file to support the medical necessity of the item.
How long can you use KX modifier?
Nope, there is no upper limit—as long as the services you are providing are medically necessary. However, there are additional steps you must take if you believe treatment beyond the manual medical review threshold of $3,700 is medically necessary.
What is the Medicare threshold for physical therapy in 2022?
$2,150KX Modifier and Exceptions Process This amount is indexed annually by the Medicare Economic Index (MEI). For 2022 this KX modifier threshold amount is: $2,150 for PT and SLP services combined, and. $2,150 for OT services.
Does Medicare cover outpatient physical therapy?
Yes. Physiotherapy can be covered by Medicare so long as it's a chronic and complex musculoskeletal condition requiring specific treatment under the CDM.
How much does Medicare reimburse for physical therapy?
However, in 2018, the therapy cap was removed. Original Medicare covers outpatient therapy at 80% of the Medicare-approved amount. When you receive services from a participating provider, you pay a 20% coinsurance after you meet your Part B deductible ($233 in 2022).
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.
Does Medicare accept physical status modifiers?
Physical Status Modifiers Note: Medicare does not recognize Physical Status P modifiers.
When should I submit a rap?
CMS proposes to align the No-Pay RAP with the one-time NOA which begins January 1, 2022.
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.
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.
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
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, ...
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 ...
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: