Insurance & Billing

You are correct, for 2026, CMS set the KX modifier threshold at $2,480 for PT and SLP combined with a separate $2480 for OT services.

Generally speaking, $2480 isn't a «hard» cap, it's a «soft cap». The KX modifier isn't a magic bullet, but it tells Medicare that the services are still needed and the medical necessity is contained in the medical record.

That having been said, Medicare can still deny it or pay it now and audit the provider later.

My favorite «go to solution» for situations like this are the FREE, DPT-student-led clinics for any patient who lives near a university or college with a PT program. Those clinics were meant to serve the people you're describing here — out of resources but still in need; while teaching the future DPTs. Availability may vary based on the university, the current patient load, and the academic school year calendar.

When my husband utilized a free DPT clinic, he received simultaneous services from: one, 3rd year DPT student, two, 2nd year DPT students, was observed by multiple undergrads, and had between 1-2 professors also treating and supervising.

Hope this helps!

THANK YOU for sharing!

Hi Marty! Your question is very interesting.

Medicare eligibility due to disability is usually connected to SSDI, not SSI. In most cases, once a person is approved for SSDI, there is a 24-month waiting period before Medicare coverage can begin.

Because every situation is different, the best next step would be for the patient to contact the Social Security Administration directly to confirm whether he may qualify for SSDI. My understanding is that the 40-quarter requirement is mainly related to retirement benefits, and SSA may apply different work-credit rules for disability benefits, especially for younger individuals who have not had enough time to build a long work history.

It may also be helpful for the patient to ask SSA to explain the possible benefits, limitations, and long-term impact before making a final decision. If disability benefits are approved at a young age, it may have future implications for earnings and benefits, so it is important that he receives guidance directly from SSA.

My suggestion is for the patient to call SSA, confirm his eligibility, ask about the pros and cons, and then decide whether moving forward with the SSDI application is the best option for his situation.

I truly hope this info helps you guide your patient toward the next steps that are best for her/his/their situation. Have a great day!

If someone is receiving SSI/SSDI under the age of 65 they will be eligible for medicare after 2 years. I would find out why the procedure is not covered and go from there.

I believe after 2 years they become eligible for Medicare. What’s their diagnosis and what is the procedure?

Here is an investigative article I recently wrote on WISeR: www.thinkglobalhealth.org/article/ai-driven-pilot-program-delays-access-to-care-for-americans

Good information to know. Thank you Dalia.

Good information. I have an investigative journalism piece on WISeR that will likely be published later this month and will share.

I would really like to connect with others about this because I have been working on this issue for over a year.

When Medicare began covering Principal Illness Navigation (PIN) services in 2024, I was very hopeful that this would finally give more patients access to professional navigation services. Unfortunately, as an independent navigator, I have found actually getting these services reimbursed to be extremely difficult.

In the process I have been working through, the treating practitioner who establishes the care plan—such as the oncologist or radiation oncologist—must be involved, and the navigator's services are connected to that practitioner's billing. I have also encountered requirements involving reassignment of benefits and documentation identifying the PIN services/navigation being provided. In my situation, we have been working with the G0023/G0024 PIN service codes.

This is where I keep hitting a wall.

Many physicians and practices understandably do not want to enter into a reassignment/billing arrangement with an independent navigator because of the administrative responsibility, compliance concerns and potential risk to their practice.

I have had several conversations and meetings regarding Medicare enrollment and billing trying to determine whether there is a compliant way for an independent PIN to provide these services without creating such a burden for the treating physician. So far, I have not found a workable solution.

What frustrates me most is the impact on patients. I see people who genuinely need navigation services but cannot afford private-pay advocacy. Medicare created PIN services specifically to address many of these needs, yet accessing the benefit through an independent navigator seems incredibly difficult.

Has anyone here successfully created a model where an independent navigator provides PIN services that are billed to Medicare?

I would especially love to hear:

• How are you structured with the physician/practice?
• Who bills Medicare?
• Did you need a reassignment of benefits?
• How did you handle the initiating visit and care plan requirements?
• How are you compensated by the billing practice?
• Have you found a compliant model that doesn't place an unreasonable administrative burden on the physician?

If anyone has successfully navigated this, I would really appreciate connecting and comparing notes. After more than a year of working on it, I would love to find a practical solution—especially because there are so many patients who need these services and simply cannot afford to pay for them out of pocket. Feel free to contact me via email at Aimee@CCC.Care or leave me a message here. Thanks

Hi Natasha,
The only Independent Advocate that I know that is billing Medicare is Terry McLellan — Sunnavhca. She is located in TX. I'm sure she will be happy to have a conversation with you. Here's her email: terry@sunnavhca.com
Let her know I referred you.
Tammy

Hi, Rachel!
Do you mean you are trying to become an advocate who accepts Medicare?

if so, there are a number of agencies around the country that accept Medicare. It is my understanding that an RN must work under a licensed supervising clinician, and the setup is long, indepth and complex. I know of one RN advocate who is deep into the process and actually building a training program she intends to offer once she has reached sort of 'a good endpoint' with the process.

I hope other nurses might respond here to provide more information, although if this question is about accepting Medicare as reimbursement, it's likely in the wrong conversation space, and I can move it for you.

If you would like the list of agencies that we at GNA are aware of and have had at least some contact with/knowledge of, feel free to ask. I'll gladly share it here.

Thanks for sharing, karen! Id love to see you start a conversation about long term care claims, knowing that's a niche you know well.

Thank you! this post is HUGELY helpful!

Such a great scenario to give that allows clients to more easily understand the benefit of advocates!

LOVE this!

Great job, Jeff!