KX — SPECIFIC REQUIRED DOCUMENTATION ON FILE. (EFFECTIVE DATE 7/1/2002) This modifier may be used to indicate that specific required documentation is on file in the patient’s medical record. Documentation must be submitted upon request. Applicable policies include: Manual and power mobility bases and accessories, Glucose monitors & supplies, PAP devices and accessories, Respiratory Assist Devices (RAD), Commodes, Hospital beds and accessories, Therapeutic Shoes for Diabetics, Heavy duty walkers, Urological Supplies, Epoetin, Support surfaces – Groups 1, 2, and 3, Refractive Lenses – Anti reflective coating, tint, and oversize lenses, polycarbonate lenses, Cervical Traction devices – Codes E0849 and E0855, External infusion (insulin) pumps, High Frequency chest wall oscillation devices, Nebulizers (Brovana or Perforomist) – J7605 and J7606, Negative Pressure Wound Therapy, Patient lifts – E0636 and E1035, Speech generating devices, Wheelchair seating, Orthopedic Footwear, Home Dialysis supplies, Oral Antiemetic – J8502 and J8540.
Use the KX 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 modifier for all patients with these conditions will likely show up on data analysis as aberrant and invite inquiry. Be sure that documentation is sufficiently detailed to support the use of the modifier.
When exceptions are in effect and the beneficiary qualifies for a therapy cap exception, the provider shall add a KX modifier to the therapy HCPCS code subject to the cap limits. The KX modifier shall not be added to any line of service that is not a medically necessary service; this applies to services that, according to a local coverage determination by the contractor, are not medically necessary services
The GN, GO, or GP therapy modifiers are currently required to be appended to therapy services. In addition to the KX modifier, the GN, GP and GO modifiers shall continue to be used. Providers may report the modifiers on claims in any order. If there is insufficient room on a claim line for multiple modifiers, additional modifiers may be reported in the remarks field. Follow the routine procedure for placing HCPCS modifiers on a claim as described below.
For claims paid by a carrier or an A/B MAC(B), it is only appropriate to append the KX modifier to a service that reasonably may exceed the cap. Use of the KX modifier when there is no indication that the cap is likely to be exceeded is abusive. For example, use of the KX modifier for low cost services early in an episode when there is no evidence of a previous episode that might have exceeded the cap is inappropriate.
KX Modifier
If there is a requirement in a specific policy to use a KX modifier to indicate that an item meets coverage criteria, then it is used in addition to the GK or GL modifier. For example:
• If a power wheelchair that does not meet coverage criteria specified in the policy is provided and an ABN is obtained, the supplier bills the HCPCS code for the PWC that is provided with a GA modifier and no KX modifier on one claim line and the HCPCS code for the PWC that meets coverage criteria with a GK modifier and a KX modifier on the next claim line.
• If a supplier does not obtain an ABN and therefore provides an upgrade without any additional charge to the beneficiary, the supplier either (1) bills the HCPCS code for the item that meets coverage criteria with the GL modifier and a KX modifier or (2) bills the HCPCS code for the PWC that is provided with a GZ modifier and no KX modifier on one claim line and the HCPCS code for the PWC that meets coverage criteria with a GK modifier and a KX modifier on the next claim line. The specific situations in which the GZ/GK combination is used instead of the GL are discussed above .
By appending the KX modifier, the provider is attesting that the services billed:
Are reasonable and necessary services that require the skills of a therapist;
Are justified by appropriate documentation in the medical record, Qualify for an exception using the automatic process exception.
Update from Medicare on usage of KX modifier
The Balanced Budget Act of 1997 applies annual financial limitations for outpatient therapy services for Medicare Part B. These limitations are also referred to as “therapy caps.” The therapy caps are updated each year based on the Medicare economic index.
Providers of outpatient therapy services are required to submit the KX modifier on their therapy claims, when an exception to the cap is requested for medically necessary services. Section 202 of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) extended the therapy cap exceptions process through December 31, 2017. As a reminder, excessive use of the KX modifier including routine use of the modifier prior to reaching the cap limits may indicate abusive billing.
Change request 9865 establishes that outpatient therapy caps for 2018 will be $2010 for physical therapy and speech-language therapy combined, and for occupational therapy.
