Select Page

Medicare KX Modifier Physical Therapy

by | May 19, 2022 | Medicare

Medicare KX Modifier Physical Therapy 2022 Update

This is an interesting quote from Medicare Claims Processing Manual
Chapter 5 – Part B Outpatient Rehabilitation and CORF/OPT Services:

“It no longer represents an exception request but serves as a confirmation that services are medically necessary after the beneficiary has exceeded the KX modifier threshold of incurred expenses.”

When should a physical therapist add the KX Modifier?

Internal tracking of therapy services utilization is the responsibility of the physical therapist, occupational therapist or speech language pathologist.  Nancy Beckley advises to add the KX modifier as close to or on the claim date of service upon which the financial threshold is exceeded.

In our clinic we develop an internal tracking system that allows our therapists to determine the most likely date of service that may exceed the financial threshold. This system is based on the expected therapy utilization indicated on the plan of care.

Many modern EMRs will also offer a financial tracking functionality.

What happens if a claim exceeds the financial threshold without the KX Modifier?

If the financial threshold is exceeded you may find the Medicare EOB shows a partial payment or non-payment with reason code “119 Benefit maximum for this time period or occurrence has been reached.”

If this happens, the recommended fix is to use your MAC portal and reopen the claim, append the KX modifier, and allow the claim to reprocess.

* Watch the video below to learn how to reopen a claim that has already processed without the Medicare KX Modifier. 

Where does the Medicare KX Modifier go on the CMS 1500 Claim?

When adding the KX modifier to a physical therapy claim, the modifier will usually go after the professional discipline modifier.

Table of PT, OT, SLP discipline modifiers:

GP Modifier Physical Therapy
GO Modifier Occupational Therapy
GN Modifier Speech Language Pathology
CQ Modifier Services Rendered By Physical Therapist Assistant
CO Modifier Services Rendered By Occupational Therapist Assistant

What is the Medicare Financial Threshold for 2022

Medicare no longer has a financial CAP on therapy services. Medicare uses the term financial threshold to indicate utilization of therapy services within a calendar year. If you would like to learn more about how CMS tracks the financial threshold, click here.

Physical Therapy Medicare Financial Threshold 2022

The financial threshold for 2022 is $2,150 for PT and SLP services combined.

* In 2022 physical therapy and speech language pathology continue to be combine when tracking financial utilization.

Occupational Therapy Medicare Financial Threshold 2022

The financial threshold for 2022 is $2,150 for OT occupational therapy services

Speech Language Pathology Financial Threshold 2022

The financial threshold for 2022 is $2,150 for PT and SLP services combined.

* In 2022 physical therapy and speech language pathology continue to be combine when tracking financial utilization.

What documenation is required when using the Medicare KX Modifier?

Documentation to support utilization of the KX modifier depends on several factors.

1. Is this highly complex case which has been determined during your initial evaluation?

If this is a highly complex case, your initial evaluation and plan of care will indicate it as such and the duration of your plan of care should provide objective findings supporting the expected utilization of the KX modifier to support medical necessity.

2. Has this patient utilized therapy services earlier this year?

Your initial evaluation and plan of care documentation should indicate that your patient has already received therapy services for the same condition or a different condition within the calendar year.

In my practice I find that many pateints will have a total knee replacement performed in January, then schedule a second total knee replacement for 6 ot 12 weeks later.

This patient will likely exceed the established financial threshold. Your clinical documentation should record this information.

Anthony Maritato, PT

Anthony Maritato, PT

Private Practice Owner / Physical Therapist

After starting a private practice physical therapy clinic in 2022 with his wife Kathy Maritato, PT, Tony and Kathy grew their practice to five locations across two states.

Now, Tony and Kathy enjoy spending time treating patients in the morning, coaching therapists in the evening, and being home to play with their dog Tucker and 4 boys.