Medicare therapy review threshold increased; claims may be rebilled from Jan 1, 2018

Effective immediately, we've increased our Medicare therapy claim review threshold to $5,000, and we can retroactively reprocess claims from Jan 1, 2018. Depending on claim total and each member's therapy cap status, we may need medical records to reconsider and pay old claims.

What's changing?

CMS has a targeted medical review therapy cap at $3,000, and we've decided to increase our targeted medical review therapy cap amount to $5,000 to better meet the needs of our members. This change will require providers to bill with the appropriate modifier and possibly send medical records.

For 2018 claims:

  • In 2018, our threshold amount was $2,010. For any member over this amount, a provider can re-bill claims with a KX modifier.

For 2019 claims:

  • In 2019, threshold amount is $2,040. For a member already over this threshold amount, a provider can re-bill claims with a KX modifier. 

2019 Specific claims and threshold amounts

  • Providers need to track member's therapy services to $2,040 ($2,040 for physical and speech therapy, and an additional $2,040 for occupational therapy).
  • Claims received between $2,040 and $5,000 with the KX modifier will be paid (if no modifier is present, claim will be denied as "resubmit with valid modifier").
  • Claims received at $5,000 or greater with KX modifier will be subject to medical review and medical records will need to be submitted. The Medical team will determine if they agree with the medical records as to why the member still requires therapy/rehab services.
  • Any claims received at $5,000 or greater billed with the KX modifier but without medical records will be denied for needing to submit medical records.
  • Providers billing through EDI will need to either submit a paper claim with medical records, or mail the notes separately with member ID included.
For more information on Medicare therapy services and cap information visit our therapy and caps page