Overview
Supplier usage of the KX modifier identifies that the requirements identified in the medical policy have been met. Documentation is essential to support that the item is reasonable and necessary and that the specific coverage criteria specified in each policy have been met.
Below is a list of LCDs which include a KX modifier requirement for some or all items within that specific LCD.
Use of the KX modifier with any other DMEPOS is inappropriate usage.
** Ankle-Foot/Knee-Ankle-Foot Orthosis
** Automatic External Defibrillators
** Cervical Traction Devices
** Commodes
** External Infusion Pumps
** Glucose Monitors
** High Frequency Chest Wall Oscillation Devices
** Hospital Beds
** Immunosuppressive Drugs
** Knee Orthoses
** Manual Wheelchair Bases
** Nebulizers
** Negative Pressure Wound Therapy Devices
** Oral Antiemetic Drugs (Replacement for Intravenous Antiemetic’s)
** Oral Appliances for Obstructive Sleep Apnea / Respiratory Assist Devices
** Orthopedic Footwear
** Patient Lifts
** Positive Airway Pressure Devices
** Power Mobility Devices
** Pressure Reducing Support Surfaces
** Refractive Lenses
** Speech Generating Devices
** Therapeutic Shoes for Persons with Diabetes
** Transcutaneous Electrical Nerve Stimulators (TENS)
** Urological Supplies
** Walkers
** Wheelchair Options and Accessories
** Wheelchair Seating
Reimbursement Guidelines (LCD); suppliers should review the LCDs carefully to understand the documentation requirements and the proper use of the KX modifier for each policy.
It is important to remember, if the requirements specified in the LCD are not met the KX modifier must not be used.
Exceptions to Therapy Caps – General
The following policies concerning exceptions to caps due to medical necessity apply only when the exceptions process is in effect. Except for the requirement to use the KX modifier, the guidance in this section concerning medical necessity applies as well to services provided before caps are reached.
Provider and supplier information concerning exceptions is in this chapter and in Pub.
Exceptions shall be identified by a modifier on the claim and supported by documentation.
The beneficiary may qualify for use of the cap exceptions process at any time during the episode when documented medically necessary services exceed caps. All covered and medically necessary services qualify for exceptions to caps. All requests for exception are in the form of a KX modifier added to claim lines. (See subsection D. for use of the KX modifier.)
Use of the exception process does not exempt services from manual or other medical review processes as described in Pub. 100-08. Rather, atypical use of the exception process may invite contractor scrutiny, for example, when the KX modifier is applied to all services on claims that are below the therapy caps or when the KX modifier is used for all beneficiaries of a therapy provider. To substantiate the medical necessity of the therapy services, document in the medical record
The KX modifier, described in subsection D., is added to claim lines to indicate that the clinician attests that services at and above the therapy caps are medically necessary and justification is documented in the medical record.
It is very important to recognize that most conditions would not ordinarily result in services exceeding the cap. Use the KX 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 modifier for all patients with these conditions will likely show up on data analysis as aberrant and invite inquiry. Be sure that documentation is sufficiently detailed to support the use of the modifier.
In justifying exceptions for therapy caps, clinicians and contractors should not only consider the medical diagnoses and medical complications that might directly and significantly influence the amount of treatment required. Other variables (such as the availability of a caregiver at home) that affect appropriate treatment shall also be considered. Factors that influence the need for treatment should be supportable by published research, clinical guidelines from professional sources, and/or clinical or common sense.
Ankle-Foot/Knee-Ankle-Foot Orthosis
Suppliers must add a KX modifier to the AFO/KAFO base and addition codes only if all of the coverage criteria in the “Indications and Limitations of Coverage and or Medical Necessity” section of the LCDs have been met and evidence of such is retained in the supplier’s files and available to the DME MAC upon request.
If all of the criteria in the Indications and Limitations of Coverage and/or Medical Necessity section have not been met, the GA or GZ modifier must be added to the code. When there is an expectation of a medical necessity denial, suppliers must enter the GA modifier on the claim line if they have obtained a properly executed Advanced Notice of Non-coverage (ANN) or the GZ modifier if they have not obtained a valid ANN.
