Per-Beneficiary KX Modifier Thresholds

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

Therapy Type 2020 2021
Physical Therapy (PT and Speech-Language Pathology Combined $2080 $2110
Occupational Therapy (OT) $2080 $2110

 

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

Therapy Thresholds Apply To:

All Part B Outpatient Therapy Settings and Providers Including: Outpatient Hospitals as Detected By:
  • Therapists in private practice
  • Offices of physicians and certain non-physician practitioners
  • Part B skilled nursing facilities
  • Home health agencies
  • Rehabilitation agencies (also known as Outpatient Rehabilitation Facilities-ORFs)
  • Comprehensive Outpatient Rehabilitation Facilities (CORFs)
  • Hospital outpatient departments (HOPDs)
  • Critical Access Hospitals (CAHs)
  • Type of Bill 12X, 22X, 23X, 74X, 75X or 085X
  • Revenue code 042X, 043X, or 044X
  • Modifier GN, GO, or GP
  • Dates of service on/after January 1, 2014

 

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).

Therapy Type 2021-2028
Physical Therapy (PT and Speech-Language Pathology Combined $3000
Occupational Therapy (OT) $3000

 

Resources

 

Last Updated Mon, 21 Dec 2020 21:14:19 +0000