February 15, 2018

Question:
Are you using the KX modifier correctly on PT/OT claims?

Answer:

One Medicare carrier has concerns that the KX modifier if not being used appropriately. National Government Services (NGS) shared the following concern in their January Newsletter released 1/25/18. Bottom line is that clients serviced by this carrier are receiving claims in January with this modifier which means the patients cap was met in January. Review internal processes to ensure caps are calculated prior to each scheduled therapy session to allow for accurate use of this modifier and the inclusion of ABNs or other documentation is present as required.

“INCORRECT USE OF THE KX MODIFIER FOR THE PHYSICAL THERAPY EXCEPTION PROCESS

We are experiencing an increase of claims submitted with the KX modifier for services performed in January 2018.

CMS has placed an annual limitation on per beneficiary-incurred expenses for outpatient therapy services for Medicare Part B; these are referred to as therapy caps. The therapy caps amounts are determined on a calendar year (CY) basis which means that all beneficiaries begin a new cap each year.

For CY 2018, the limit on incurred expenses is $2,010 for physical therapy and speech and language pathology services combined. There is separate limit of $2,010 for occupational therapy services.

While there are cap amounts imposed on Part B therapy services, CMS realizes in certain circumstances you may need to treat a patient whose condition exceeds the cap amounts. This is always based on the medical necessity of the patient. If this is the case you must append a KX modifier to each line of coding you believe will exceed the therapy cap. By applying the KX modifier you are attesting your medical record reflects the medical necessity of the patient receiving services exceed the $2,010 cap amount.

The exception process is based on calendar year.

We are seeing an increase in claims for January 2018 services with the KX modifier appended to them, yet the 2018 PT/SLP or OT cap has not yet been reached. This is an incorrect use of the KX modifier.

Therapy providers are required to calculate therapy caps before submitting claims to NGS. Before submitting your claims to NGS, please review patient records and determine if your patient’s therapy cap has been met. If so, and the Medicare patient requires additional medically necessary treatment under the exception guidelines, then submit the claim with the appropriate KX modifier.”

Source: National Government Services

*This response is based on the best information available as of 02/15/18.