Claims lines billed with codes without a KX, GA or GZ modifier will be rejected as missing information
The KX modifier has differing requirements for usage depending on the specific Local Coverage Determination
The GN, GO, or GP therapy modifiers are currently required to be appended to therapy services. In addition to the KX modifier, the GN, GP and GO modifiers shall continue tobe used. Providers may report the modifiers on claims in any order. If there is insufficient room on a claim line for multiple modifiers, additional modifiers may be reported in the remarks field.
• For institutional claims, sent to the A/B MAC(A):
o When the cap is exceeded by at least one line on the claim, use the KX modifier on all of the lines on that institutional claim that refer to the same therapy cap (PT/SLP or OT), regardless of whether the other services exceed the cap. For example, if one PT service line exceeds the cap, use the KX modifier on all the PT and SLP service lines (also identified with the GP or GN modifier) for that claim. When the PT/SLP cap is exceeded by PT services, the SLP lines on the claim may meet the requirements for an exception due to the complexity of two episodes of service.
o Use the KX modifier on either all or none of the SLP lines on the claim, as appropriate. In contrast, if all the OT lines on the claim are below the cap, do not use the KX modifier on any of the OT lines, even when the KX modifier is appropriately used on all of the PT lines.
Q & A
Q: Why is the “KX” Modifier used?
A: The KX modifier is used whenever maximum service units have been met. For claims paid by a carrier or A/B MAC, it is only appropriate to append the KX modifier to a service that reasonably may exceed the cap. Use of the KX modifier when there is no indication that the cap is likely to be exceeded is considered abusive.
Q: What are the guidelines for the use of the “KX” Modifier?
A: The KX modifier is added to claim lines to indicate that the clinician attests that services are medically necessary and justification is documented in the medical record. Even though no special documentation is submitted to the contractor for automatic process exceptions, the clinician is responsible for consulting guidance in the Medicare manuals and in the professional literature to determine if the beneficiary qualifies for the automatic process exception. In addition, the clinician’s opinion is not binding on the Medicare contractor; the Medicare contractor makes the final determination concerning whether the claim is payable.
Q: When are exceptions to the therapy caps for services provided in a SNF setting considered?
Revised 09/2015
A: Since the creation of therapy caps, Congress has enacted several moratoria. The Deficit Reduction Act of 2005 directed CMS to develop exceptions to therapy caps for calendar year 2006 and the exceptions have been extended periodically. The cap exception for therapy services billed by outpatient hospitals was part of the original legislation and applies as long as caps are in effect.
Q: Does the KX modifier apply to all claims types?
A: Since the limitations apply to outpatient services, they do not apply to skilled nursing facility (SNF) residents in a covered Part A stay, including patients occupying swing beds. Rehabilitation services are included within the global Part A per diem payment that the SNF receives under the prospective payment system (PPS) for the covered stay. Also, limitations do not apply to any therapy services covered under prospective payment systems for home health or inpatient hospitals, including critical access hospitals.
Revised 09/2015
Q: What are the regulations for submitting medical records when exceeding the cap (with the use of a “KX” modifier?
A: Documentation justifying the services shall be submitted in response to any Additional Documentation Request (ADR) for claims that are selected for medical review. If medical records are requested for review, clinicians may include, at their discretion, a summary that specifically addresses the justification for therapy cap exception and they should follow the documentation requirements listed
Overview
Supplier usage of the KX modifier identifies that the requirements identified in the medical policy have been met. Documentation is essential to support that the item is reasonable and necessary and that the specific coverage criteria specified in each policy have been met.
Below is a list of LCDs which include a KX modifier requirement for some or all items within that specific LCD.
use of the KX modifier with any other DMEPOS is inappropriate usage.
