HCPCS Modifier KX

Description
Requirements specified in the medical policy have been met. Documentation on file. 

Guidelines and Instructions
This multipurpose informational modifier may be submitted on claims for:

• Outpatient physical therapy (PT), occupational therapy (OT or speech language pathology) and 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 KX modifier threshold (previously known as the therapy 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 HCPCS 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 HCPCS 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 HCPCS 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 HCPCS 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 HCPCS modifier for all patients with these conditions will likely show up on data analysis as aberrant and invite inquiry.

CY 2023, the KX Modifier Threshold Amounts

• $2,230 for physical therapy (PT) and speech-language pathology (SLP) services combined; and
• $2,230 for occupational therapy (OT) services

CY 2022, the KX Modifier Threshold Amounts

• $2,150 for physical therapy (PT) and speech-language pathology (SLP) services combined; and
• $2,150 for occupational therapy (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 for Outpatient Therapy 

• CMS Medicare Benefit Policy Manual (Pub. 100-02), Chapter 15, Section 220.3 (PDF)
• CMS Medicare Claims Processing Manual (Pub. 100-04), Chapter 5, Section 10.2 and 10.3 (PDF)
• CMS Medicare Benefit Policy Manual, (Pub 100-02), Chapter 6, §20.5.2 §20.5.3 — “incident to” regulations (PDF)
• Complying with Outpatient Rehabilitation Therapy Documentation Requirements MLN Factsheet (PDF)

References for Gender/Procedure Conflicts

• CMS Medicare Claims Processing Manual (Pub. 100-02), Chapter 32, Section 240 - Special Instructions for Services with a Gender/Procedure Conflict  (PDF)