KX Modifier on Outpatient Physical Therapy, Occupational Therapy or Speech Language Pathology Claims

Reminders

Providers report KX modifier on a claim line(s) to confirm the medical records contain specific required documentation that meets the appropriate LCD's requirements. For outpatient PT, OT or SLP services, the KX modifier is added to claim lines to indicate that the clinician attests that services at and above the therapy threshold(s) are medically necessary and justification is documented in the medical record.

KX Modifier Threshold

The BBA of 2018 repealed application of the Medicare outpatient therapy caps but retains the former cap amounts as a threshold above which claims must include the KX modifier as confirmation that such services are medically necessary as justified by appropriate documentation in the medical record.

For CY 2023, the threshold on incurred expenses is $2,230 for PT and SLP services combined and a separate threshold of $2,330 for OT services.

Note: The amount(s) applied toward deductible and coinsurance on therapy claims count toward the outpatient therapy limit(s).

You can determine if your patient is approaching their outpatient therapy threshold(s) by checking the patient’s eligibility record in NGSConnex. If you have not signed up for NGSConnex please visit the aforementioned link.

The therapy threshold(s) apply to all Part B outpatient therapy settings and providers including:

HOPDs
CAHs (TOB 85X)
Part B SNFs
Rehabilitation agencies (also known as ORFs)
CORFs
HHAs (TOB 34X)
Therapists’ private practices
Offices of physicians and certain NPPs

The presence of the KX modifier demonstrates that services billed:

Qualify for the annual threshold
Are reasonable and necessary services that require the skills of a therapist
Are justified by appropriate documentation in the medical record
Therapy services submitted without the KX modifier, for claims above the therapy threshold, will be denied

Targeted Medical Review Threshold

Along with the KX modifier threshold, the BBA of 2018 retains the targeted MR process at:

The MR threshold is $3,000 for PT and SLP services and $3,000 for OT services for CY 2023 and each calendar year until 2028 at which time it is indexed annually by the MEI

The targeted MR process means that not all claims exceeding the MR threshold amount are subject to review as they once were. For a general overview of the MR process, visit CMS' Medical Review and Education web page.

Additional Therapy Modifiers

The NGS LCD L33580 “Speech-Language Pathology” describes the coverage limits of outpatient SLP services under Medicare Part B when you provide such services under a therapy POC. Your claim must include the following modifier to distinguish the discipline of the POC under which the service is delivered:

GN – Services delivered under an outpatient SLP POC

The NGS LCD L33631 “Outpatient Physical and Occupational Therapy Services” describes the coverage limits of outpatient PT and OT services under Medicare Part B when services are provided under a therapy POC. Your claim must include one of the following modifiers to distinguish the discipline of the POC under which you delivered the service:

GO ‒ Services delivered under an outpatient OT POC; or
GP ‒ Services delivered under an outpatient PT POC

The modifiers are applicable to all claims from physicians, NPPs, PTPPs, OTPPs, CORFs, ORFs, HOPDs and SNFs billing under Medicare Part B, HHAs (when not rendered under a HH POC, but rendered under a therapy POC), and any other billing for PT or OT services. However, physical therapists may only report modifier GP and occupational therapists may only report modifier GO.

Providers may report the modifiers on claims in any order.

Therapy Services Furnished by PTA or OTA

For claims with DOS on/after 1/1/2020, Medicare requires the following modifiers to be billed to identify therapy services that were furnished in whole or in part by a PTA or OTA.

CQ modifier: PT services furnished in whole or in part by PTAs and
CO modifier: OT services furnished in whole or in part by OTAs.

Report modifier CQ with the therapy modifier GP and report modifier CO with the therapy modifier GO. If you submit claims with modifiers not so paired, the claim will be rejected and returned to you unprocessed.

For additional information on the therapy assistant modifiers, refer to the CMS Therapy Services web page as well as the CMS Billing Examples Using CQ/CO Modifiers for Services Furnished In Whole or In Part by PTAs and OTAs