Using the KX Modifier

Clinicians can become confused when it comes time to affix the KX modifier or the Advance Beneficiary Notice of Noncoverage. And despite the Medicare therapy cap repeal, not much has changed operationally since then. To simplify this process, here’s what you need to know about using the KX modifier to avoid claims denials and ensure payment. 

Apply the KX modifier when providing medically necessary services above the soft cap

Clinicians should apply the KX modifier to medically necessary services above the designated limit ($2,010 in 2018). This will signal Medicare to pay the claim. Continue to track your patients’ progress toward the desired threshold so you know when to apply the modifier.

This also means all your documentation should fully support the medical necessity of your services, as Medicare performs targeted reviews for claims over the secondary threshold of $3,000. However, don’t let this prevent you from billing Medicare for services above the threshold as long as they are, in fact, medically necessary. Don’t let fear of the KX modifier delay your patients’ progression through their care. 

Let NCDs and LCDs determine medical necessity

Medically necessary is a tricky term. What Medicare considers “reasonable and necessary” can be cloudy and opaque at best. The term varies, so it’s best to consult the National Coverage Determinations and Local Coverage Determinations. It’s up to you as the clinician to know your current NCDs and LCDs. In order to gain an understanding, you can download the NCD manual here and use this search tool to identify LCDs associated with your geographical location. 

Issuing ABN for services above the soft cap that are not medically necessary

If a patient would like a service that is not medically necessary, you can issue an ABN prior to performing the service. Issuing the ABN stands whether or not your patient has reached the soft cap yet. Once the ABN is signed and on file, you should still submit claims to Medicare with a GA modifier. This will trigger Medicare to reject those claims. But in doing so, you can collect payment directly from your patients for those services.