Home Health & Hospice Week

Home care providers that also furnish Part B outpatient therapy in the home should take note of new therapy thresholds for medical review.

Old way: Before the Bipartisan Budget Act of 2018, Medicare had annual therapy caps for outpatient therapy, HHH Medicare Administrative Contractor Palmetto GBA notes on its website. When patients’ therapy services exceeded the caps, therapy providers had to include a KX modifier to secure payment for the services under a cap exception.

New way: Now, BBA 18 has repealed the caps, but replaced them with “thresholds above which claims must include the KX modifier to confirm that services are medically necessary as justified by appropriate documentation in the medical record,” the Centers for Medicare & Medicaid Services explains in an MLN Matters article. Claims “for therapy services above these amounts without the KX modifier are denied. These amounts are now known as the KX modifier thresholds.”

As with therapy caps, there is one KX modifier threshold amount for physical therapy and speech-language pathology services combined, and a separate amount for occupational therapy services, CMS explains. For calendar year 2019, the KX modifier threshold amounts are $2,040 for PT/SLP services and $2,040 for OT services.

New threshold: Another BBA 18 provision “maintains the targeted medical review process … but at a lower threshold than the $3,700 amount established as part of the therapy caps exceptions process,” CMS adds. For CY 2018 through 2028 “this now-termed Medical Review (MR) threshold amount is $3,000 for PT and SLP services combined and $3,000 for OT services,” according to the MLN Matters article at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11055.pdf.