Physical Therapists

10/23/08: Highmark Medicare Services – Time is running out!

Are you prepared for the transition from National Government Services (NGS) to Highmark Medicare Services which is taking place November 14, 2008? While we’ve been advised that it is not necessary to fill out the very extensive applications again, they do require a completed EFT form. With that EFT form, did you include a letter asking to continue to receive paper remittances for those of you who were already receiving and wish to continue receiving paper EOB’s?
Please also know that there are forms currently being used that are different than what is being used for Highmark. The good news is the web-site seems to be very user friendly and most of the diagosis codes we are all familiar with in dealing with NGS, seem to be the same with Highmark.

To view those forms and all other pertinent information relative to Physical Therapy, please visit their

10/1/08: Medicare Changes – KX modifier re-instated!

Information was released by CMS that Medicare would no longer be allowing the KX modifier to be used effective 7/1/08. This was outlined in the 7/1/08 article below. However, soon after that article was published, CMS announced that Outpatient therapy service providers were permitted to resume submitting claims with the KX modifier. They further advised that this decision would be retroactive back to 7/1/08. Please keep in mind the use of the KX modifier is for services over the dollar cap of $1810 for 2008. We would suggest all readers look for potential changes regarding the use of the ‘KX’ modifier in 2009 as the information suggested this reversal may not be permanent.

7/1/08: Medicare Changes

There have been some changes to the Medicare Part B benefits that physical therapists need to be aware of. This information is relative to physical therapists NOT rendering services in a hospital setting. Remember that benefits for those types of services are processed under Medicare Part A.If you are not already aware, the cap for Physical Therapy & Speech-Language Pathology combined has increased from $1780 to $1810 per year effective 2008. That is the good news.

The bad news is that effective 7/1/08 Medicare is no longer recognizing the ‘KX’ modifier for services billed by these specialties under the Medicare Part B benefits. This modifier was used by providers when submitting claims to inform Medicare that the patient’s condition and treatment would exceed the cap allowance and should qualify for an exception. In this way the patient would hopefully be eligible for services to be reimbursed above the cap allowance.

Since the ‘KX’ modifier will no longer be accepted 7/1/08, we contacted Medicare to question what should be done when a patient’s care is such that it will exceed the cap allowance. They offered two options.

1)Have the patient sign an ABN notice that informs them their care may be denied due to exceeding the allowance cap. In this way you can use the ‘GA’ modifier on the claim submission and if the claim is denied stating the maximum has been met, the claim will deny with a “PR” denial which indicates ‘patient responsibility’. This will allow the provider to balance bill the secondary (if applicable) or to bill the patient directly.

2)Send the patient to a facility in which the patient can use their outpatient hospital benefits which is Medicare Part A.

The following is a link for providers to read further on this new change. This link in particular will take you to the website of National Government Services (one of the Medicare Carriers). From there you can use the hyperlinks to move to the actual CMS website to view their published information as well:

Here is also a link we found to a page of a website that notifies patients of the change.