Per-Beneficiary KX Modifier Thresholds - JE Part A

The annual per-beneficiary incurred expenses amounts are now called the KX modifier thresholds for Calendar year (CY) 2021. These amounts were previously associated with the financial limitation amounts that were more commonly referred to as "therapy caps" before the Bipartisan Budget Act (BBA) of 2018 was signed into law repealing the application of the caps.

A provision of Section 50202 of the BBA of 2018 adds Section 1833(g)(7)(A) of the Act to preserve the former therapy cap amounts as thresholds above which claims must include the KX modifier to confirm that services are medically necessary as justified by appropriate documentation in the medical record.

• KX Modifier Threshold
• Medical Review Threshold

KX Modifier Threshold

Medicare will deny your claims for therapy services above these amounts without the KX modifier.

Therapy Thresholds Apply To:

Medical Review Threshold

Another provision of Section 50202 of the BBA of 2018 adds Section 1833(g)(7)(B) of the Act to maintain the targeted medical review process but at a lower threshold amount of $3,000.

This threshold amounts are termed the Medical Record (MR) threshold amount for Physical Therapy (PT) and Speech Language Pathology (SLP) services combined and another for Occupational Therapy (OT) services and will remain at $3,000 until CY 2028 at which time it will be updated by the Medicare Economic Index (MEI).

Resources

• CMS Medicare Learning Network (MLN) Matters (MM) 11532
• CMS MM 12014
• CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 5, Section 10.2 and Section 10.3
• CMS Change Request (CR) 10509 - Correction to Publication 100-04, Chapter 5
• CMS Therapy Services