(Medicare Claims Processing Manual)

 For institutional claims, sent to the A/B MAC(A):  o When the cap is exceeded by at least one line on the claim, use the KX modifier on all of the lines on that institutional claim that refer to the same therapy cap (PT/SLP or OT), regardless of whether the other services exceed the cap.  For example, if one PT service line exceeds the cap, use the KX modifier on all the PT and SLP service lines (also identified with the GP or GN modifier) for that claim.  When the PT/SLP cap is exceeded by PT services, the SLP lines on the claim may meet the requirements for an exception due to the complexity of two episodes of service.   o Use the KX modifier on either all or none of the SLP lines on the claim, as appropriate.  In contrast, if all the OT lines on the claim are below the cap, do not use the KX modifier on any of the OT lines, even when the KX modifier is appropriately used on all of the PT lines.  Refer to Pub.100- 04, Medicare Claims Processing Manual, chapter 25, for more detail.   By appending the  KX modifier, the provider is attesting that the services billed:   Are reasonable and necessary services that require the skills of a therapist; (See Pub. 100 -02, chapter 15, section 220.2); and    Are justified by appropriate documentation in the medical re cord, (See Pub. 100-02, chapter 15, section 220.3); and    Qualify for an exception using the automatic process exception.   If this attestation is determined to be inaccurate, the provider/supplier is subject to sanctions resulting from providing inaccurate information on a claim.   When the KX modifier is appended to a therapy HCPCS code, the contractor will override the CWF system reject for services that exceed the caps and pay the claim if it is otherwise payable.   Providers and suppliers shall continue to append correct coding initiative (CCI) HCPCS modifiers under current instructions.    If a claim is submitted without KX modifiers and the cap is exceeded, those services will be denied.  In cases where appending the KX modifier would have been appropriate, contractors may reopen and/or adjust the claim, if it is brought to their attention.   Services billed after the cap has been exceeded which are not eligible for exceptions may be billed for the purpose of obtaining a denial using condition code 21.   10.3.4 - Therapy Cap Manual Review Threshold  to Ensure Appropriate Therapy  (Rev.  4214, Issued: 01- 25-19, Effective: 01- 01-19, Implementation: 02- 26-19)  Section 50202 of the Bipartisan Budget Act of 2018 retains the targeted medical review (MR) process (first established through Section 202 of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)), but at a lower threshold amount of $3,000. For CY 2018 (and each calendar year until 2028 at which time it is indexed annually by the MEI), the MR threshold is $3,000 for PT and SLP services and $3,000 for OT services. The targeted MR process means that not all claims exceeding the MR threshold amount are subject to review as they once were. For a general overview of the MR process, go to the Medical Review and Education  website at: https://www.cms.gov/Research -Statistics -Data- and-Systems/Monitoring -Programs/Medicare- FFS-Compliance -Programs/Medical -Review/index.html   10.3.5 - Identifying the Certifying Physician  (Rev. 3367 Issued: 10- 07-15, Effective: 01- 01-16, Implementation: 01- 04-16)  Therapy plans of care must be certified by a physician or non -physician practitioner (NPP), per the requirements in the Pub. 100- 02, Medicare Benefit Policy Manual, chapter 15, section 220.1.3.  Further, the National Provider Identifier (NPI) of the certifying physician/NPP identified for a therapy plan of care must be included on the therapy claim.   For the purposes of processing professi onal claims, the certifying physician/NPP is considered a referring provider.  At the time the certifying physician/NPP is identified for a therapy plan of care, private practice therapists (PPTs), physicians or NPPs, as appropriate, submitting therapy cla ims, are to treat it as if a referral has occurred for purposes of completing the claim and to follow the instructions in the appropriate ASC X12 837 Professional Health Care Claim Technical Report 3 (TR3) for reporting a referring provider (for paper clai ms, they are to follow the instructions for identifying referring providers per chapter 26 of this manual).  These instructions include requirements for reporting NPIs.   Currently, in the 5010 version of the ASC X12 837 Professional Health Care Claim TR3, referring providers are first reported at the claim level; additional referring providers are   reported at the line level only when they are different from that identified at the claim level.  Therefore, there will be at least one referring provider identif ied at the claim level on the ASC X12 837 Professional claim for therapy services.  However, because of the hierarchical nature of the ASC X12 837 health care claim transaction, and the possibility of other types of referrals applying to the claim, the num ber of referring providers identified on a professional claim may vary.  For example, on a claim where one physician/NPP has certified all the therapy plans of care, and there are no other referrals, there would be only one referring provider identified at  the claim level and none at the line levels.  Conversely, on a claim also containing a non -therapy referral made by a different physician/NPP than the one certifying the therapy plan of care, the billing provider may elect to identify either the nontherap y or the therapy referral at the claim level, with the other referral(s) at the line levels.  Similarly, on a claim having different certifying physician/NPPs for different therapy plans of care, only one of these physician/NPPs will be identified at the c laim level, with the remainder identified at the line levels.  These scenarios are only examples:  there may be other patterns of representing referring providers at the claim and line levels depending upon the circumstances of the care and the manner in w hich the provider applies the requirements of the ASC X12 837 Professional Health Care Claim TR3.  For situations where the physician/NPP is both the certifier of the plan of care and furnishes the therapy service, he/she supplies his/her own information, including the NPI, in the appropriate referring provider loop (or, appropriate block on Form CMS 1500).  