Everything You Need to Know About Modifier KX and 59

In July, WebPT hosted a webinar all about modifiers. During that presentation, compliance expert Tom Ambury and I discussed these sometimes confusing billing add-ons. And while yes, they are merely add-ons, they are anything but easy. That’s why I’ve dedicated my last two posts to these little buggers. Last month I covered the ABN-related modifiers. Today, I’m doing the same for the KX modifier and modifier 59—in a question and answer format. Hope this helps!

Therapy Cap-Related Modifier: KX

Q. Is the therapy cap based on allowable charges or what I bill?
A. The therapy cap is based on allowable charges, according to your region’s Medicare allowable fee schedule.
Q. Should I obtain prior authorization before applying the KX modifier?
A. No; right before you hit the cap ($1,920 for occupational therapy services and $1,920 for physical therapy and speech language pathology services combined), simply begin attaching the KX modifier to your claims. This is the automatic exception process. Just make sure you have on file complete and defensible documentation that supports the medical necessity of your services.
Q. Is attaching a KX modifier an automatic red flag for an audit?
A. No, attaching a KX modifier is perfectly acceptable, as long as the services you are providing in excess of the cap are, in fact, medically necessary. If your KX modifier practices fall outside of the norm, though, Medicare may request additional information or conduct an audit. In other words, if you apply the KX modifier significantly more or less than your regional peers do, Medicare may want to know why.
Q. But I thought all therapy services required the KX modifier. Is this not the case?
A. All therapy services definitely do not require the KX modifier. As the APTA explains, “The provider should [apply] the KX modifier to the therapy procedure code that is subject to the cap limits only when a beneficiary qualifies for a therapy cap exception. By attaching the KX modifier, the provider is attesting that the services billed:

  • Qualified for the cap exception;
  • Are reasonable and necessary services that require the skills of a therapist; and
  • Are justified by appropriate documentation in the medical record.”

Q. What should I do if I know early on that my patient is going to exceed the therapy cap?
A. Immediately begin thoroughly documenting why you believe the patient will exceed the therapy cap. However, don’t include the KX modifier on your claims until you are as close as possible to reaching the cap without going over. Attaching the KX modifier before it is necessary is a big no-no and could very well result in a Medicare audit.
Q. Is there an upper limit for the therapy cap?
A. Nope, there is no upper limit—as long as the services you are providing are medically necessary. However, there are additional steps you must take if you believe treatment beyond the manual medical review threshold of $3,700 is medically necessary. If you are in a prepayment state, your Medicare Administrative Contractor (MAC) will notify you that you must submit the appropriate documentation to an assigned Recovery Audit Contractor (RAC). If you are in a post-payment state, you will continue to receive reimbursement until you submit the appropriate documentation to your RAC, who will determine whether the services are covered. Please note that in the latter scenario, you’ll have to reimburse Medicare if it deems that the services in question are not, in fact, medically necessary.
Q. Am I in a pre- or post-payment review state?
A. Florida, California, Michigan, Texas, New York, Louisiana, Illinois, Pennsylvania, Ohio, North Carolina, and Missouri are all prepayment review states. All other states are post-payment review states.
Q. Does the therapy cap apply to initial evaluations and reevaluations?
A. Evaluations and reevaluations don’t count toward the cap as long as you’re performing them specifically for the purpose of determining whether additional services are medically necessary. If that’s the case, they will only count if you provide any treatment during the same visit.
Q. How do I know if it’s appropriate to apply the KX modifier for the services I want to provide?
A. Well, are the services you want to provide critical to the patient’s ability to function adequately in his or her daily life? Has the patient not yet reached his or her prior (or maximum) level of function?
If either answer is yes, you should probably continue treating the patient above the therapy cap by applying the KX modifier. If either answer is no, you may want to consider discharging the patient or providing services on a cash-basis, in which case you’ll want to issue an ABN and attach the GA modifier to the claim).
Q. If Medicare rejects my claim because of the cap, can I go back and rebill with the KX modifier?
A. Sure. If you receive a rejection because of the cap, you may go back and rebill using the KX modifier. Just make sure your documentation thoroughly supports the medical necessity of your services.
Q. How do I track my patients’ progress toward the therapy cap?
A. First, ask all new Medicare patients if they have received any therapy services—PT, OT, or SLP—at any time during the current calendar year. Once you know the total number of visits, you can safely calculate progress toward the cap by assuming $80 to $100 per visit.
You also can access this information through CMS in one of two ways:

  1. You can electronically view dollar amounts accrued toward the therapy limits on the ELGA or ELGB screens within the CWF (Common Working File) or on the HIQA screen for those providers who bill through fiscal intermediaries, or
  2. You can contact your Medicare contractor directly and request information regarding therapy services provided to a particular beneficiary. However, you should note that the amount accrued toward the financial limit is based on the claim received date rather than the date of service.

Q. Do I need to provide Medicare with supporting documentation when I submit my claim?
A. No, you don’t need to submit documentation to support the use of the KX modifier, unless Medicare requests you to do so. However, you should always have it ready just in case.

CCI-Edit Pair-Related Modifier: 59

Q. What is modifier 59?
A. Modifier 59 informs Medicare that you performed a procedure or service separately and distinctly from another non-evaluation and management service on the same day. Thus, you should receive payment for both CPT codes. For more information on how to appropriately use modifier 59—and support its use through documentation—check out this blog post by compliance expert Tom Ambury.
Q. Where can I find a list of codes with which to use modifier 59?
A. You can find all of the CCI edit pairs in the chart at the bottom of this blog post.
Q. Should I apply modifier 59 to the primary or secondary code in the pair?
A. You should apply modifier 59 to the secondary code in the edit pair (the ones listed in the far right column of the chart at the bottom of this blog post). Please note that you only need to apply modifier 59 to the individual code in question, not all line items.

Have more modifier questions? Send ’em my way in the comments section below, and I’ll respond with answers as soon as I can. Also, if you missed out on our modifier webinar, you can watch a recorded version for free right here.

About the Author

Heidi Jannenga, PT, MPT, ATC/L, Founder and COO of WebPT

As Chief Operating Officer, Heidi leads the product strategy and oversees the WebPT brand vision. She co-founded WebPT after recognizing the need for a more sophisticated industry-specific EMR platform and has guided the company through exponential growth, while garnering national recognition. Heidi brings with her more than 15 years of experience as a physical therapist and multi-clinic site director as well as a passion for healthcare innovation, entrepreneurship, and leadership.

An active member of the sports and private practice sections of the APTA, Heidi advocates for independent small businesses, speaks as a subject matter expert at industry conferences and events, and participates in local and national technology, entrepreneurship, and women-in-leadership seminars. Heidi is a mentor to physical therapy students and local entrepreneurs and leverages her platform to promote the importance of diversity, company culture, and overall business acumen for private practice physical therapy clinics.

Heidi was a collegiate basketball player at the University of California, Davis, and remains a life-long fan of the Aggies. She graduated with a BS in Biological Sciences and Exercise Physiology and went on to earn her MPT at the Institute of Physical Therapy in St. Augustine, Florida. When she’s not enjoying time with her daughter Ava, Heidi is perfecting her Spanish, practicing yoga, or hiking one of her favorite Phoenix trails.