KX Modifier - Medicare coverage of PT
I have a client on Traditional Medicare who has been getting PT twice a week and is nearing her $2480 cap of coverage. The outpatient rehab office did add a KX modifier to see if that can help to get more coverage after after she meets her cap.
I anticipate that they will deny coverage with the KX modifier. Anything we can/should be doing not to prepare if we want to appeal the denial other than getting medical records?
Thanks in advance!
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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!