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Printed Date: 9/22/2015
On January 1, 2006, Medicare implemented financial limitations on covered therapy services (therapy caps). An exception to the therapy cap may be made when a beneficiary requires continued skilled therapy, (in other words, therapy beyond the amount payable under the therapy cap) to achieve his or her prior functional status or maximum expected functional status within a reasonable amount of time. Documentation supporting the medical necessity of those therapy services must be available in the patient's medical record.
Verify whether the patient has exceeded the therapy cap prior to submitting claims to Medicare through the Palmetto GBA eServices tool or Interactive Voice Response (IVR) unit.
Online Verification for Therapy Caps through eServices
If the service qualifies as an exception and may be reimbursed over and above the cap, submit HCPCS modifier KX with the service. Documentation in the patient's medical record must support the use of this modifier.
HCPCS modifier KX must be submitted in addition to HCPCS modifier GN, GO or GP with therapy services when therapy cap meets all guidelines for an automatic exception. HCPCS modifier KX allows the approved therapy services to be paid, even though they are above the therapy cap financial limits.
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Last Updated: 02/08/2018