When a claim denies for benefits maxed. Go to the claim, flip all lines back to Medicare.


Do not submit any new claims for this patient as they will deny.


Contact the practice to see if adding the KX modifier is appropriate. Such as, "Does this patient qualify for use of the KX modifier?"


Add a note on the account in EZC.


Once a response is received, add KX modifier(s) to all payable line items (not FLR codes or PQRS codes) and do a reopening either on the portal or by phone. Again note the account in EZC. The only time you would resubmit a corrected claim is if the MAC does not allow portal or phone reopenings.


*There are a couple of practices that do not require you to request approval prior to adding the KX modifiers. This is noted on the client information sheet for that practice. Be sure to notify the practice if they have requested so. If not required, simply add a note on the account, add the KX to the claims and do a reopening (or corrected claim).

Also, go to the case in QEMR, case info tab., pg. 2 and be sure to put a check mark in the box

that says Cap Exceeded and enter the date of the first claim where the benefits maxed.