CMS Pub. 100-04, ch. 5, § 10.3.3

NOTE: Effective for dates of service on or after January 1, 2018, the KX modifier

continues to be used. It no longer represents an exception request but serves as a

confirmation that services are medically necessary after the beneficiary has exceeded the

KX modifier threshold of incurred expenses. Medicare claims systems process claims

with and without the KX modifier in the same manner described below and in section

10.4.

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.

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; (See

Pub. 100-02, chapter 15, section 220.2); and

• Are justified by appropriate documentation in the medical record, (See Pub.

100-02, chapter 15, section 220.3); and

• Qualify for an exception using the automatic process exception.

If this attestation is determined to be inaccurate, the provider/supplier is subject to

sanctions resulting from providing inaccurate information on a claim.

When the KX modifier is appended to a therapy HCPCS code, the contractor will

override the CWF system reject for services that exceed the caps and pay the claim if it is

otherwise payable.

Providers and suppliers shall continue to append correct coding initiative (CCI) HCPCS

modifiers under current instructions.

If a claim is submitted without KX modifiers and the cap is exceeded, those services will

be denied. In cases where appending the KX modifier would have been appropriate,

contractors may reopen and/or adjust the claim, if it is brought to their attention.

Services billed after the cap has been exceeded which are not eligible for exceptions may

be billed for the purpose of obtaining a denial using condition code 21.