Objective measures
Then and now
- Range of motion, strength grades
- Outcome scores, timed tasks
Checklist · Medicare therapy threshold
KX modifier documentation requirements: the checklist the chart has to pass
Short answer: KX is an attestation that medical necessity is already in the record. Above $2,480 in 2026 ($2,540 proposed for 2027) a claim without KX is denied; with KX and no documentation, RAC topic 0228 reads it.
KX · attestation, not a form
$2,480 · CY 2026 threshold
$3,000 · targeted medical review
RAC 0228 · approved Apr 15, 2026
Edition
Oct 2026
Focus
KX modifier
Audience
PT · OT · SLP
Metric
$2,480 threshold
Codes
KX · GP GO GN
Length
7 min read
When each document is due, and where KX enters
Top row: the episode sequence. Lanes: how long each requirement stays live.
- 1Evaluation + planGoals, type, amount, duration, frequency [3]
- 2CertificationPhysician or NPP signature within 30 days of day one
- 3Progress reportsAt least every 10 treatment days, by the clinician
- 4Accrual nears $2,480Counted across every provider this year [1]
- 5Checklist passes, KX onNecessity statement written before the claim
- 6Recert + $3,000 lineRecertify by day 90; medical review exposure above $3,000
Plan of care
Whole episode; recertified every 90 days
Certification
Signed and dated within 30 calendar days
Progress reports
Every 10 treatment days, gain against each goal
KX attestation
From the visit that crosses the threshold
RAC exposure
Above $3,000
AlwaysDated gatesRecurringReview exposure
How one PT beneficiary crosses the lines in a year
Illustrative. CMS counts fee schedule amounts less any multiple procedure payment reduction, across every provider that year, hospital outpatient departments included [1].
Below the KX thresholdKX requiredAbove targeted medical review
Read the right numberYour ledger is the floor; the Medicare accrual in the eligibility response or contractor portal decides when KX goes on.
$2,480 now, $2,540 proposed
Medicare therapy thresholds per beneficiary per calendar year
CY 2027: $2,480 times an estimated 2.5 percent MEI increase, rounded to the nearest ten dollars; recomputed for the final rule [1].
KX threshold, CY 2026PT + SLP combined; OT separately
$2,480in force, 100%
KX threshold, CY 2027proposed
$2,540+2.4% vs 2026, proposed
Targeted medical review2026 and 2027
$3,000flat, 121% of the 2026 KX line
$0$1,000$2,000$3,000
In forceProposed, CY 2027 PFS ruleReview line, moves with MEI from 2028
Eight items the chart must show before KX goes on
From Benefit Policy Manual Chapter 15 and the RAC topic 0228 references. Assemble before the claim, not after the records request.
| Item | What a reviewer looks for | Source |
|---|---|---|
| Plan of care | Diagnoses, long-term goals, type, amount, duration and frequency; consistent with the evaluation | BPM Ch. 15, 220.1.2 42 CFR 410.61 |
| Certification | Physician or NPP signature dated within 30 days of day one (evaluation included); verbal order signed within 14 days | BPM Ch. 15, 220.1.3 42 CFR 424.24 |
| Recertification | Every 90 days, or when the plan is significantly modified | BPM Ch. 15, 220.1.3 |
| Progress reports | Every 10 treatment days; objective progress toward goals; clinician participation | BPM Ch. 15, 220.3 |
| Treatment notes | Every visit: date, services, total timed minutes and total treatment time, signature, credentials | BPM Ch. 15, 220.3 CPM Ch. 5, 20.2 |
| Evaluation and re-evaluation | The evaluation behind the plan; any re-evaluation tied to a documented change in function | BPM Ch. 15, 220.3 |
| Medical necessity above the threshold | Why skilled therapy must continue: the deficit, the open measurable goal, the timeframe, why an unskilled program is not yet appropriate | RAC topic 0228 SSA 1862(a)(1)(A) |
| Correct units and modifiers | Units supported by timed minutes; GP, GO or GN every line; CQ or CO for assistant minutes | CPM Ch. 5, 20.2 CMS therapy page |
The part reviewers read first
Each report above the threshold answers three questions: what measurable gain, which goal is still open, why a therapist and not a home program. "Tolerated treatment well, continue plan" supports nothing. Details: Medicare progress report requirements.
