Knowledge Base Article

I like people with a passion for life and enthusiasm for the things they do. It certainly makes life more enjoyable if you love what you are doing. However, it is important to balance enthusiasm with appropriate limits. I am enthusiastic about reading and I read for pleasure nightly before bedtime, but I have to cut myself off at some point to ensure I have time for a good night of sleep. Others may have to balance exercise or other activities with their physical limitations, especially when they are not as young as they once were. And it is good to love your job, but important to take time off too. Bottom line - it is good to have passion, but also good to know your limits.

Hopefully as healthcare workers, we have passion for our jobs. I understand that healthcare disciplines for rehabilitative therapy want to ensure their patients get the maximum benefit from the services Medicare covers. However, most Medicare rehabilitative services have duration limits.

Specifically:

• Cardiac rehabilitation (CR) program sessions are limited to a maximum of 2 1-hour sessions per day for up to 36 sessions over up to 36 weeks, with the option for an additional 36 sessions over an extended period of time if approved by the Medicare contractor.
• Pulmonary rehabilitation (PR) program sessions are limited to a maximum of 2 1-hour sessions per day for up to 36 sessions, with the option for an additional 36 sessions if medically necessary.
• There are physical therapy (PT), occupational therapy (OT), and speech language pathology (SLP) therapy thresholds (formerly therapy cap amounts) above which services are only covered if services beyond the threshold are medically necessary as justified by appropriate documentation in the medical record. For CY 2019 this therapy threshold amount is:
• $2,040 for PT and SLP services combined, and
• $2,040 for OT services.

The good news for enthusiastic rehabilitative therapists and providers is that Medicare does allow medically necessary additional services up to a defined point. This is where the KX modifier comes in.

For cardiac and pulmonary rehab, Medicare contractors shall accept the inclusion of the KX modifier on the claim lines as an attestation by the provider of the service that documentation is on file verifying that further treatment beyond the 36 sessions is medically necessary up to a total of 72 sessions for that beneficiary.

For PT, OT, and Speech therapy, claims with therapy services exceeding the threshold amounts must include the KX modifier as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record.

This means that for CR, PR, PT, OT, and SLP services exceeding Medicare’s duration limits as described above, a KX modifier is required on the line item(s) in order for Medicare to make payment for the services. In reviewing Medicare remittances, I often see denials of these types of services with Claim Adjustment Reason Code (CARC) 119 - Benefit maximum for this time period or occurrence has been reached. Many of these denials could be avoided with the inclusion of the KX modifier. Providers should only use the KX modifier for rehabilitative services when it is appropriate – that is, the services are medically necessary and there is documentation in the medical record to support that. Properly applying the KX modifier requires that providers keep up with the number of sessions for CR and PR, and with the beneficiary’s therapy amounts for PT, OT, and SLP. The Medicare eligibility systems contain information on therapy spending to date as well as information on the number of PR and CR sessions billed to date.

Other things to remember about these duration limits - Cardiac Rehab is limited to 72 sessions for an episode of care. Within that episode, sessions beyond 72 will deny for payment even if the KX modifier is included. There is not a lifetime limit of 72 sessions for cardiac rehab; a patient qualifies for 36 (within 36 weeks) and up to 72 sessions after each qualifying cardiac episode. Pulmonary rehab is limited to a maximum of 72 sessions in a lifetime and PR sessions beyond 72 will deny for payment even if the KX modifier is included. Unlike the time limit of 36 sessions within 36 weeks for cardiac rehab, there is no stated time limit for providing the 36-72 sessions of pulmonary rehab.

There are no set dollar limits for PT, OT, and SLP therapy, other than the requirements for medical necessity and patient benefit. At some point, therapy treatment for a condition generally reaches a plateau where further therapy adds no benefit for the patient or simply becomes routine maintenance therapy that does not require the skills of a therapist and therefore does not meet the Medicare therapy benefit definition. Also note that PT and SLP services combined, and OT services are subject to a targeted medical review (MR) at a threshold amount of $3,000. Not all claims exceeding the MR threshold amount are subject to review as they once were, but only selected claims based on billing patterns.

The lesson for hospitals here is to proactively be aware of the session and dollar limits for rehabilitative services and appropriately use the KX modifier to ensure proper payment. It is also a good idea to monitor your claim denials, specifically looking for denials with CARC 119. Once denied, you would have to appeal the claim to receive payment, which may not be worth the time and effort. However, reviewing these denials will let you know if upfront systems are working. If not, you may want to make process changes to ensure appropriate reimbursement. No matter how much passion we have for healthcare, we still need to be paid to keep the doors open.