- Outpatient Occupational and Physical Therapy Services Billing Guide
- Introduction to Outpatient OT and PT Services
- Outpatient Occupational and Physical Therapy Coverage
- Caregiver Training Services
- KX Modifier Threshold
- 2024 Annual Update to the Therapy Code List: Remote Therapeutic Monitoring
- Annual Update to the Therapy Code List
- Targeted Medical Review
- Functional Reporting - Using the G Codes
- What is the Advance Beneficiary Notice of Noncoverage and When to Use It in Outpatient Therapy
- Maintenance Programs
- Multiple Procedure Payment Reduction
- The National Correct Coding Initiative
- Comprehensive Error Rate Testing Program
- Recovery Auditor
- Common Billing Errors and Remittance Message
- Medical Review Therapy Documentation Checklist for Additional Development Request Letters
- Common Questions and Answers
- Related Content
- Related Articles
Targeted Medical Review
CMS knows in certain circumstances you may need to treat a patient whose condition exceeds the KX modifier threshold amounts. This is always based on the medical necessity of the patient. If this is the case, you must append a KX modifier to each line of coding you believe will exceed the therapy cap. By applying the KX modifier, you are also attesting your medical records reflect the medical necessity of the patient receiving services.
The targeted MR process means that not all claims exceeding the KX modifier threshold amount will be subject to review as they once were. For calendar years 2018 through 2028, the MR threshold will remain $3,000 for PT and SLP services and $3,000 for OT services.
There are no required specific diagnosis codes that would give you the automatic exception. You would simply utilize the coding you are currently using for the patient and document in their medical record the medical necessity for continued services.
Reviewed 11/2/2023