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

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

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.