news article details
Modifier KX on Outpatient Physical Therapy, Occupational Therapy or Speech Language Pathology Claims
Providers report modifier KX on a claim line(s) to confirm the medical records contain specific required documentation that meets the appropriate LCD's requirements. For outpatient PT, OT or SLP services, the KX modifier is added to claim lines to indicate that the clinician attests that services at and above the therapy threshold(s) are medically necessary and justification is documented in the medical record.
To report the KX modifier on a claim line(s), add it to each therapy procedure code once the patient has met the specific therapy threshold. In doing so, you are stating that your claim meets specific documentation requirements and that such documentation is available upon request from National Government Services.
KX Modifier Threshold
The BBA of 2018 repealed application of the Medicare outpatient therapy caps but retains the former cap amounts as a threshold above which claims must include the KX modifier as confirmation that such services are medically necessary as justified by appropriate documentation in the medical record.
- For CY 2022, the threshold on incurred expenses is $2,150 for PT and SLP services combined and a separate threshold of $2,150 for OT services.
- For CY 2021, the threshold on incurred expenses is $2,110 for PT and SLP services combined and a separate threshold of $2,110 for OT services.
Note: The amount(s) applied toward deductible and coinsurance on therapy claims count toward the outpatient therapy limit(s).
You can determine if your patient is approaching their outpatient therapy threshold(s) by checking the patient’s eligibility record in NGSConnex. If you have not signed up for NGSConnex please visit the aforementioned link.
The therapy threshold(s) apply to all Part B outpatient therapy settings and providers including:
- CAHs (TOB 85X)
- Part B SNFs
- Rehabilitation agencies (also known as ORFs)
- HHAs (TOB 34X)
- Therapists’ private practices
- Offices of physicians and certain NPPs
Your documentation must support and justify that the beneficiary qualifies for the therapy threshold 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
Targeted Medical Review Threshold
Along with the KX modifier threshold, the BBA of 2018 retains the targeted MR process at a lower threshold amount of $3,000.
- The MR threshold is $3,000 for PT and SLP services and $3,000 for OT services for CY 2021 and each calendar year until 2028 at which time it is indexed annually by the MEI
The targeted MR process means that not all claims exceeding the MR threshold amount are subject to review as they once were. For a general overview of the MR process, go to the Medical Review and Education website.
Therapy Plan of Care/Modifiers
The NGS LCD L33580 “Speech-Language Pathology” describes the coverage limits of outpatient SLP services under Medicare Part B when you provide such services under a therapy POC. Your claim must include the following modifier to distinguish the discipline of the POC under which the service is delivered:
- GN – Services delivered under an outpatient SLP POC
The NGS LCD L33631 “Outpatient Physical and Occupational Therapy Services” describes the coverage limits of outpatient PT and OT services under Medicare Part B when services are provided under a therapy POC. Your claim must include one of the following modifiers to distinguish the discipline of the POC under which you delivered the service:
- GO ‒ Services delivered under an outpatient OT POC; or
- GP ‒ Services delivered under an outpatient PT POC
The modifiers are applicable to all claims from physicians, NPPs, PTPPs, OTPPs, CORFs, ORFs, HOPDs and SNFs billing under Medicare Part B, HHAs (when not rendered under a HH POC, but rendered under a therapy POC), 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.
Therapy Services Furnished by PTA or OTA
For claims with DOS on/after 1/1/2020, Medicare requires the following modifiers to be billed to identify therapy services that were furnished in whole or in part by a PTA or OTA.
- CQ modifier: PT services furnished in whole or in part by PTAs and
- CO modifier: OT services furnished in whole or in part by OTAs.
Report modifier CQ with the therapy modifier GP and report modifier CO with the therapy modifier GO. If you submit claims with modifiers not so paired, we will reject/return them to you as unprocessable.
For additional information on the therapy assistant modifiers, refer to the CMS Therapy Services website as well as the CMS Billing Examples Using CQ/CO Modifiers for Services Furnished In Whole or In Part by PTAs and OTAs
- Outpatient Occupational and Physical Therapy Billing Guide
- CMS Therapy Services web page
- Billing Examples Using CQ/CO Modifiers for Services Furnished In Whole or In Part by PTAs and OTAs
- CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 12
- CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15
- CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 5