Know your modifier KX rules to ensure payment.
The annual update to the threshold amounts for physical therapy, speech-language pathology, and occupational therapy is now available. Modifier KX threshold amounts are increased by 1.4 percent from calendar year (CY) 2020.
Modifier KX Threshold
The Centers for Medicare & Medicaid Services (CMS) uses the former therapy caps amounts, repealed by the Bipartisan Budget Act of 2018, to establish modifier KX threshold amounts.
CY 2021 modifier KX threshold amounts are:
- $2,110 for physical therapy (PT) and speech-language pathology (SLP) services combined; and
- $2,110 for occupational therapy (OT) services.
When to Apply Modifier KX
Append modifier KX Specific required documentation on file to medically necessary services that exceed the dollar amounts above when submitting a claim. Patient progress must be tracked and documented up to this point, with documentation fully supporting the necessity of the service(s).
Establishing medical necessity with proper documentation in the health record (no additional special documentation is needed) and subsequently using modifier KX when appropriate will help you avoid claim denials. Make sure to consult your Medicare manuals to confirm that each patient meets medical necessity as defined by Medicare.
If you know that a service is not medically necessary or think it might not be, you can issue an Advance Beneficiary Notice of Noncoverage (ABN) to your patient to inform them that the therapy they are about to receive might not be covered by Medicare. Learn more about medical necessity in AAPC’s Knowledge Center.
Targeted Medical Review Process
The targeted medical review process threshold amount is $3,000. There is a Medical Record (MR) threshold amount for PT and SLP services combined and another for OT services. All claims exceeding the MR threshold amount may be subject to review. The amount will remain at $3,000 until CY 2028, according to a CMS Transmittal.
For more information about therapy services, read “Therapy Services: The Uphill Climb to Better Codes and Reimbursement” by Lynn S. Berry, PT, CPC.