Medicare has a limit or "cap" for any beneficiary receiving speech-language pathology, occupational, and physical therapy services. Your practice might have experienced denial code CO-119.
Denial code CO-119 or "Maximum Benefit Reached" is likely the result of reaching this therapy services threshold.
What does the CO-119 denial code mean?
The Medicare beneficiary has reached the maximum allowable benefit for physical therapy services.
The physical therapy threshold and what it means for your practice.
You may have heard of the physical therapy threshold, which is a specific dollar amount that limits the amount a physical therapist can bill for the services. The physical therapy threshold is set by Medicare every year.
As of January 1, 2022, the 2022 therapy threshold limits for Medicare are:
$2,150 for physical therapy and speech-language pathology services, combined.
$2,150 for occupational therapy services.
The therapy threshold is not meant to be a hard cap. Granted the therapist can prove "medical necessity" it is possible to bill beyond this limit.
Use the KX modifier to bill beyond the therapy threshold
If you have received the denial code CO-119 or PR – 119, the KX modifier can be used to bill beyond the therapy threshold for Medicare patients. The KX modifier is used to indicate medical necessity of services.
Each charge must include the KX modifier. You do not have to obtain prior authorization to use this modifier.
If you do not include the appropriate modifiers for claims exceeding the therapy threshold, your reimbursement will be delayed or denied. In theory, it is possible to provide unlimited services under that code as long as they remain medically necessary.
How to determine medical necessity
According to the Centers for Medicare and Medicaid Services (CMS), medical necessity is defined as “health-care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms, and that meet accepted standards of medicine.”
Medicare does not cover physical therapy, occupational therapy, or speech-language pathology services for fitness, wellness, or preventive purposes.
Do I need to include specific documentation for Denial Code CO-119 or to use KX modifier?
Denial code CO-119 doesn't have a specific documentation requirement for this denial code. You don't need to include any additional information with your claim.
You should always strive for defensible documentation when submitting any claims. However, you don’t need to change anything about your normal documentation process when your notes cross the therapy threshold.
Conclusion
The KX modifier can be used to bill beyond the therapy threshold for Medicare patients.
Choosing the right electronic medical record (EMR) and billing system can ease the burden of billing and compliance. PatientStudio's All-in-one practice management software can reduce the administrative burden of keeping up with compliance and reduce the chances of denied claims.