MACs to reprocess denied claims with modifier -KX

CMS instructed Medicare Administrative Contractors (MAC) to review previously denied outpatient therapy claims reported with modifier -KX (requirements specified in the medical policy have been met).

These claims may have been denied for exceeding the per beneficiary cap on physical therapy and speech language pathology combined as well as the separate occupational therapy cap. The Bipartisan Budget Act of 2018 permanently removed those caps retroactive to January 1. Although the cap was removed, providers are still required to report modifier -KX for services in excess of the prior cap amounts, CMS stated in MLN Matters 10531. Furthermore, although the effective date is January 1, the implementation date—the date on which MACs will begin to reprocess claims—is April 2.

CMS notes that institutional claims eligible for reprocessing include claims with revenue codes 042x, 043x, or 044x and modifiers -GN, -GO, or -GP. In addition, MACs are instructed to reprocess therapy claims with modifier -KX that were denied due to an invalid date CMS provided on February 12.

Providers should note that MACs might not automatically reprocess 2018 therapy claims. Claims that can’t be automatically reprocessed must be brought to the attention of the MAC. Providers should direct specific questions about modifier -KX to their MAC.