Physician Fee Schedule CY 2024

Therapists use the KX modifier to receive payment for medically necessary services above the annual therapy dollar threshold (or soft cap). The KX modifier communicates to Medicare to pay the claim when it is above the annual threshold amount.

For the 2024 calendar year, the KX Modifier threshold amounts are:

• $2,330 for PT and SLP services combined
• $2,330 for OT services

The Medicare Claims Processing Manual (MCPM) in Chapter 5, section 10.3.3 explains the use of the KX modifier that confirms outpatient (Medicare Part B) services are medically necessary after the beneficiary has exceeded the KX modifier threshold of incurred expenses. The provider is subject to sanctions if the attestation is not accurate.

The MCPM states that:

“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 record (See Pub. 100-02, chapter 15, section 220.3); and
• Qualify for an exception using the automatic process exception.”

The Medicare Administrative Contractor (MAC) will override the Common Working File system rejection for services that exceed the threshold and pay the claim when the KX modifier is added to a therapy HCPCS code.

The Medicare Claims Processing Manual, Chapter 5, section 10.3.2 reviews the Exceptions Process. It references the Medicare Benefit Policy Manual, Chapter 15, section 220.3, Documentation for Therapy Services, and states that if medical records are requested for review, clinicians may include, at their discretion, a summary that specifically addresses the justification for therapy cap exception.

Medicare Part B

Deductible

The annual Medicare Part B deductible for 2024 will be $240.00.

If the Medicare Part B deductible is not met prior to the Medicare beneficiary receiving Medicare Part B outpatient therapy services, then the allowed amount up to the Medicare Part B deductible will count towards their annual therapy threshold. If the Medicare Part B deductible was met before they received Medicare Part B therapy, then the full annual threshold amount is available provided the beneficiary has not used part of it for therapy earlier in the calendar year.

The therapy threshold amount is based on the Medicare allowed amount for each CPT code, not on what you charge or what you receive from Medicare. The threshold calculation is after the Multiple Procedure Payment Reduction (MPPR) is applied and is before the 2% sequestration reduction is applied.

Targeted Medical Review

Thresholds 2024

Medicare continues to perform targeted reviews for claims that are over the secondary medical review threshold. The 2024 targeted medical review remains at $3,000 for PT and ST combined and is a separate $3,000 for OT. There is no additional documentation that is required above the $3,000. Documentation should always support the medical necessity of the treatment and that the treatment requires the skills of the therapist. The Centers for Medicare and Medicaid Services (CMS) hired Noridian Healthcare Solutions as the Supplemental Medical Review Contractor (SMRC) that conducts these targeted reviews.

Reasonable and Necessary

What does Medicare consider “reasonable and necessary”? It can vary based on both National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), plus Billing and Coding Articles, so it is important to read the most current versions available.

An ABN (CMS-R-131) must be issued if you provide services that the beneficiary would like to receive but are not medically necessary. With a signed ABN, you should submit the claim to Medicare with a GA modifier so it will be rejected. After the Medicare denial, then payment can be collected from beneficiaries.

Caregiver Training Services (CTS)

The CY 2024 Physician Fee Schedule Final Rule was published in the Federal Register on November 16, 2023 and it finalizes their proposal to activate codes (CPT codes 96202, 96203, 97550, 97551, and 97552) for qualifying clinicians to bill when practitioners train (in person) and involve one or more caregivers to assist patients with certain diseases or illnesses (such as dementia) in carrying out an individualized treatment plan or a therapy plan of care without the patient present. These codes are found on page 285 of the Final Rule and are not eligible for use in telehealth services.

They are eligible for use by physicians and all non-physician practitioners (NPP) eligible to bill under the physician fee schedule with an individualized treatment plan or a therapist (PT, OT, or SLP) providing services under the therapy plan of care.

The Final Rule includes definitions of a caregiver that are broader than earlier definitions and includes “an adult family member or other individual who has a significant relationship with, and who provides a broad range of assistance to, an individual with a chronic or other health condition, disability, or functional limitation”, and “a family member, friend, or neighbor who provides unpaid assistance to a person with a chronic illness or disabling condition.”

