Modifier KX and Outpatient Physical Therapy Webcast - Questions and Answers

The following questions were received on the September 26, 2019, Railroad Medicare Modifier KX and Outpatient Physical Therapy webcast.  

Q1.  We have always required an MD, DO, or DPM to sign the plan of care (POC). Just to clarify, we can also accept a nurse practitioner (NP) signature?

A1. Yes.  According to the CMS MLN  905365 Outpatient Rehabilitation Therapy Services: Complying with Documentation Requirements Booklet (PDF, 848 KB), "The physician’s/NPP’s signature and date on a correctly written POC (with or without an order) satisfies the certification requirement for the duration of the POC or 90 calendar days from the date of the initial treatment, whichever is less. Include the initial evaluation indicating the treatment need in the POC."

Addendum:  Yes. See the Code of Federal Regulations requirements for outpatient physical and speech-language pathology services furnished by providers under Medicare Part B (42 CFR §424.24) below:

c) Outpatient physical therapy and speech-language pathology services—

(1) Content of certification.
(i) The individual needs, or needed, physical therapy or speech pathology services.
(ii) The services were furnished while the individual was under the care of a physician, nurse practitioner, clinical nurse specialist, or physician assistant.
(iii) The services were furnished under a plan of treatment that meets the requirements of §410.61 of this chapter.

(2) Timing.
The initial certification must be obtained as soon as possible after the plan is established.

(3) Signature.
(i) If the plan of treatment is established by a physician, nurse practitioner, clinical nurse specialist, or physician assistant, the certification must be signed by that physician or nonphysician practitioner.
(ii) If the plan of treatment is established by a physical therapist or speech-language pathologist, the certification must be signed by a physician or by a nurse practitioner, clinical nurse specialist, or physician assistant who has knowledge of the case.

Resources:
MLN Outpatient Rehabilitation Therapy Services: Complying with Documentation Requirements Booklet (PDF, 848 KB)

42 CFR §424.24 

Q2. What happens when the referring provider is not cooperative in signing the POC and returning it to us?

A2. According to the CMS MLN 905365 Outpatient Rehabilitation Therapy Services: Complying with Documentation Requirements Booklet (PDF, 848 KB), outpatient rehabilitation therapy services must relate directly and specifically to a written treatment plan (also known as the POC). You must establish the treatment plan/POC before treatment begins, with some exceptions. CMS considers the treatment plan/POC established when it is developed (written or dictated) by a PT, an OT, an SLP, a physician, or an NPP. The guidelines state "Record the signature and professional identity of the person who established the POC and the date they established it” and “The physician’s/NPP’s signature and date on a correctly written POC (with or without an order) satisfies the certification requirement for the duration of the POC or 90 calendar days from the date of the initial treatment, whichever is less. Include the initial evaluation indicating the treatment need in the POC. The physician/NPP certifies the initial POC with a dated signature or verbal order within 30 days following the first day of treatment (including evaluation). The physician/NPP must sign and date verbal orders within 14 days”.  Because of these requirements, the POC would require the POC contain the certification.

Q3. Do you have an example of a justification statement that can be used for documentation to support the KX modifier?

A3
. There are no specific justification statements. The documentation should have notes that support the patient's condition and how they require the skills of the licensed therapist for the delivery of the services. These should be evident in the evaluation, progress notes, and plan of care in the patient record. 

Q4. If the patient stops therapy for a month due to any reason, and then returns for therapy after the certification period ends for the same condition, should this be a re-evaluation with a new certification period? 

A4. The question “Should this be a re-evaluation with a new certification period?” addresses two distinct topics:

  1. Does the beneficiary require a new certification period?
  2. Does the beneficiary require a re-evaluation?

In regard to question 1, the answer is yes. When a certification period has ended, a new certification or a recertification is required for therapy services to be covered.

In regard to question 2, this is a clinician decision. Per the IOM 100-02 Medicare Benefit Policy Manual, Chapter 15, Section 220 A:  “Re-evaluation is separately payable and is periodically indicated during an episode of care when the professional assessment of a clinician indicates a significant improvement, or decline, or change in the patient's condition or functional status that was not anticipated in the plan of care. Although some state regulations and state practice acts require re-evaluation at specific times, for Medicare payment, reevaluations must also meet Medicare coverage guidelines. The decision to provide a reevaluation shall be made by a clinician.”

Please note that a certification interval is distinct from an episode of care. (Both of these terms are defined in the IOM 100-02, Chapter 15, Section 220 A.)

Resource:
IOM 100-02 Medicare Benefit Policy Manual, Chapter 15, Section 220 A (PDF, 1.26 MB)

Q5. If the certification period ends and the patient is sick for the last week of certified POC, how should the therapist record the start date of the next certification period if the patient is to continue services?
 
A5. Since, in your example, the initial certification has ended without a recertification within the duration of that plan of care, a recertification would be required.

See the Medicare Benefit Policy Manual, IOM 100-02, Chapter 15, Section 220.1.3 - Certification and Recertification of Need for Treatment and Therapy Plans of Care, for additional guidance.

Resource:
IOM 100-02 Medicare Benefit Policy Manual, Chapter 15, Section 220.1.3 (PDF, 1.26 MB)

Q6. What is the course number?

A6
. RRB2095126

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