Goal status
Each long-term goal, dated
- Met, progressing or revised
- Two flat reports need a reason or a revision
Skilled need
One sentence per report
- Complex program progression
- Changing presentation, safety
Approved April 15, 2026: complex review of KX claims
All A/B MACs, outpatient hospital and professional claims: coverage criteria, coding and whether KX was appropriate; 42 CFR 405.930 covers a missed records request [4]. Line by line: Therapy Operator on topic 0228.
| Discipline | Codes in scope | Line modifier |
|---|---|---|
| Physical therapy | 97012, 97035, 97110, 97112, 97116, 97124, 97140, 97150, 97530, 97535, 97161, 97162, 97163, 97164 | GP CQ |
| Speech-language pathology | 92507, 92520, 92521, 92522, 92523, 92524, 92526, 92606, 92609, 92610, 92630, 92633, 96125, 97129, 97130 | GN |
| Occupational therapy | 97165 to 97168, 97110, 97112, 97530, 97535, 97542, 97750, 97760, 97761, 97014, 97032, G0281 to G0283, strapping codes 29200 to 29550 | GO CO |
Four steps that make the attestation true every month
1
Open the KX packet template
One folder per beneficiary over the threshold, eight items as tabs.
2
Fill it from the chart the day KX first goes on
An item missing, the modifier waits.
3
Re-check at each progress report
The necessity statement changes as goals close; a copied paragraph is a finding.
4
Pull ten packets a month, time the assembly
Over a day means a records request will be missed.
Five ways the attestation stops being true
KX by billing rule
Appended to every line past the threshold; nobody checks the chart.
FixTurn the rule into a clinician prompt
Late certification
Signed past 30 days, no evidence the plan was sent.
FixSend-date logged on day one
Calendar-month reports
Three visits a week means 12 or more between reports.
FixCount treatment days, not months
Units above minutes
A CARC 151 denial on a KX claim invites a records request.
FixUnits calculator on KX lines
Copied paragraph
Necessity text carried forward unchanged across reports and patients.
FixStatement rewritten at every report
Takeaway
KX is a promise that the chart already proves medical necessity. If a billing rule makes the promise, turn it into a prompt: show the clinician the checklist before the claim goes out.
Five checks on the claims above $2,480
List every Medicare beneficiary above $2,480Medicare accrual, not your ledger; PT plus SLP, and OT.
Find where KX is appendedIf a billing rule does it, put the clinician prompt in front.
Check certification and recert dates30 days from day one; recert every 90.
Audit units against timed minutes on KX linesThe therapy units calculator checks the unit side.
Plan for $2,540 and the OT rulebookCY 2027 fee schedule impact, OT billing guide 2027. Our PT and OT billing teams run the packet test monthly.
Frequently asked questions
What does the KX modifier attest to?
Per the CY 2027 PFS proposed rule: services above the threshold are reasonable and necessary, and documentation of medical necessity is in the medical record. Claims above the threshold without KX are denied.
What are the KX modifier thresholds for 2026 and 2027?
CY 2026: $2,480 for PT and SLP combined and $2,480 for OT. CY 2027: $2,540 each, proposed on an estimated 2.5 percent MEI increase, final amounts in the final rule. Targeted medical review stays at $3,000 through 2027.
How often does Medicare require a therapy progress report?
At least once every 10 treatment days from the first day of the episode, evaluation included (Benefit Policy Manual Chapter 15, 220.3), written by the clinician and showing objective progress toward the long-term goals.
What documentation will a RAC request for a KX claim?
Topic 0228 cites 42 CFR 410.61 and 424.24, Benefit Policy Manual Chapter 15 sections 220 and 230, Claims Processing Manual Chapter 5 section 20.2 and the reasonable and necessary standard: plan, certifications, progress reports, treatment notes with minutes, evaluation and a medical necessity statement, within the response window.
- Federal Register public inspection, CMS-1847-P, CY 2027 PFS proposed rule: KX modifier thresholds and attestation, targeted medical review
- CMS, Therapy Services: CY 2026 KX modifier thresholds, medical review threshold, CQ/CO
- Medicare Benefit Policy Manual, Chapter 15, sections 220.1.2, 220.1.3 and 220.3
- CMS, Approved RAC Topic 0228: Therapy Claims Billed with KX Modifier (April 15, 2026)
- Medicare Claims Processing Manual, Chapter 5, section 20.2, Reporting of Service Units With HCPCS
Checked October 25, 2026. Rules change; confirm against the source. Items marked proposed come from the CY 2027 PFS proposed rule and are not final until the final rule publishes.
Want your KX claims put through the packet test?
We pull claims above the threshold, assemble the response file from your chart and tell you which items a reviewer would not find.