HCPCS Modifier KX
Specific required documentation on file.
Guidelines and Instructions
This modifier may be submitted on claims for:
- Outpatient physical therapy (PT), occupational therapy (OT or speech language pathology) and SLP services
- Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) submitted to the DME Medicare Administrative Contractors
- Gender-specific services for beneficiaries who are transgender, hermaphrodites or have ambiguous genitalia
For speech language pathology, physical therapy or occupational therapy services:
- Submit this modifier when the patient has already met the financial cap for PT/SLP or OT, and the service qualifies as an "exception" to be reimbursed over and above the cap
- Use of the KX HCPCS modifier indicates that the clinician attests that services at and above the therapy caps are medically necessary and reasonable, and justification is documented in the patient’s medical record
- Exceptions to the caps are allowed for medically necessary outpatient services only when Congress legislates the exceptions. Suppliers and providers can continue to use the KX HCPCS modifier to request an exception to the therapy cap on claims that are over the annual cap amounts.
- There is no manual process for requesting exceptions. When the service qualifies for an automatic claims processing exception based on the medical necessity of the service for the patient’s condition, submit the service with HCPCS modifier KX. Note that "automatic" refers to the manner in which the claim is processed and does not indicate that the exception itself is automatic.
- HCPCS modifiers GN, GO and GP are currently required to be appended to therapy services and must continue to be used in addition to the KX HCPCS modifier when a service meets the guidelines for an automatic exception to the therapy cap. This allows the approved therapy services to be paid, even though they are above the therapy cap financial limits.
- It is important to recognize that most conditions would not ordinarily result in services exceeding the cap. Use the KX HCPCS modifier only in cases where the condition of the individual patient is such that services are appropriately provided in an episode that exceeds the cap. Routine use of the KX HCPCS modifier for all patients with these conditions will likely show up on data analysis as aberrant and invite inquiry.
CY 2021, the KX Modifier Threshold Amounts
- $2,110 for physical therapy (PT) and speech-language pathology (SLP) services combined; and
- $2,110 for occupational therapy (OT) services
Obtaining Therapy Cap Information
You may access the accrued amount or remaining amount of therapy services from the Medicare beneficiary eligibility inquiry and response transactions.
Required documentation for CPT codes 97110, 97112, 97140 and 97530:
- Evaluation and plan of care including any other pertinent characteristics of the beneficiary
- Certifications and recertifications
- The history and physical exam pertinent to the patient’s care (including the response or changes in behavior to previously administered skilled services)
- The skilled services provided
- A detailed rationale that explains the need for the skilled service in light of the patient’s overall medical condition and experiences
- The complexity of the service to be performed
- Progress reports written by the clinician
- Services related to progress reports are to be furnished on or before every 10th treatment day
- Treatment notes for each visit detailing the patient’s response to the skilled services provided (may also serve as progress notes)
- When appropriate, a separate justification statement for services that are more extensive than is typical for the condition treated
- Payment and coverage conditions require that the plan must be reviewed as often as necessary but at least whenever it is certified or recertified to complete the certification requirements. It is not required that the same physician or NPP who participated initially in recommending or planning the patient's care certify and/or recertify the plans.
- CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 15, section 220.3 (PDF, 1.28 MB)
- CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 5, section 10.2 and 220-230.1 (PDF, 693 KB)
- CMS Medicare Benefit Policy Manual, (Pub 100-02), Chapter 6, §20.5.2 — “incident to” regulations
- LCD 34428: Outpatient PT
- LCD 34427: Outpatient OT
- Outpatient Rehabilitation Therapy Services: Complying with Documentation Requirements Booklet (PDF, 848 KB)
References for Gender/Procedure Conflicts
- CMS MLN Matters article MM6638 (PDF, 79 KB), Instructions Regarding Processing Claims Rejecting for Gender/Procedure Conflict