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.
Hi, Lorna! We've just started a quarterly gathering of the social workers that are plugged into GNA now. Our next meeting is in October. Check an eye out on the GNA closed FB group as well as here. Welcome!
Lynn, Glad to know you're here. CPOs are so important! I see a lot of ortho, SCI, neuro, and TBI — so I imagine we may have some crossover. I'll be keeping you in mind for a complex CPO case.
I can attest that when my husband was in the sub-acute rehab for 60 days, not a single staff member ever said, «Here's your toothbrush and spit cup.» If I wasn't there that day, the teeth didn't get brushed.
That was last year, and he just went through an extraction. UGH!
Shelbey, I've sent several people to your GNA profile recently. Hopefully they turn into business for you.
Welcome to 2026! My name is Kim Feth, and I'm a medical social worker turned mom and then wife managing medical crisis turned professional, private healthcare advocate. My practice is pretty much 50% insurance and billing issues and 50% complex discharge and pathway patients.
I wake up every day excited to see what problems I get to solve.
I appreciate this community of advocates who support each other while honoring that each advocate is unique and different.
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!
I'm so glad you're here and that you introduced yourself! I now realize I never introduced myself, so I'm going to do that now! Kim
That was last year, and he just went through an extraction. UGH!
Shelbey, I've sent several people to your GNA profile recently. Hopefully they turn into business for you.
Welcome to 2026! My name is Kim Feth, and I'm a medical social worker turned mom and then wife managing medical crisis turned professional, private healthcare advocate. My practice is pretty much 50% insurance and billing issues and 50% complex discharge and pathway patients.
I wake up every day excited to see what problems I get to solve.
I appreciate this community of advocates who support each other while honoring that each advocate is unique and different.
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