* Ankle-Foot/Knee-Ankle-Foot Orthosis
* Automatic External Defibrillators
* Cervical Traction Devices
* Commodes
* External Infusion Pumps
* Glucose Monitors
* High Frequency Chest Wall Oscillation Devices
* Hospital Beds
* Immunosuppressive Drugs
* Knee Orthoses
* Manual Wheelchair Bases
* Nebulizers
* Negative Pressure Wound Therapy Devices
* Oral Antiemetic Drugs (Replacement for Intravenous Antiemetic’s)
* Oral Appliances for Obstructive Sleep Apnea / Respiratory Assist Devices
* Orthopedic Footwear
* Patient Lifts
* Positive Airway Pressure Devices
* Power Mobility Devices
* Pressure Reducing Support Surfaces
* Refractive Lenses
* Speech Generating Devices
* Therapeutic Shoes for Persons with Diabetes
* Transcutaneous Electrical Nerve Stimulators (TENS)
* Urological Supplies
* Walkers
* Wheelchair Options and Accessories
* Wheelchair Seating
Reimbursement Guidelines
The KX modifier has differing requirements for usage depending on the specific Local Coverage Determination (LCD); suppliers should review the LCDs carefully to understand the documentation requirements and the proper use of the KX modifier for each policy.
It is important to remember, if the requirements specified in the LCD are not met the KX modifier must not be used.
Most LCDs include a modifier which indicates the documentation requirements are not met by appending either a GA or GZ modifier if a claim is denied for missing one of these modifiers it must be resubmitted.
Use of the KX Modifier for Therapy Cap Exceptions
When exceptions are in effect and the beneficiary qualifies for a therapy cap exception, the provider shall add a KX modifier to the therapy HCPCS code subject to the cap limits. The KX modifier shall not be added to any line of service that is not a medically necessary service; this applies to services that, according to a local coverage determination by the contractor, are not medically necessary services.
The codes subject to the therapy cap tracking requirements for a given calendar year are listed at: http://www.cms.hhs.gov/TherapyServices/05_Annual_Therapy_Update.asp#TopOfPage.
The GN, GO, or GP therapy modifiers are currently required to be appended to therapy services. In addition to the KX modifier, the GN, GP and GO modifiers shall continue to be used. Providers may report the modifiers on claims in any order. If there is insufficient room on a claim line for multiple modifiers, additional modifiers may be reported in the remarks field. Follow the routine procedure for placing HCPCS modifiers on a claim as described below.
• For professional claims, sent to the A/B MAC(B), refer to:
o Pub.100-04, Medicare Claims Processing Manual, chapter 26, for more detail regarding completing Form CMS 1500, including the placement of HCPCS modifiers. NOTE: The Form CMS 1500 currently has space for providing four modifiers in block 24D, but, if the provider has more than four to report, he/she can do so by placing the -99 modifier (which indicates multiple modifiers) in block 24D and placing the additional modifiers in block 19.
o The ASC X12N 837 Health Care Claim: Professional Implementation Guide for more detail regarding how to electronically submit a health care claim transaction, including the placement of HCPCS modifiers. The ASC X12N 837 implementation guides are the standards adopted under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) for submitting health care claims electronically. The 837 professional transaction currently permits the placement of up to four modifiers, in the 2400 loop, SV1 segment, and data elements SV101-3, SV101-4, SV101-5, and SV101-6. Copies of the ASC X12N 837 implementation guides may be obtained from the Washington Publishing Company.
o For claims paid by a carrier or an A/B MAC(B), it is only appropriate to append the KX modifier to a service that reasonably may exceed the cap. Use of the KX modifier when there is no indication that the cap is likely to be exceeded is abusive. For example, use of the KX modifier for low cost services early in an episode when there is no evidence of a previous episode that might have exceeded the cap is inappropriate.
• For institutional claims, sent to the A/B MAC(A):
o When the cap is exceeded by at least one line on the claim, use the KX modifier on all of the lines on that institutional claim that refer to the same therapy cap (PT/SLP or OT), regardless of whether the other services exceed the cap. For example, if one PT service line exceeds the cap, use the KX modifier on all the PT and SLP service lines (also identified with the GP or GN modifier) for that claim. When the PT/SLP cap is exceeded by PT services, the SLP lines on the claim may meet the requirements for an exception due to the complexity of two episodes of service.
o Use the KX modifier on either all or none of the SLP lines on the claim, as appropriate. In contrast, if all the OT lines on the claim are below the cap, do not use the KX modifier on any of the OT lines, even when the KX modifier is appropriately used on all of the PT lines. Refer to Pub.100-04, Medicare Claims Processing Manual, chapter 25, for more detail.
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