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Outpatient Occupational and Physical Therapy Services Billing Guide
- Introduction to Outpatient OT and PT Services
- Outpatient Occupational and Physical Therapy Coverage
- Caregiver Training Services
- KX Modifier Threshold
- 2024 Annual Update to the Therapy Code List: Remote Therapeutic Monitoring
- Annual Update to the Therapy Code List
- Targeted Medical Review
- Functional Reporting - Using the G Codes
- What is the Advance Beneficiary Notice of Noncoverage and When to Use It in Outpatient Therapy
- Maintenance Programs
- Multiple Procedure Payment Reduction
- The National Correct Coding Initiative
- Comprehensive Error Rate Testing Program
- Recovery Auditor
- Common Billing Errors and Remittance Message
- Medical Review Therapy Documentation Checklist for Additional Development Request Letters
- Common Questions and Answers
- Related Content
- Related Articles
KX Modifier Threshold
The Bipartisan Budget Act of 2018 repealed application of the Medicare outpatient therapy caps but retains the former cap amounts as a threshold above which claims must include the KX modifier as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record.
- For CY 2024, the limit on incurred expenses is $2,330 for PT and SLP services combined. There’s another limit of $2,330 for OT services.
- For CY 2023, the limit on incurred expenses is $2,230 for PT and SLP services combined. There’s another limit of $2,230 for OT services.
Deductible and coinsurance amounts paid by the beneficiary for therapy services count toward the amount applied to the limit.
Providers can find out if your patient is approaching their therapy cap by checking the patient’s eligibility record in NGSConnex. If you have not signed up for NGSConnex please visit the aforementioned link.
The therapy cap applies to all Part B outpatient therapy settings and providers including:
- Therapists’ private practices
- Offices of physicians and certain NPPs
- Part B SNFs
- HHAs (TOB 34X)
- Rehabilitation agencies (also known as ORFs)
- CORFs
- HOPDs
- CAHs (TOB 85X) ‒ (2014)
Related Content
- Change Request 13371: 2024 Annual Update of Per-Beneficiary Threshold Amounts
- Annual Therapy Update
- Change Request 12923: 2023 Annual Update of Per-Beneficiary Threshold Amounts
Reviewed 10/07/2024