2025 HCPCS code KX
(Active) Effective Date: N/A Revision Date: N/A Medical necessity exception - Modifiers Feed
Modifier KX signifies that the healthcare provider has documented the medical necessity for a service that exceeds usual limits or doesn't meet standard coverage criteria.
Modifier KX can be used with other applicable modifiers for the specific service or procedure.
Medical necessity must be clearly established and documented in the medical record. The documentation should explain why the additional services or exceptions to standard coverage are required for the patient's specific condition and how they contribute to the patient's overall health and well-being.
The physician or other qualified healthcare professional is responsible for ensuring the service's medical necessity is documented in the patient's medical record and that all requirements specified in the applicable medical policy are met before appending modifier KX.
In simple words: KX is added to a medical bill when a treatment or service is needed but goes beyond the usual limits allowed. The doctor has recorded why the extra treatment or service is necessary for your specific situation.
Modifier KX is used to indicate that the requirements specified in the medical policy have been met and the service provided is medically necessary, even if it exceeds typical limits, such as therapy caps, or requires an exception to standard coverage guidelines.It's used to bypass gender-specific edits for patients with ambiguous genitalia and transgender patients. The provider attests that the documentation supports the medical necessity of the service.
Example 1: A patient requires physical therapy beyond the standard therapy cap due to a complex medical condition. The physician documents the medical necessity for the additional therapy and appends modifier KX to the physical therapy codes., A patient with diabetes requires a continuous glucose monitor (CGM) and related supplies, even if not meeting the usual coverage criteria. If the physician deems it medically necessary and documents the justification, modifier KX is appended to the CGM HCPCS code., A transgender patient requires a gender-specific procedure that might be denied due to automated claims processing edits. Modifier KX is used to bypass these edits, allowing for appropriate processing and payment if other coverage criteria are met.
Documentation must support the medical necessity of the service exceeding the limits or not meeting standard coverage criteria. This includes detailed clinical notes justifying the exception, relevant diagnoses, treatment plans, and any supporting evidence like published research or clinical guidelines.
** It's important to consult the specific medical policy guidelines for each payer, as the requirements for using modifier KX might vary.
- Payment Status: Active
- Specialties:Modifier KX can be applied across various medical specialties, including physical therapy, occupational therapy, speech-language pathology, and other areas where medical necessity exceptions might be needed.
- Place of Service:Various. Applicable to wherever the underlying service is performed, which could include inpatient or outpatient settings.