Therapy Threshold, KX Modifier & The ABN FAQs

In this week’s article, I wanted to answer some of the most commonly asked questions I receive concerning the Medicare therapy threshold (formerly, the Medicare therapy cap), the KX modifier, claims exceeding $3,000 in a calendar year and when to and when not to use an advance beneficiary notice of noncoverage (ABN) for Medicare beneficiaries who exceed the annual therapy threshold and $3,000 in a calendar year. In this article, I will answer the following questions:

1. Why is it called the therapy threshold and not the therapy cap?

2. Why must I still use the KX modifier?

3. Will the annual therapy threshold dollar amount still increase each calendar year?

4. What is this $3,000.00 targeted medical review threshold?

5. Once a Medicare beneficiary exceeds the annual therapy threshold, do I use the KX modifier, issue an ABN or do both?

6. Once a Medicare beneficiary exceeds the annual targeted medical review threshold, do I use the KX modifier, issue an
ABN or do both?

7. Who is responsible for conducting the medical record reviews of claims that exceed the targeted medical review threshold?

8. What criteria is used to determine which claims that exceed $3,000 in a calendar year will be reviewed?

Lets begin!

Question