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Therapy Caps (Medicare Part B) KX Modifier Thresholds: Top 4 Things to Know

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Regulation written on multiple road sign-1Through your feedback and requests (thank you by the way) today’s blog is a clarification of the Therapy Caps. 

In 2018, the Bipartisan Budget Act of 2018 (HR 1892), canceled the existence of Medicare Part B Therapy Caps. The historically named Medicare Part B Therapy Caps (now known as the KX Modifier Thresholds) went into effect January 1, 2019. 

The Act maintained the requirement that a modifier be included on claims over the exception threshold.  The modifier represents confirmation that the services are medically necessary.

Overall, the below 4 items are important for you and your staff to know: 

  1. Tracking Thresholds

    The time frame for tracking these thresholds is January 1st- December 31st, 2019.
    In other words, the period of review is t the Calendar Year for:
    • physicians,
    • therapists,
    • and other providers submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs, for outpatient therapy services provided to Medicare Beneficiaries.PDPM Calculator
  2. Threshold Amounts

    The Physical, Occupational and Speech Therapy KX Modifier threshold amounts:
    • Physical Therapy (PT) and Speech-Language Pathology (SLP) services combined is $2,040.
    • Occupational Therapy (OT) services, the CY 2019 threshold amount is $2,040.
  3. No Modifier = Denial of Payment

    Claims for therapy services above these amounts without the KX Modifier are denied.
  4. Targeted Manual Medical Review

    The regulation also decreases the dollar amount which claims may be subject to targeted manual medical review.  A sample of claims above the $3,000 mark may undergo a review of the claim to assess whether the services were medically necessary.

I hope this helps the readers.  I look forward to the next Freaky Friday Webinar 6.21.19.New call-to-action

Harmony Healthcare International (HHI) is available to assist with any questions or concerns that you may have.  You can contact us by clicking here.  Looking to train your staff?  Join us in person at one of our our upcoming Competency/Certification Courses.  Click here to see the dates and locations. 


harmony20 October 29-30 2020 Encore Boston Harbor

Topics: Medicare Part B, Therapy Caps


Kris Mastrangelo, OTR/L, LNHA, MBA

WRITTEN BY

Kris Mastrangelo, OTR/L, LNHA, MBA
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