Medicare KX Modifier for Physical Therapy
What is the Medicare KX Modifier and Why is it Used?
This is an interesting quote that explains what the Medicare KX Modifier is: (Source) 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“It no longer represents an exception request but serves as a confirmation that services are medically necessary after the beneficiary has exceeded the KX modifier threshold of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 the KX Modifier be Used?
“The KX Modifier should be used when the patient has used close to $2,150 in combined physical therapy AND speech-language pathology benefits in the calendar year AND continues to require medically necessary therapy services.” – Tony Maritato, PT
The therapist is ultimately responsible for tracking therapy services utilization for the calendar year. This can be done via the Medicare MAC Portal.
Nancy Beckley advises adding 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 annual Medicare therapy financial threshold and alerts our billing department and clinical staff to add the KX modifier for physical therapy if continued therapy services are medically necessary.
Many modern EMRs will also offer a financial tracking functionality toward the Medicare financial threshold, but it is important that your EMR bases this calculation on the allowed amount and not the billed amount.
What happens if the physical therapy Medicare financial threshold is exceeded without the KX modifier?
If the Medicare 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” added to the Medicare EOB.
If this happens, the recommended fix is to use your MAC portal and reopen the claim, add the Medicare KX modifier to the modifier field, and allow the claim to reprocess.
*** Do NOT resubmit a new claim as this will be rejected as a duplicate claim.
* 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 a CMS 1500 Claim form?
The KX modifier goes in the modifier box in field 24 D to the right of the CPT codes. If you are billing a physical therapy claim, the modifier will usually go after the professional discipline GP modifier.
kx modifier medicare for physical therapy
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 documentation is required when using the Medicare KX Modifier?
Documentation to support the utilization of the KX modifier depends on several factors.
- Complexity and comorbidities
- Stability or variability of symptoms
- Extenuating circumstances beyond the therapist’s or patient’s control
A thorough initial evaluation and possible reevaluation will provide the data to support an episode of therapy beyond the norm.
Consider risk factors like possible cardiac event or stroke during a treatment session which requires frequent monitoring by the therapist and would not be appropriate for unlicensed support personnel.
Medicare mentions an example in which a patient with an unhealed, unstable humeral fracture may require passive range of motion and requires the skills of a therapist to assess and maintain safe positioning of the upper extremity.
Resources:
If you would like to learn more about Medicare billing and documentation, please take a look at my course: Zero to Paid Medicare Billing for PT, OT, SLP.
What are Common Uses of the MedicareKX Modifier
1. Is this a highly complex case that 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 patients will have a total knee replacement performed in January, then schedule a second total knee replacement for 6 to 12 weeks later.
This patient will likely exceed the established financial threshold. Your clinical documentation should record this information.
Summary and Key Points:
- The Medicare KX Modifier is used to indicate a service continues to be medically necessary.
- Add the KX Modifier to your physical therapy claim as close to exceeding the financial threshold as possible.
- If you exceed the financial threshold log into your MAC Portal account and reopen the claim to add the KX modifier.
- Do NOT add the KX modifier to all claims at the start of care.
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