There are two sets of CPT Codes, one set for behavioral management/modification and the other for caregiver training services under a therapy plan of care.

Behavioral Management/Modification Codes

The behavioral management/modification codes support face-to-face time spent by the physician or other qualified health professional providing group behavior management/modification training to guardians or caregivers of patients with a mental or physical health diagnosis. Practitioners must receive the consent of the patient although the patient does not attend the group training. The goals and outcomes of the sessions focus on the person-centered treatment plan interventions aimed at effectively implementing the person-centered treatment plan by addressing challenging behaviors and other behaviors that may pose a risk to the person, and/or others. Each behavior must be clearly identified and documented in the treatment plan, and the caregiver should be trained in positive behavior management strategies.

During the face-to-face service time, caregivers are taught how to structure the patient’s environment to support and reinforce desired patient behaviors, to reduce the negative impacts of the patient’s diagnosis on the patient’s daily life, and to develop highly structured technical skills to manage the patient’s challenging behavior.

• CPT code 96202 (Multiple-family group behavior management/modification training for parent(s)/guardian(s)/caregiver(s) of patients with a mental or physical health diagnosis, administered by a physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of parent(s)/guardian(s)/caregiver(s); initial 60 minutes).
  
  
• CPT 96203 (Multiple-family group behavior management/modification training for parent(s)/guardian(s)/caregiver(s) of patients with a mental or physical health diagnosis, administered by a physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of parent(s)/guardian(s)/caregiver(s); each additional 15 minutes (List separately in addition to code for primary service)).

Therapy Plan of Care

The CPT Codes 97550. 97551, and 97552 support face-to-face time spent by the physician or other qualified health professional providing caregiver training services under a therapy plan of care established by a PT, OT, or SLP. The patient does not attend the group training, but practitioners are required to receive the consent of the patient. The consent must be specific to the caregiver training services and documented in the medical record. The treating practitioner must also document the need for each occurrence of the CTS. The standard for caregiver training is to provide the training with the patient present so deviating from this should occur only when needed and have documentation supporting the reason.

The goals and outcomes of the sessions should focus on the person-centered treatment plan interventions aimed at effectively implementing the person-centered treatment plan by improving the patient’s ability to successfully perform activities of daily living (ADLs). Activities of daily living generally include ambulating, feeding, dressing, personal hygiene, continence, and toileting. Each behavior should be clearly identified and documented in the treatment plan, and the caregiver should be trained in positive behavior management strategies.

During the face-to-face service time, caregivers are taught by the treating practitioner how to facilitate the patient’s activities of daily living, transfers, mobility, communication, and problem-solving to reduce the negative impacts of the patient’s diagnosis on the patient’s daily life and assist the patient in carrying out a treatment plan. This training for the caregiver includes the development of skills such as safe activity completion, problem-solving, environmental adaptation, training in the use of equipment or assistive devices, or interventions focusing on motor, process, and communication skills.

These codes are also designated as “sometimes therapy” services and are not subject to the Multiple Procedure Payment system. The services described by these codes are always provided under a therapy plan of care when provided by PTs, OTs, and SLPs; but, in cases where they are appropriately furnished by physicians and NPPs outside a therapy plan of care, where the services are not integral to a therapy plan of care, they can be furnished under a treatment plan by physicians and NPPs.

• CPT Code 97550 (Caregiver training in strategies and techniques to facilitate the patient’s functional performance in the home or community (e.g., activities of daily living [ADLs], instrumental ADLs [IADLs], transfers, mobility, communication, swallowing, feeding, problem-solving, safety practices) (without the patient present), face-to-face; initial 30 minutes). This code is reported based on the time spent training for a single patient regardless of the number of caregivers present.
• CPT Code 97551 (each additional 15 minutes (List separately in addition to code for primary service) (Use 97551 in conjunction with 97550).
• CPT Code 97552 (Group caregiver training in strategies and techniques to facilitate the patient’s functional performance in the home or community (e.g., activities of daily living [ADLs], instrumental ADLs [IADLs], transfers, mobility, communication, swallowing, feeding, problem-solving, safety practices) (without the patient present), face-to-face with multiple sets of caregivers). This code is used when the multiple sets of caregivers represent separate patients.

