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The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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Using the KX Modifier

Therapists can check the amount of expenses that have been made year to date (YTD) for the patient on the MAC websites:

CGS - First Coast - National Government Services - Noridian - Novitas - Palmetto - WPS

 Therapy Type  2021  2022  2023
 Physical and Speech Therapy Combined  $2110  $2150  $2230
 Occupational Therapy  $2110  $2150  $2230

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

  • Therapists’ Private Practices;
  • Offices of Physicians and NPPs;
  • Part B Skilled Nursing Facilities;
  • Home Health Agencies;
  • Rehabilitation Agencies (also known as ORFs);
  • Comprehensive Outpatient Rehab Facilities;
  • Outpatient Hospital Departments; and
  • Critical Access Hospitals.

    By using the KX modifier on the claim, the therapy supplier or provider is attesting that the services are medically necessary, and that supportive justification is documented in the medical record.

    The threshold is based on the incurred expanses made for the patient’s outpatient therapy services.  It does not matter if therapy services are provided by one therapist or multiple therapists in different organizations.   

    Claims for outpatient therapy services incurred above the threshold amounts without the KX modifier will be denied.  Must be appended to all claims filed after the threshold amount has been reached.   

    Targeted Medical Review

    The BBA of 2018 retains the targeted medical review (MR) process but at a lower threshold amount of $3,000. For CY 2022 (and each calendar year until 2028 at which time it is indexed annually by the MEI), the MR threshold is $3,000 for PT and SLP services and $3,000 for OT services.

    To prevent improper payments, Medicare contractors operate the medical review program. Medical reviews involve the collection and clinical review of medical records and related information to ensure that payment is made only for services that meet all Medicare coverage, coding, billing, and medical necessity requirements.

    About Us

    Therapy Comply is a healthcare compliance firm that seeks to bring high quality web-based compliance guidance and one-on-one consulting services to small and medium size physical, occupational, and speech therapy practices.

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