Question

You are a PT working in a Private Practice Outpatient facility, and as such, are subject to the reimbursement cap under Medicare Part B reimbursement structure. When you reach the initial cap, you can continue to be reimbursed through the exception process. In order to communicate this to the payer, what modifier must be added to your billing code(s)?

1) -59
2) -76
3) -KX
4) -NP

Answer 1

The correct modifier to be used by a PT working in a Private Practice Outpatient facility for services exceeding the Medicare Part B reimbursement cap, through the exception process, is -KX (option 3).

Step-by-step explanation:

As a Physical Therapist (PT) working in a Private Practice Outpatient facility, when providing services to Medicare Part B patients, there is a reimbursement cap which limits the amount that can be reimbursed for physical therapy services. However, in cases where medically necessary services exceed this cap, there is an exception process that allows continued reimbursement. In order to indicate that services above the cap are medically necessary on the billing claim, the modifier -KX must be appended to the relevant Current Procedural Terminology (CPT) codes. This modifier signals to Medicare that the services provided exceed the cap for covered physical therapy services and affirms that documentation is available on hand to justify the necessity of the services.

Hence, the answer is option 3.