Therapy CPT Codes Undervalued?

The CY 2024 Physician Fee Schedule Final Rule addresses (on page 96), nineteen (19) therapy codes that have practice expense elements that could potentially increase after review by the AMA Relative Value Scale Update Committee (AMA RUC).   These codes are on the January meeting agenda for AMA RUC.

Telehealth Medicare Services and Flexibilities

CMS implemented several Telehealth regulations in the CY 2024 Physician Fee Schedule Final Rule including the extension of the COVID-19 Public Health Emergency flexibilities that were included in the Consolidated Appropriations Act of 2023.

For instance:

• The temporary expansion of the scope of Telehealth originating sites for services provided via Telehealth to include any site in the U.S. where the patient is at the time of the Telehealth service, including a person’s home.
• The expansion of the definition of Telehealth practitioners to include qualified occupational therapists (OTs), physical therapists (PTs), speech-language pathologists (SLPs), and audiologists.
• The continued payment for Telehealth services rural health clinics (RHCs) and federally qualified health centers (FQHCs) provide using the methodology established for those Telehealth services during the public health emergency (PHE).
• Delaying the requirement for an in-person visit with the physician or practitioner within 6 months prior to initiating mental health telehealth services, and, again, at subsequent intervals as the Secretary determines appropriate, as well as similar requirements for RHCs and FQHCs.
• The continued coverage and payment of Telehealth services included on the Medicare Telehealth Services List (as of March 15, 2020) until December 31, 2024.
• Adding mental health counselors (MHCs) and marriage and family therapists (MFTs) as distant site practitioners for purposes of providing Telehealth services.
• Temporarily allowing outpatient therapy services delivered by institutional providers—including skilled nursing facilities, and home health agencies (to individuals who are not homebound—to be furnished via Telehealth, including to beneficiaries in their homes.
• CMS finalized its proposal to remove the frequency limitations through 2024 for certain inpatient visits, nursing facility visits, and critical care consultation services. 
• This aligns with other Telehealth flexibilities extended by the CAA 2023 and allows CMS further time to gather more information about Telehealth practice patterns.

CMS clarified that Modifier '95' should be used when the clinician is in the hospital and the patient is in the home, and for when outpatient therapy services are provided via Telehealth by PT, OT, or SLPs.

New CPT Codes added to the list of Medicare Telehealth services include:

• CPT codes 0591T - 0593T for health and well-being coaching services, added on a temporary basis
• HCPCS code G0136 for Social Determinants of Health Risk Assessment, added on a permanent basis.

Telehealth Origination Site Facility Fee

For CY 2024, the payment amount for HCPCS code Q3014 (Telehealth originating site facility fee) is $29.96. The patient is responsible for any unmet deductible amount and Medicare coinsurance.

Payment for Outpatient Therapy (including PT, OT, SLP), DSMT, and Medical Nutrition Therapy (MNT) Services

When institutional staff provide the services to patients in their homes through communication technology, institutional providers are able to continue billing for PT, OT, SLP, DSMT (Diabetes Self-Management Training) and MNT (Medical Nutrition Therapy) services provided remotely in the same way they could during the PHE and through the end of CY 2023. Changes to this are limited to outpatient hospitals and Critical Access Hospitals.

Supervision Policy for PT & OT Therapists in Private Practice

Direct supervision of therapy assistants has been required in private practice since 2005. Starting January 1, 2024, general supervision of therapy assistants is allowed for remote therapeutic monitoring (RTM) services.

Resources

CY 2024 Medicare Physician Fee Schedule Final Rule, Federal Register, 11.16.23

• https://www.federalregister.gov/documents/2023/11/16/2023-24184/medicare-and-medicaid-programs-cy-2024-payment-policies-under-the-physician-fee-schedule-and-other

CY 2024 Medicare Physician Fee Schedule Final Rule Fact Sheet

• https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2024-medicare-physician-fee-schedule-final-rule

MLN Matters #13452 has a Medicare Physician Fee Schedule Summary for CY 2024

• https://www.cms.gov/files/document/mm13452-medicare-physician-fee-schedule-final-rule-summary-cy-2024.pdf