Can I Use the KX Modifier Above $3700?

June 22, 2015
Rick Gawenda

I am often asked by therapists, office managers, biller’s, billing companies, etc., if the application of the KX modifier is allowed for Medicare beneficiaries who have exceeded $3700 physical and speech therapy combined in a calendar year or a separate $3700 for occupational therapy in a calendar year. Providers of therapy services are under the impression that Medicare beneficiaries have 2 therapy caps, one at $1940 in calendar year 2015 and a second therapy cap at $3700. Providers are also under the impression that once a Medicare beneficiary exceeds $3700, the KX modifier is no longer allowed to be applied to CPT codes on the claim form and that they must have the Medicare beneficiary or their representative sign an advance beneficiary notice of noncoverage even though the treating therapist has determined services are still medically necessary and require the unique skills of a therapist to provide.

Lets make one thing clear. There is only one annual therapy cap and in 2015, it is

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  1. We were under the impression you needed to have anything above the $3700 approved through our fiscal intermediary PRIOR to the services being provided.

  2. I had read somewhere on the site that the exceptions process was expected to change mid-July 2015. Any update on this?

  3. I have two questions regarding the use of ABN that i would like for you to clarify.
    First- Patient’s that are Medicare primary and have a Secondary carrier that will P/U with a denial from Medicare. It is medically necessary to continue care but care will be paid by the secondary. Is it right to use the GA modifier at $1,940.00 and to not use the KX modifier so that Medicare shows patient liability and the secondary will pay as per their plan. Can I use the GA modifier in this instance.

    1. If you feel therapy is medically necessary for the secondary to pay, shouldn’t the therapy then be medically necessary for the Medicare program to pay? If the therapist feels therapy is still medically necessary and requires the unique skills of a therapist to provide and they are above the therapy cap dollar threshold, you would want to use the KX modifier.