HCPCS Modifier KX

Description
Specific required documentation on file.

Guidelines/Instructions
This modifier may be submitted on claims for:

  • Outpatient physical therapy (PT), occupational therapy (OT or speech language pathology (SLP services
  • Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) submitted to the DME Medicare Administrative Contractors
  • Gender-specific services for beneficiaries who are transgender, hermaphrodites or have ambiguous genitalia 

For speech language pathology, physical therapy or occupational therapy services:

  • Submit this modifier when the patient has already met the financial cap for PT/SLP or OT, and the service qualifies as an "exception" to be reimbursed over and above the cap
  • Use of the KX modifier indicates that the clinician attests that services at and above the therapy caps are medically necessary and reasonable, and justification is documented in the patient’s medical record
  • Exceptions to the caps are allowed for medically necessary outpatient services only when Congress legislates the exceptions. Suppliers and providers can continue to use the KX modifier to request an exception to the therapy cap on claims that are over the annual cap amounts.
  • There is no manual process for requesting exceptions. When the service qualifies for an automatic claims processing exception based on the  medical necessity of the service for the patient’s condition, submit the service with HCPCS modifier KX. Note that "automatic" refers to the manner in which the claim is processed and does not indicate that the exception itself is automatic.
  • HCPCS modifiers GN, GO and GP are currently required to be appended to therapy services and must continue to be used in addition to the KX modifier when a service meets the guidelines for an automatic exception to the therapy cap. This allows the approved therapy services to be paid, even though they are above the therapy cap financial limits.
  • It is important to recognize that most conditions would not ordinarily result in services exceeding the cap. Use the KX modifier only in cases where the condition of the individual patient is such that services are appropriately provided in an episode that exceeds the cap. Routine use of the KX modifier for all patients with these conditions will likely show up on data analysis as aberrant and invite inquiry.

Annual Therapy Cap Limits

  • For 2018, the financial limits on outpatient therapy services are $2,010 for combined PT and SLP services and $2,010 for OT services 
  • For 2017, the financial limits on outpatient therapy services are $1,980 for combined PT and SLP services and $1,980 OT services   

Obtaining Therapy Cap Information
You may access the accrued amount or remaining amount of therapy services from the Medicare beneficiary eligibility inquiry and response transactions.

References

References for Gender/Procedure Conflicts

Contact Palmetto GBA JM Part B Medicare

Email Part B

Contact a specific JM Part B department

Provider Contact Center: 855-696-0705

TDD: 866-830-3188

Other Palmetto GBA Sites

Palmetto GBA Home

DMEPOS Competitive Bidding Program

Jurisdiction J Part A MAC

Jurisdiction J Part B MAC

Jurisdiction M Part A MAC

Jurisdiction M Part B MAC

Jurisdiction M Home Health and Hospice MAC

MolDX

National Supplier Clearinghouse MAC

PDAC

RRB Specialty MAC Providers

RRB Specialty MAC Beneficiaries

Anonymous

 


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