No, attaching a KX modifier is perfectly acceptable, as long as the services you are providing in excess of the cap are, in fact, medically necessary. If your KX modifier practices fall outside of the norm, though, Medicare may request additional information or conduct an audit.
Full Answer
What does the KX modifier mean in a medical policy?
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.
Can a supplier add a KX modifier to the AFO/Kafo base and addition codes?
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 are the reimbursement guidelines (LCD)?
Reimbursement Guidelines (LCD); suppliers should review the LCDs carefully to understand the documentation requirements and the proper use of the KX modifier for each policy. It is important to remember, if the requirements specified in the LCD are not met the KX modifier must not be used.
How do I appeal a denied claim with a KX modifier?
Append KX modifier to claim without verifying coverage criteria and existence of documentation Denied claims requiring a change specific to KX modifier, whether it be adding or removing it, must be requested via Written Redetermination only There are no appeal rights allowed for unprocessable claims with remark code MA130.
What does the KX modifier indicate?
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.
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 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.
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.
When should KX modifier 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.
How do you use the KX modifier for Medicare?
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.
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 DME require a modifier?
In addition to an appropriate HCPCS code for the DME item, many HCPCS codes require a modifier. The modifiers are used to provide more information about the item.
Does Medicare require modifiers?
GY and GX Modifiers No ABN is required with the GY modifier. The provider or supplier may use this modifier when a beneficiary needs Medicare to deny the claim so that it can be submitted to the beneficiary's secondary insurance. concerning these modifiers also apply to Part B claims submitted by Part A providers.
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.
What modifiers do physical therapists use?
For physical therapists, use -GP, occupational therapists, use -GO, and speech language pathologists, use -GN. KX Modifier- Patients with Medicare insurance have a threshold for therapy services, and once the patient exceeds that threshold, Medicare does not usually reimburse for provided services.
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!
When to issue ABN?
Issue an ABN for services above the soft cap that you do not believe are medically necessary. If your patient would like to receive services that are not medically necessary, issue an ABN prior to performing those services. That stands whether or not your patient has reached the soft cap.
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.
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.
General Information
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
Article Guidance
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.
ICD-10-CM Codes that Support Medical Necessity
The presence of an ICD-10 code listed in this section is not sufficient by itself to assure coverage. Refer to the LCD section on “ Coverage Indications, Limitations, and/or Medical Necessity ” for other coverage criteria and payment information.
ICD-10-CM Codes that DO NOT Support Medical Necessity
For the specific HCPCS codes indicated above, all ICD-10 codes that are not specified in the preceding section. For all other HCPCS codes, diagnoses are not specified.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.
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:
LCD Information
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
General Information
Section 1833 (e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider.” It is expected that the beneficiary's medical records will reflect the need for the care provided.