The elimination of the hard cap on Medicare therapy services by the Congress did not only remove one rule – it paved the way towards adopting a new system of payment thresholds and triggers as well as different sets of rules for physical therapist assistants (PTAs) and occupational therapy assistants (OTAs) among others.
Currently, there is a threshold for using KX modifiers and a trigger for possible medical review.
Here, the main idea is that any outpatient therapy is now subject to a $2,010 threshold. The service delivered beyond that require a KX modifier that indicates that the service meets the criteria for payment exception.
So, when the therapy reaches $3,000, it is subject to possible targeted medical review. Even though the CMS did not receive additional funding to conduct these reviews, that is the current plan.
What’s also important to mention is that these thresholds apply to all part B outpatient therapy services. These also include the services provided by hospital outpatient departments. As we already mentioned, the $2,010 threshold is for use of the KX modifier and the $3,000 one is for potential targeted medical review.
Right now, there are three tips that we advise you to use when going for the KX modifier for outpatient therapy – in order to stay out of trouble.
- The first rule is simple – you should use the KX modifier only when the therapist (not the biller) has made a determination that in your case, skilled therapy is medically necessary over the $1920 therapy cap.
- There must be specific documentation in the medical record which states that therapy beyond the $1920 cap is medically necessary with specifics to meet the medical necessity of the skilled documentation requirements.
- The KX modifier is appended that are close to $1920 (and is not applied from the first visit) which is another abuse practice you should have in mind
The best way to document the use of the KX modifier for outpatient therapy is to use single complex episodes of requiring therapy over the cap – or single episodes of care involving both physical therapy and speech-language pathology services.
If you decide to use multiple episodes of care, make sure to develop a subsequent plan of care – set up to immediately identify the likelihood of therapy that is exceeding the cap.