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CarePoint Therapy Management Blog

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Functional Limitation G Codes: Should Therapists Assign 59 or KX Modifiers?

  
  
  

A contract therapy client in New York asked the following question …  “If a patient exceeds the Medicare Part B therapy cap, is it CMS’s expectation that a KX modifier should be assigned to G codes as well?  I know we need to assign KX modifiers to the entire month’s billing regardless of when the actual therapy cap was exceeded during that month. However, according to CMS KX modifiers are not needed for the G codes?  Can you point me to the documentation that supports this?”

Our response is as follows …   The new G codes should not have either 59 or KX modifiers attached.  The 59 modifier would be inappropriate on these G codes since they are non-billable codes.  The KX modifier would be inappropriate on them as well.  The Claims Processing Manual only states that, “KX is not required.”  CMS training calls have indicated that 59 or KX modifiers should not be used on the G codes.  We do have a $.01 charge so the codes can be processed.  Specifically, the Medicare Claims Processing Manual, Pub 104 chapter 5, section 10.6 states:

Each reported G code must also contain the following line of service information:

  • Functional severity modifier CI through CM.

  • Therapy modifier indicating the related discipline/POC GP, GO or GN for PT, OT, and SLP services, respectively.

  • Date of the related therapy service.

  • Nominal charge, e.g., a penny, for institutional claims submitted to the Fiscal Intermediaries and A/MAC’s.  For professional claims, a zero charge is acceptable for the service line.  If the provider's billing software requires an amount for professional claims, a nominal charge, e.g., a penny, may be included.

Note: The KX modifier is not required on the claim line for non-billable G codes, but would be required with the procedure code for medically necessary therapy services furnished once the beneficiary’s annual cap has been reached.

CarePoint therapy management software clients should be aware that any modifiers in the M2 field of non-billable G codes will be deleted automatically from the database when a Billing Interface file is created.  This will ensure that no G codes have any modifiers other than the functional limitation modifiers CI through CM when the UB-04 claim forms are created.  See the screen shot below …

Functional Limitations - G Code - g codes - KX modifier - 59 modifier

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