As the months of 2025 pass, the importance of thorough documentation and adherence to regulatory standards has never been greater, particularly for those providing services under Medicare Part B. Recently, there has been an increasing focus on therapy services, especially regarding the application of the KX modifier and the implementation of maintenance therapy programs. These components are vital in ensuring that patients receive the skilled care they need, even when that care extends beyond the Medicare standard threshold.
Following the end of the Public Health Emergency (PHE), the Centers for Medicare & Medicaid Services (CMS) resumed and intensified external audits. During the PHE, audits were paused, but they have since returned with renewed vigor. The Training, Probe, and Educate (TPE) audit program is a key element in this shift. TPE audits aim to improve billing accuracy by identifying providers with unusually high claim error rates or those exhibiting atypical billing practices. The audits also focus on services and items known to have high national error rates that represent a financial risk to Medicare. Common errors that trigger TPE scrutiny include missing provider signatures and credentials, encounter notes that do not support eligibility criteria, and documentation that lacks justification for medical necessity. Incomplete certifications and recertifications also frequently contribute to claims denials.
What Medicare Part B Therapy Services Cover
Medicare Part B covers therapy services aimed at restoring or maintaining a patient’s functional status. This includes physical therapy to improve mobility, occupational therapy to assist with daily living, and speech-language pathology to address communication and swallowing difficulties. While these services are subject to annual financial thresholds, continued treatment beyond these caps can be approved when accompanied by the KX modifier. The KX modifier indicates that a service is medically necessary and that the documentation in the medical record supports this necessity. It is not merely a billing code—it is a clinical attestation that skilled therapy is required beyond the capped amount to either restore a prior level of function or prevent further deterioration.
The 2025, the CMS threshold for therapy services is $2,410 for combined physical therapy and speech-language pathology, and $2,410 for occupational therapy. Exceeding this limit requires not only correct use of the KX modifier but also a compelling clinical narrative. Therapists must detail the patient’s condition, any associated complexities, and how these factors directly influence the treatment needs. The documentation must clearly justify why the patient requires continued therapy and demonstrate the unique skills applied by the therapist.
Defensible Documentation: What It Should Include
To support the use of the KX modifier, therapists must present defensible documentation. This means showing compliance with Medicare billing rules, developing a clear plan of care with functional and measurable goals, and providing detailed explanations for why specific treatments are needed, including their type, duration, and frequency. Standardized assessments are an important part of this process, offering objective benchmarks to measure progress and support continued skilled intervention.
Beyond the initial evaluation, documentation should capture detailed updates from each treatment session, noting any changes in the patient’s condition or response to therapy. If a patient is not making measurable progress, documentation should include a clinical rationale for why therapy must continue—such as the risk of functional decline or increased health complications without skilled intervention. Caregiver training, patient limitations, and the outcomes of return demonstrations should also be included to reflect the broader scope of care.
Examples of strong KX documentation include describing specific patient challenges such as post-hospitalization muscle wasting, cognitive impairments following extended illness, or comorbidities like COPD, Parkinson’s disease, or congestive heart failure. For instance, a patient recovering from a recent hospitalization might need ongoing therapy due to significant weakness and balance issues. The therapist could document their use of standardized tools like the Berg Balance Scale to demonstrate both clinical monitoring and therapeutic progress, and explain how skilled interventions are tailored to ensure safety and improve function. Each note must tie the necessity for therapy to tangible risks—like increased fall risk or respiratory distress—that would occur without continued skilled involvement.
It is also important to document the rationale for continued therapy above the threshold, especially in the event of multiple episodes. Often, the MAC will review all episodes within the calendar year, and not just the one episode identified in the document request. They are looking to understand why there might need to be multiple episodes. Although a KX “statement” is not a requirement, it is a best practice!
When Maintenance Therapy Is Medically Necessary
In the case of maintenance therapy, coverage under Medicare Part B is available under specific conditions. Unlike rehabilitative therapy, which aims to improve function, maintenance therapy is designed to preserve a patient’s current abilities and prevent decline. This distinction is especially important for individuals with chronic or progressive conditions such as multiple sclerosis, Parkinson’s disease, or post-stroke complications. In these cases, skilled therapy may still be needed even if the patient is not expected to improve. The goal is to maintain their condition and prevent further deterioration, which can only be achieved through the specialized skills of a licensed therapist.
The 2013 Jimmo v. Sebelius settlement was a landmark moment for maintenance therapy coverage. It clarified that the absence of improvement should not be the sole reason for denying Medicare coverage. This ruling reinforced the right to ongoing therapy for patients with chronic or disabling conditions, provided that skilled care is necessary. It also highlighted the importance of documenting the intent and outcomes of maintenance therapy, even when no functional gains are anticipated.
Therapists play an essential role in designing and periodically reassessing individualized maintenance programs. These programs must be tailored to each patient’s medical status and functional needs, and should be adjusted as the patient’s condition evolves. Whether the program includes stretching for muscle stiffness or caregiver-guided passive range-of-motion exercises, the determining factor for Medicare coverage is not whether the patient improves, but whether the care requires the expertise of a skilled therapist. For example, maintaining joint mobility in a patient with severe contractures is a complex task that demands clinical judgment and specialized technique, regardless of whether the patient shows measurable improvement.
Incorporating standardized assessments into the documentation—such as the Berg Balance Scale or the Modified Barthel Index—adds objectivity and defensibility. These tools help track a patient’s condition over time and can provide concrete evidence for the continued necessity of therapy. This is particularly important for patients whose decline may not be obvious from session to session but whose risks increase significantly without skilled support.
Conclusion
Ultimately, whether providing rehabilitative or maintenance therapy, clear, comprehensive, and objective documentation remains the cornerstone of defensible Medicare billing. Therapists must paint a full picture of the patient’s condition, the clinical reasoning behind continued intervention, and the consequences of withdrawing care. When used correctly, the KX modifier serves not just as a billing mechanism, but as a clinical safeguard—ensuring that patients continue to receive the skilled services they need to remain safe, stable, and independent.
LW Consulting, Inc. (LWCI) offers a comprehensive range of services to assist your organization in maintaining compliance, identifying trends, providing education and training, or conducting documentation and coding audits. For more information, contact LWCI to connect with one of our experts!
