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Modifier KX for use with Physical Therapy, Occupational Therapy or Speech Language Pathology Claims

What you need to know

Modifier KX is used to confirm specific required documentation is on file in accordance with the appropriate LCD. For physical therapy, occupational therapy or speech language pathology services, the KX modifier is added to claim lines to indicate that the clinician attests that services at and above the therapy caps are medically necessary and justification is documented in the medical record.

By adding modifier KX to a claim, you are stating that your claim has met specific documentation requirements, and would be available upon request from NGS, as the MAC.

Add this modifier to each procedure code once the specific therapy cap has been met.

KX Modifier Threshold

The Bipartisan Budget Act of 2018 repealed application of the Medicare outpatient therapy caps but retains the former cap amounts as a threshold above which claims must include the KX modifier as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record.

  • For CY 2022, the limit on incurred expenses is $2,150 for PT and SLP services combined. There’s another limit of $2,150 for OT services.
  • For CY 2021, the limit on incurred expenses is $2,110 for PT and SLP services combined. There’s another limit of $2,110 for OT services.

Deductible and coinsurance amounts paid by the beneficiary for therapy services count toward the amount applied to the limit.

Providers can find out if their patient is approaching their therapy cap by checking the patient’s eligibility record in NGSConnex. If you have not signed up for NGSConnex please visit the aforementioned link.

The therapy cap applies to all Part B outpatient therapy settings and providers including:

  • Therapists’ private practices
  • Offices of physicians and certain NPP
  • Part B SNFs
  • HHAs (TOB 34X)
  • Rehabilitation agencies (also known as ORFs)
  • CORFs
  • HOPDs
  • CAHs (TOB 85X) ‒ (2014)

Therapy Plan of Care/Modifiers

The LCD for outpatient physical and occupational therapy services describes the coverage limits of outpatient physical and occupational therapy services under Medicare Part B, billed when services are provided under a therapy plan of care. The claim must include one of the following modifiers to distinguish the discipline of the plan of care under which the service is delivered:

  • GO ‒ Services delivered under an outpatient occupational therapy plan of care; or
  • GP ‒ Services delivered under an outpatient physical therapy plan of care.

The modifiers are applicable to all claims from physicians, NPPs, PTPPs, OTPPs, CORFs, ORFs, outpatient hospital departments, SNFs billing under Medicare Part B, HHAs (when not rendered under a home health plan of care, but rendered under a therapy plan of care), and any other billing for PT or OT services. However, physical therapists may only report modifier GP and occupational therapists may only report modifier GO.

Providers may report the modifiers on claims in any order.

Documentation must support and justify that the beneficiary qualifies for the therapy cap exception and that services are reasonable and necessary and require the skills of a therapist.

The presence of the KX modifier demonstrates that services billed:

  • Qualify for the annual threshold.
  • Are reasonable and necessary services that require the skills of a therapist.
  • Are justified by appropriate documentation in the medical record.
  • Therapy services submitted without the KX modifier, for claims above the therapy threshold, will deny.

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Published 5/31/2022