Speech-Language Pathology Services with KX HCPCS Modifiers Procedural Codes

This electronic Comparative Billing Report (eCBR) focuses on providers that submit claims for patients receiving services for speech-language pathology (SLP) with the KX HCPCS modifier. 

For your personalized SLP results log on to eServices. 

eCBR information is one of the many tools used by Palmetto GBA to assist individual providers in identifying variation and improving performance. Becoming proactive in addressing potential billing issues and performing internal audits will help ensure you are in compliance with Medicare guidelines.

Outpatient speech therapy services are provided by speech-language pathologists and are necessary for the diagnosis and treatment of speech and language disorders that result in communication disabilities and swallowing disorders (dysphagia). When Medicare payments for a beneficiary's combined physical therapy and speech therapy exceed an annual therapy spending threshold (e.g., $2,010 in 2018), the provider must append the KX HCPCS modifier to the appropriate Healthcare Common Procedure Coding System (HCPCS) reported on the claim. 

The KX HCPCS modifier denotes that outpatient physical therapy and speech therapy services combined have exceeded the annual spending threshold per beneficiary. Additionally, the KX HCPCS modifier indicates that the services provided are reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. 

According to the October 2019 Office of the Inspector General (OIG) Work Plan, the OIG will determine whether claims using the KX HCPCS modifier adhere to Federal requirements regarding the use of speech-language pathology (SLP) services with KX HCPCS modifiers. In addition, the OIG will evaluate payment trends to identify Medicare payments for outpatient speech therapy services billed using the KX HCPCS modifier that are potentially unallowable. The OIG expects to complete the review in 2024.

We encourage you to take advantage of the educational resources that are included in this correspondence along with the comparative billing chart. 

Methods

The metric reviewed in this eCBR is the percentage of covered charge for claims with CPT® codes 92507, 92526 and 97130 and with KX modifier compared to peers within state and jurisdiction. This report is an analysis of Medicare Part B of A and Part B claims extracted from the Palmetto GBA data warehouse. The analysis below shows the percentage of your covered charge for codes with KX modifier compared to your peers within the state and Jurisdiction J/M.

Example of eCBR Results from eServices

Resources 

• CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.3, Documentation Requirements for Therapy Services (PDF)
• Medicare Part B Payments for Speech-Language Pathology
• Medicare Claims Processing Manual, Chapter 5, Sections 10.2 and 220–230.1 (PDF)
• Medicare Benefit Policy Manual (cms.gov), Chapter 6, Section 20.5.2 “Incident to” regulations (PDF)
• MLN905365 — Complying with Outpatient Rehabilitation Therapy Documentation Requirements