Physical and Occupational Therapy Services Using the KX HCPCS Modifier: Overview of Key Components

This electronic Comparative Billing Report (eCBR) focuses on providers that submit claims for physical therapy (PT) and occupational therapy (OT) using CPT® Codes 97110, 97112, 97140 and 97530 using the KX modifier. eCBR information is one of the many tools used to assist individual providers in becoming proactive in addressing potential billing issues and performing internal audits to ensure compliance with Medicare guidelines.

For your personalized individual PT and OT using the KX modifier with CPT Codes 97110, 97112, 97140 and 97530 eCBR results log on to eServices.

This electronic Comparative Billing Report (eCBR) focuses on providers that submit claims for PT and OT using CPT® Codes 97110, 97112, 97140 and 97530 using the KX HCPCS modifier. eCBR information is one of the many tools used to assist individual providers in becoming proactive in addressing potential billing issues and performing internal audits to ensure compliance with Medicare guidelines.

Log on to eServices for your personalized individual PT and OT using the KX HCPCS modifier with CPT® Codes 97110, 97112, 97140 and 97530 eCBR results.

The key components of PT and OT services billed with the KX HCPCS modifier are:

1. When the patient has already met the financial threshold for PT or OT, and the service qualifies as an "exception" to be reimbursed over and above the threshold 
2. Use of the KX HCPCS modifier indicates that the clinician attests that services at and above the therapy threshold are medically necessary and reasonable, and justification is documented in the patient’s medical record regarding medical decision-making
3. When the service qualifies for an automatic claims processing exception based on medical necessity of the service for the patient’s condition, submit the service with HCPCS modifier KX

"Automatic" refers to the manner in which the claim is processed and does not indicate that the exception itself is automatic.

PT and OT services (CPT® Codes 97110, 97112, 97140 and 97530) Documentation Requirements
Evaluation and plan of care including any other pertinent characteristics of the beneficiary:

• Certifications and recertifications 
• The history and physical exam pertinent to the patient’s care (including the response or changes in behavior to previously administered skilled services) 
• The skilled services provided 
• A detailed rationale that explains the need for the skilled service in light of the patient’s overall medical condition and experiences 
• The complexity of the service to be performed 
• Progress reports written by the clinician 
• Services related to progress reports are to be furnished on or before every 10th treatment day 
• Treatment notes for each visit detailing the patient’s response to the skilled services provided (may also serve as progress notes) 
• When appropriate, a separate justification statement for services that are more extensive than is typical for the condition treated 
• Payment and coverage conditions require that the plan must be reviewed as often as necessary, but at least whenever it is certified or recertified to complete the certification requirements. It is not required that the same physician or NPP who participated initially in recommending or planning the patient's care certify and/or recertify the plans.

Education Resources
The Provider Outreach and Education (POE) team has published an educational article to address the issues pertinent to PT and OT CPT® Codes 97110, 97112, 97140 and 97530. Your practice is being advised to review article KX HCPCS modifier used with Outpatient PT and OT.

Methods
The metrics reviewed in this eCBR are the proportion of billing for each HCPCS code in the grouping with comparisons done to peers within the state and jurisdiction. This report is an analysis of Medicare Part A and B claims extracted from the Palmetto GBA data warehouse. The analysis shows the portions of your PT and OT services using the KX HCPCS modifier CPT® Codes 97110, 97112, 97140 and 97530 claims at each level compared to the peers in your jurisdiction.

Example of eCBR Results from eServices