CMS Updates CY 2021 Outpatient Therapy Per-Beneficiary Edit/Audit Threshold Amounts

CMS
​​Late in 2020 the Centers for Medicare and Medicaid Services (CMS) published the annual update to the per-beneficiary incurred expenses amounts now called the KX modifier thresholds and related policy for Calendar Year (CY) 2021. These amounts were previously associated with the financial limitation amounts that Medicare more commonly referred to as “therapy caps.” The Bipartisan Budget Act (BBA) of 2018 repealed those caps while also retaining and adding limitations to ensure appropriate therapy. This policy does not limit the amount of medically necessary Medicare Part B therapy services a beneficiary may receive, it just establishes coding modifier requirements to obtain payments beyond the updated KX modifier thresholds, and also reaffirms the specific $3,000 claim audit threshold requirements for the Medicare Administrative Contractors (MACs).  

For CY 2021, the KX modifier threshold amounts are:
  • $2,110 for Physical Therapy (PT) and Speech-Language Pathology (SLP) services combined, and
  • ​$2,110 for Occupational Therapy (OT) services. 

MLN Matters Article MM12014 provides a summary and background related to this policy. Change Request CR 12014 issued to the MACs provide implementation instructions. 

Please make sure your billing staffs are aware of these updates.