KX Modifier Therapy Caps

diane.prince@optum360.com

Do you know if outpatient departments are a part of the therapy cap for hospital owned facilities and do we need to bill with the KX Modifier (bill type 12X)? I think the therapy cap only applies to Critical Care Hospitals. I know Medicare is holding Claims, I just wanted to ensure I’m billing correctly.

dwilliamsrsi

At the current time, outpatient hospitals (described under the Social Security Act, section 1833(a)(8)(B) are not subject to the therapy caps.  The Medicare Physician Fee Schedule Final Rule contains a detailed discussion, but the statutory authority for continuing the therapy caps for outpatient hospitals expired on December 31, 2017.  Medicare is holding claims in the expectation that Congress may act to reinstate the therapy cap to outpatient hospitals.  Modifier KX expired on December 31, 2017 as part of the exceptions process.  According to the current guidelines, anything over the cap is patient responsibility.  

diane.prince@optum360.com

Thank You so much, I appreciate the clarification on the KX modifier.

valerie@valorizeconsulting.com

The Bipartisan Budget Act of 2018 provides a fix for the therapy cap by permanently extending the current exceptions process, eliminating the need to address this issue from year to year. Among the provisions included in the new policy:

• Claims that go above $2,010 (adjusted annually) still will require the use of the KX modifier for attestation that services are medically necessary.
• The threshold for targeted medical review will be lowered from the current $3,700 to $3,000 through 2027; however, CMS will not receive any increased funding to pursue expanded medical review, and the overall number of targeted medical reviews is not expected to increase.
• Claims that go above $3,000 will not automatically be subject to targeted medical review. Instead, only a percentage of providers who meet certain criteria will be targeted, such as those who have had a high claims denial percentage or have aberrant billing patterns compared with their peers.