Therapists have grown accustomed to using the KX modifier for outpatient therapy in order to over ride the therapy caps. For 2014, the therapy caps are $1920 for PT and SLP combined and $1920 for OT. When a patient exceeds one of the therapy caps, and therapy is still medically necessary the beneficiary’s financial limitations (therapy caps) can be over ridden with the use of the KX modifier on every claim line for therapy at or over the $1920 limit. Various CMS Medicare contractors are reporting that error rates from the Comprehensive Error Rate Testing Program (CERT) contain unnecessary errors related to therapist inappropriate use of the KX modifier to override, or bypass the therapy caps. In fact some MACs find this process so pervasive that they routinely provide email updates to encourage providers on the proper use of the therapy caps. (Heads up to Florida providers).
3 Tips on the Use of the KX Modifier for Outpatient Therapy
Even though the use of the KX modifier for an “automatic exceptions” process has been around since 2006, therapist are often unclear about its use, and in fact may not be aware of its use on specific patients if their billing software is automatically adding the KX modifier. These 3 tips on the use of the KX modifier for outpatient therapy will assist therapists and provider groups alike to stay clear of claims edits and chart audits by CMS contractors
- The KX modifier should only be used when the therapist (not the biller or the billing company) has made a determination that skilled therapy is medically necessary over the $1920 therapy caps. Therapist clinical judgment on this is the over riding factor.
- A therapist must provide specific documentation in the medical record addressing that therapy beyond the $1920 therapy cap is medically necessary and provide specifics to meet the medical necessity of skilled care documentation requirements.
- The KX modifier is appended on claims at or very close to the $1920 cap, and should not applied from the first visit, even if the therapist knows that the cap will likely be exceeded. At least one MAC has notified therapists that a pattern of early application of the KX modifier may be consider an abuse practice.
How to Document the Use of the KX Modifier for Outpatient Therapy
There are many reasons why a patient may exceed the therapy cap, and it is best practice to document the reason as soon as possible in either the therapy plan of care or progress report. The following scenarios suggest that a patient may exceed the therapy cap and should be documented as early as the initial plan of care:
- A single complex episode of care requiring therapy over the cap – for example a complex shoulder rehabilitation per protocol
- A single episode of care involving both physical therapy and speech-language pathology services – for example a stroke rehab program wherein both PT and SLP are utilizing the combined PT/SLP cap.
- A subsequent plan of care (in a calendar year) for a non-related problem – for example a total knee replacement rehab program in January followed by an unrelated episode for carpel tunnel syndrome
- Multiple episodes of care for the same presenting rehab diagnosis requiring additional therapy – for example a knee replacement rehab program followed by a subsequent knee rehab program necessitated by a revision
All the above indicate how the plan of care can be set up to immediately identify the likelihood of therapy exceeding the cap, it is still necessary for the therapist to weave the entire story together and address the medical necessity related to functional outcomes.
It’s all about function! But the story needs to address the details in order to support the therapy necessary to achieve the function.