HCPCS Modifier KX

Published 07/01/2024

Description
Requirements specified in the medical policy have been met. Documentation on file. 

Guidelines and Instructions
This multipurpose informational 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 
  • Dental services, performed on/after January 1, 2023, for which providers are certain that they possess information to support that the dental services are inextricably linked to a covered medical service that demonstrates adherence to the requirements of the policy and that coordination of care between the medical and dental practitioners has occurred and have met the criteria of the payment policy. (See References for Dental Services section below for details.)

For speech language pathology, physical therapy or occupational therapy services:

  • Submit this modifier when the patient has already met the KX HCPCS modifier threshold (previously known as the therapy cap) for PT/SLP or OT, and the service qualifies as an "exception" to be reimbursed over and above the threshold
  • Use of the KX HCPCS modifier indicates that the clinician attests that services at and above the therapy thresholds are medically necessary and reasonable, and justification is documented in the patient’s medical record
  • Exceptions to the thresholds 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 threshold on claims that are over the annual threshold 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 threshold. This allows the approved therapy services to be paid, even though they are above the HCPCS KX Modifier threshold of incurred expenses. 
  • It is important to recognize that most conditions would not ordinarily result in services exceeding the threshold. 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 threshold. 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 2024, the KX Modifier Threshold Amounts

  • $2,330 for PT and SLP services combined; and
  • $2,330 for OT services

CY 2023, the KX Modifier Threshold Amounts

  • $2,230 for PT and SLP services combined; and
  • $2,230 for OT services

Obtaining Therapy Threshold Information
You may access the accrued amount or remaining amount of therapy services from the Medicare beneficiary eligibility inquiry and response transactions.

References for Outpatient Therapy 

References for Gender/Procedure Conflicts

References for Dental Services


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