Overview

The KX HCPCS modifier signals that “requirements specified in the medical policy have been met” and that services are medically necessary beyond a payer’s threshold (most commonly Medicare outpatient therapy thresholds for PT/OT/SLP). It attests that supporting documentation exists in the medical record. (Sources: APTA, NGS Medicare)

Why we need it

• Compliance: Medicare requires KX on claim lines once the beneficiary’s annual therapy threshold is exceeded (PT+SLP combined, and OT separately). Without KX, claims at/above the threshold can be denied.

• Payment continuity: KX allows medically necessary therapy to continue beyond the threshold, with the understanding those services may be subject to targeted medical review (generally over $3,000).

Types of Thresholds for Medicare

PT/SLP vs OT Medicare threshold remaining

• PT/SLP and OT are tracked in two separate “buckets” each calendar year. For CY2025 the thresholds are:

  • PT + SLP combined: $2,410

  • OT: $2,410

• Deductible and coinsurance count toward these amounts.

• “Threshold remaining” = threshold amount − total allowed therapy spend to date in that bucket (per calendar year)

CPT Codes that require a KX Modifier

Physical & Occupational Therapy

Speech-Language Pathology (SLP)

Common Occupational Therapy CPT Codes That Require the KX Modifier (when over threshold)

When would be KX modifier auto-applied?

• Patient has Medicare benefits applicable to outpatient therapy for the encounter

• Auto-apply KX modifier preference is enabled

• Rendering provider’s discipline maps to PT/SLP or OT for Medicare service type

• The CPT code is in the qualifying therapy list for that service type (PT/SLP vs OT)

• The calculation year is the appointment’s calendar year

• The patient’s Medicare therapy threshold remaining for that service type is ≤ 0 (i.e., threshold exceeded)

• KX isn’t already on the line; it’s appended alongside other therapy modifiers (e.g., GP/GO/GN)

• If a precomputed “threshold remaining” value is supplied and indicates exceeded, it’s used

Configuration

Setting PT/OT threshold on a per-patient level

1. On EHR > Calendar, click on any calendar cell.

2. Click on the expand content

3. On Appointment Details drawer > visits, expand the "Medicare Threshold Remaining"

4. Click on "Other Medicare Threshold Used".

You can modify the value according to your preference.

5. You can see the updated remaining value

$390.00 Medicare Threshold Remaining (PT/SLP)

Enabling auto-apply KX modifier preference

1. Go on EHR > Preferences

2. Click on General Tab

3. In the search box, type "KX"

4. You would see an entry titled "Auto-Apply KX Modifier"

5. Click on the switch to enable it

6. Once you click it, you will see the message "Setting updated successfully"

Click on the switch again if you want to turn it off.

Setting KX modifier traits on a template

1. Go to Templates Page

2. Create or edit a Template

3. Drag and drop Paragraph Answer

Only “Paragraph Answer” supports question traits at the moment

4. Fill the form

5. Click on Create a new trait

6. Type in the trait name

7. Type in a prompt that should be evaluated

8. Click on Evaluate only if Medicare has been reached

9. Go to EHR Preferences > Appointment Types

10. Add the new template to an Appointment Type

11. Done! Now start using the Appointment Type you set up.

Usage

Applying the KX modifier in the Treatment section

1. Go to a Appointment section of any selected Patient

2. You’ll notice that for Medicare thresholds, there are two types: the PT/SLP Medicare Threshold and the OT Medicare Threshold.

3. Check if the remaining Medicare threshold (e.g., PT/SLP) is negative (i.e., the threshold has been crossed).

4. Scroll down to the Treatment section, where you can search for and choose a CPT code.

5. Select one of the procedures (i.e., CPT codes) that is KX-modifier qualified (e.g., 97110)

6. After adding the qualified procedure, the KX modifier is automatically applied with a tooltip.

Applying the KX modifier in the Flowsheet Intervention section

1. Go to a Appointment section of any selected Patient

2. You’ll notice that for Medicare thresholds, there are two types: the PT/SLP Medicare Threshold and the OT Medicare Threshold.

3. Check if the remaining Medicare threshold (e.g., PT/SLP) is negative (i.e., the threshold has been crossed).

4. Scroll down to the Flowsheet section, where you can search for and choose a CPT code(i.e. “Search For Intervention).

5. Select one of the interventions (e.g., Cervical Thrust Manipulation (HVLAT)).

6. Select one of the procedures (i.e., CPT codes) that is KX-modifier qualified (e.g., 97110)

7. Now Mark it as Done

8. The KX modifier will be applied automatically, and you can also see the tooltip.