Insurance & Billing General

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.

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

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!