Wiki Physical therapy billing: overriding Medicare tx caps

[smors1]

We have a patient who told us that we should be using the KX modifier to bill her husband's physical therapy treatment to override his therapy caps. From what we can see, KX is only for DME. Is anyone familiar with the correct use of the KX modifier as it relates to PT and, if so, what is your experience and/or recommendation. We are having them sign an ABN.

 

[Orthocoderpgu]

C. Repeal of Original Legislation and Replacement with Thresholds to Ensure Appropriate Therapy. Section 50202 of the Bipartisan Budget Act of 2018 repeals application of the Medicare outpatient therapy caps but retains the former cap amounts as a threshold of incurred expenses above which claims must include a modifier as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record. This is termed the KX modifier threshold. Along with this KX modifier threshold, the new law retains the targeted medical review process but at a lower threshold amount of $3,000. For more information about the medical review (MR) threshold see the below section 10.3.4. 10.3 - Application of Financial Limitations (Rev. 4214, Issued: 01-25-19, Effective: 01-01-19, Implementation: 02-26-19

 

[JSwise]

Yes the KX modifier can be used with PT/OT/SLP. Once you hit the "soft cap" benefit amount, you would then append the KX modifier on continuing therapy visits to alert medical necessity. I have had to use it several times in the past few years. Hope this helps, good luck... Happy Billing.