Complex
Type
- Records requested and read by a reviewer
- No response is itself a basis for denial, 42 CFR 405.930
Home / Newsletters / The Therapy Operator
The Therapy Operator · Issue 2 · late November 2026
A RAC auditor's KX request, line by line.
CMS approved RAC topic 0228 on April 15, 2026: a complex review of therapy claims billed with KX, all A/B MACs, PT, OT and SLP. Story 1: what was approved. Story 2: the six-tab response file built from the policies the RAC cites. Story 3: the threshold math, $2,480 in 2026, $2,540 proposed, $3,000 for targeted review.
0228 · approved RAC topic
KX · the attestation under review
Complex · records read
42 CFR 405.930 · no response, denial
Edition
Issue 2 Nov 2026
Focus
RAC topic 0228
Audience
PT · OT · SLP
Metric
$2,480 KX line
Effective date
Apr 15, 2026
Framework
Six-tab packet
What CMS approved, in its own words
"Therapy Claims Billed with KX Modifier, Medical Necessity, and Documentation Requirements": documentation reviewed for coverage criteria, coding guidelines and medical necessity, and appropriate use of KX evaluated [1].
- 1Apr 15, 2026Topic 0228 posted
- 2Claim selectedAdditional documentation request sent
- 3Response windowSix tabs, on time
- 4ReviewOr denial under 42 CFR 405.930
PT, OT, SLP
Scope
- 97161 to 97168, 97110, 97112, 97140, 97530, 97535, 92507, 92526 and more
All A/B MACs
Jurisdiction
- Any clinic billing Part B therapy with KX is in the population
Why KXThe therapist and provider attest that services above the threshold are reasonable and necessary and the documentation is in the record. The reviewer checks whether the record keeps that promise.
Policy references as the document list
Each policy the RAC cites maps to a document in the chart. Build the file in this order.
01
Plan of care
Tab 1 · 42 CFR 410.61; BPM Ch. 15, 220.1.2
Diagnoses, long-term goals, type, amount, duration and frequency.
02
Certification and recertification
Tab 2 · 42 CFR 424.24; 220.1.3
Physician or NPP dated signature within 30 days of day one; recertification every 90 days.
03
Evaluation and any re-evaluation
Tab 3 · 220.3
The evaluation behind the plan, complexity supported; any re-evaluation tied to a documented change in function.
04
Progress reports
Tab 4 · 220.3
Every 10 treatment days, by the clinician, objective progress toward each goal.
05
Treatment notes, dates requested
Tab 5 · 220.3; CPM Ch. 5, 20.2
Services, total timed minutes and total treatment time, signature and credentials.
06
Medical necessity above the threshold
Tab 6 · SSA 1862(a)(1)(A)
The remaining deficit, the open goal, the timeframe, why an unskilled program is not yet appropriate.
Timing matters as much as contentLog every documentation request with its due date the day it arrives; a late response is a denial without any review of the care. Item list with sources: KX documentation checklist.
$2,480 now, $2,540 proposed, $3,000 for review
Per-beneficiary thresholds, PT and SLP combined; OT separately
Accrued at fee schedule rates less any multiple procedure payment reduction, across every provider that year. Your running total is a floor, not the number the reviewer sees [3].
CY 2026 KX thresholdin force
$2,480100%; above it without KX, denied
CY 2027 KX, proposedfinal rule November
$2,540+2.4%
Targeted medical review2026 and 2027
$3,000121% of the KX line
$0$1,000$2,000$3,000
In forceProposedReview selection line
Ten KX claims, six tabs, one stopwatch
Pull ten KX claims from last quarter, assemble the six tabs for each, note the time and what is missing. A blank is a finding you fixed first; a packet over a day is a deadline you would have missed.
| Claim | Plan of care | Certification within 30 days | Progress report within 10 treatment days | Notes with total minutes | Medical necessity statement | Time to assemble |
|---|---|---|---|---|---|---|
| Example 1 | Yes | Yes | Yes | Yes | Specific to this patient | 40 min |
| Example 2 | Yes | Day 41 | Day 14 | Yes | Copied forward | 2 days |
Then fix the system, not the ten claimsA late certification is a worklist problem; a copied necessity paragraph is a template problem. The November issue covers the January rule changes.
Takeaway
KX is a promise about the chart. Six tabs, assembled before the request and timed, show whether the promise is true.
Our therapy desk
Run the packet test on ten claimsNow part of every therapy audit through physical therapy or occupational therapy billing services.
Check units the way the manual counts themThe therapy units calculator reads units from total timed minutes and places CQ and CO.
Log every documentation request with its due dateThe day it arrives.
Frequently asked questions
What is RAC topic 0228?
An approved Recovery Audit Contractor review posted April 15, 2026: a complex review of outpatient hospital and professional therapy claims billed with KX, across all A/B MACs.
What documents should a KX response file contain?
Plan of care; dated certification and recertifications; evaluation and re-evaluation; progress reports every 10 treatment days; treatment notes with total minutes; a patient-specific statement of why skilled therapy above the threshold remains necessary.
What happens if we miss the documentation request deadline?
The posting cites 42 CFR 405.930: a late or missing response supports denial without any review of the care itself.
- CMS, Approved RAC Topic 0228: Therapy Claims Billed with KX Modifier (April 15, 2026)
- CMS, Therapy Services: KX and medical review thresholds
- Federal Register public inspection, CMS-1847-P, CY 2027 PFS proposed rule
- Medicare Benefit Policy Manual, Chapter 15, sections 220.1.2, 220.1.3 and 220.3
- Medicare Claims Processing Manual, Chapter 5, section 20.2, service units
Checked October 25, 2026. Rules change; confirm against the source. Proposed items are not final until the final rule publishes.
Want the packet test run on your KX claims?
We pull ten claims above the threshold, assemble the six tabs from your chart, time it, and tell you what a reviewer would not find.