American Speech-Language-Hearing Association

Overview of the Medicare Therapy Cap Exceptions Process

Speech-Language Pathology Services

The exceptions process allows beneficiaries to access medically necessary Medicare Part B outpatient therapy services above the therapy cap. Please review the Medicare Claims Processing Manual, Chapter 5, Sections 10.2-10.5 [PDF] for a complete description of Medicare's policy for outpatient therapy caps, including the exceptions process and use of the KX modifier.

Use of the KX modifier

When the beneficiary qualifies for a therapy cap exception because of the demonstrated medical need to provide services above the therapy cap, the KX modifier is required with the CPT/HCPCS code on the claim form. The KX modifier can be included with claims prior to reaching the cap because the patient’s current accrued claims amount cannot be known for certain due to claims submitted by other providers. However, it should not routinely be used with claims significantly before reaching the cap because the KX modifier indicates services qualify for the exception. Overuse may result in additional reviews by contractors.

By appending the KX modifier, the SLP is attesting that the services billed:

  • are reasonable and necessary services that require the skills of the SLP;
  • are justified by appropriate documentation;
  • qualify for an exception.

The use of the GN modifier to identify speech-language pathology services is still required, in addition to the KX modifier. Providers may report the modifiers on claims in any order. (For example: 92507, GN, KX 92507)

Note: The KX modifier is not related to the funtional reporting requirements (G-codes) and should not be appended to the G-codes.

For speech-language pathology services, when the cap is exceeded by at least one line on the claim, use the KX modifier on all of the lines on that claim that refers to physical therapy and speech-language pathology services regardless of whether the other services exceed the cap.

To obtain a complete list of evaluation procedures that are recognized for coverage above the cap, go to CMS' Annual Therapy Update webpage.

Claims submitted when expenditures for combined speech-language pathology and physical therapy reach a $3,700 threshold will be stopped and subject to manual medical review.

Documentation

Documentation is key to ensuring compliance with the exceptions process. The speech-language pathologist's use of the KX modifier is an attestation to CMS that services are medically necessary and justification of the need for services above the cap is documented in the medical record. CMS continues to warn clinicians that the use of the automatic process for exception does not preclude a contractor from conducting other forms of medical review. Atypical use of the automatic exception process may invite contractor scrutiny. If CMS finds that documentation does not support the provision of services above the cap, the SLP may be subject to sanctions under the False Claims Act. CMS has stated that the Medicare contractor has the authority to make the final determination on whether or not to pay the claims.

Due to the increased reliance on the clinician's professional judgment, the need to appropriately document services is imperative. Documentation must show that skilled therapy services are medically necessary and that there is an expectation that the patient's condition will improve significantly in a reasonable and generally predictable period of time. Additional information on CMS documentation requirements can be found at ASHA's website or in Chapter 15, Section 220.2 of the Medicare Benefit Policy Manual [PDF].

In justifying exceptions from therapy caps, speech-language pathologists should document the medical conditions and/or complications associated with the patient. When a patient's condition is the reason for the exception, that condition must be related to the therapy goals and must either be the condition that is being treated or a complexity that directly and significantly impacts the rate of recovery of the condition being treated such that it is appropriate to exceed the caps.

Contact reimbursement@asha.org for questions.

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