This is applicable to those therapy services that are personally furnished by the physician/NPP as well as to those services that are furnished inciden t to their own and delivered by qualified personnel (see section 230.5 of this manual for qualifications for incident to personnel).   Contractors shall edit to ensure that there is at least one claim- level referring provider identified on professional therapy claims, and shall use the presence of the therapy modifiers (GN, GP, GO) to identify those claims subject to this requirement.   For the purposes of processing institutional claims, the certifying physician/NPP and their NPI are reported in the Attend ing Provider fields on institutional claim formats.  Since the physician/NPP is certifying the therapy plan of care for the services on the claim, this is consistent with the National Uniform Billing Committee definition of the Attending Provider as the i ndividual who has overall responsibility for the patients medical care and treatment that is reported on the claim.  In cases where a patient is receiving care under more than one therapy plan of care (OT, PT, or SLP) with different certifying physicians /NPPs, the second certifying physicians/NPP and their NPI are reported in the Referring Physician fields on institutional claim formats.   10.3.6 - MSN Messages Regarding the Therapy Cap  (Rev. 3367 Issued: 10- 07-15, Effective: 01- 01-16, Implementation: 01- 04-16)  Existing MSN messages 17.13, 17.18 and 17.19 shall be issued on all claims containing outpatient rehabilitation services.  Contractors add the applied amount for individual   beneficiaries and the generic limit amount to all MSNs that require them.  F or details of these MSNs, see: http://www.cms.gov/MSN/02_MSN%20Messages.asp .  10.4 - Claims Processing Requirements for Financial Limitations  (Rev.  3995, Issued: 03 -09-18, Effective: 06- 11- 18, Implementation: 06 -11-18)  A.  Requirements  Institutional Claims   Regardless of financial limits on therapy services, CMS requires modifiers (See section 20.1 of this chapter) on specific codes for the purpose of data analysis.  Beneficiaries may not be simultaneously covered by Medicare as an outpatient of a hospital and as a patient in another facility.  When outpatient hospital therapy services are excluded from the limitation, the beneficiary must be discharged from the other setting and registered as  a hospital outpatient in order to receive payment for outpatient rehabilitation services in a hospital outpatient setting after the limitation has been reached.   A hospital may bill for services of a facility as hospital outpatient services if that facility meets the requirements of a department of the provider (hospital) under 42 CFR 413.65.  Facilities that do not meet those requirements are not considered to be part of the hospital and may not bill under the hospitals provider number, even if they are owned by the hospital.  For example, services of a Comprehensive Outpatient Rehabilitation Facility (CORF) must be billed as CORF services and not as hospital outpatient services, even if the CORF is owned by the hospital.    The CWF applies the financial limitation to the following bill types 12X (with Critical Access Hospital CMS Certification Numbers), 22X, 23X, 34X, 74X, 75X and 85X using the lesser of the MPFS allowed amount (before adjustment for beneficiary liability) or the amount charged.    For SN Fs, the financial limitation does apply to rehabilitation services furnished to those SNF residents in noncovered stays (bill type 22X) who are in a Medicare -certified section of the facility, i.e., one that is either certified by Medicare alone, or is dua lly certified by Medicare as a SNF and by Medicaid as a nursing facility (NF).  For SNF residents, consolidated billing requires all outpatient rehabilitation services be billed to Part B by the SNF.  If a resident has reached the financial limitation, and  remains in the Medicare-certified section of the SNF, no further payment will be made to the SNF or any other entity.  Therefore, SNF residents who are subject to consolidated billing may not obtain services from an outpatient hospital after the cap has been exceeded.   Once the financial limitation has been reached, services furnished to SNF residents who are in a non -Medicare certified section of the facility, i.e., one that is certified only by   Medicaid as a NF or that is not certified at all by either p rogram, use bill type 23X.  For SNF residents in non- Medicare certified portions of the facility and SNF nonresidents who go to the SNF for outpatient treatment (bill type 23X), medically necessary outpatient therapy may be covered at an outpatient hospita l facility after the financial limitation has been exceeded when outpatient hospital therapy services are excluded from the limitation.   B.  Requirements -  Professional Claims   Claims containing any of the always therapy codes must have one of the therap y modifiers appended (GN, GO, GP).  Contractors shall return claims for always therapy codes when they do not contain appropriate therapy modifiers for the applicable HCPCS codes. In addition, when any code on the list of therapy codes is submitted with specialty codes 65 (physical therapist in private practice), 67 (occupational therapist in private practice), or 15 (speech -language pathologist in private practice) they always represent therapy services, because they are provided by therapists. Contractors shall return claims for these services when they do not contain therapy modifiers for the applicable HCPCS codes.   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario 2.  Group Code: CO  CARC: 4  RARC: N/A  MSN: N/A  The CMS identifies certain codes listed at: http://www.cms.hhs.gov/TherapyServices/05_Annual_Therapy_Update.asp#TopOfPage as sometimes therapy services, regardless of the presence of a financial limitation.  Claims from physicians (all specialty codes) and nonphysician practitioners, including specialty codes 50 (Nurse Practitioner), 89, (Clinical Nurse Specialist), and 97, (Physician Assistant) may be processed without therapy modifiers when they  are not therapy services.  On review of these claims, sometimes therapy services that are not accompanied by a therapy modifier must be documented, reasonable and necessary, and payable as physician or nonphysician practitioner services, and not service s that the contractor interprets as therapy services.   The CWF will capture the amount and apply it to the limitation whenever a service is billed using the GN, GO, or GP modifier.