Access: The billing behaviors described in this article are configured by StrataPT at the payer level. Clinicians and front desk staff interact with the resulting alerts and tasks in their daily workflow. Settings described here are not directly editable by clinic staff.
The KX Modifier and the Annual Therapy Threshold
Medicare sets an annual cap on outpatient therapy spending. Once a patient’s Medicare therapy charges approach that threshold, a KX modifier must be added to all claims for treatment to continue. The KX modifier is your attestation that continued treatment is medically necessary. StrataEMR tracks each Medicare patient’s year-to-date therapy spend automatically. When a patient approaches the threshold, the system prompts the clinician to approve or decline the KX modifier directly inside the documentation workflow — no manual tracking required.- Approve — StrataEMR adds the KX modifier to all claims for that patient for the remainder of the calendar year.
- Decline — Billing to Medicare stops for that patient. Any claims that have already denied for benefit maximum will be settled.
Note: StrataEMR strongly recommends enabling the auto-apply KX modifier setting for all Medicare patients. Ask your StrataPT Customer Success Manager to confirm this is enabled for your account.
Timed Units and the Procedure Minute Rule
Medicare uses the 8-minute rule (CMS standard) to determine how many billable units can be claimed for timed therapy services. Some payers follow the AMA direct-time standard instead. StrataEMR enforces the correct counting method per payer through a setting called the Procedure Minute Rule, configured by StrataPT for each payer in your account. There are three enforcement levels: None No minute validation is applied. Units are entered manually without system enforcement. Low — Compliance Only The system tracks minutes against the applicable rule (CMS or AMA) and surfaces compliance information, but does not warn or block. Use this setting to gain visibility without restricting clinician workflow. Medium — Warn / Prevent Lost Units (most commonly recommended) The system warns and blocks completion if the documented minutes qualify for more units than were selected. This prevents under-billing. For example: if a clinician documents 38 minutes of timed services (which equals 3 units under CMS rules) but selects only 2 units, the system flags the discrepancy before the document can be completed. High — Warn / Prevent Lost Minutes, 5+ Threshold The system warns when documented minutes are 5 or more past the current unit threshold but haven’t reached the next unit. This is a productivity and optimization prompt — it surfaces cases where a small amount of additional treatment time would have qualified for an additional billable unit. More actionable coaching, but more friction for clinicians.Note: The Procedure Minute Rule is set per payer by StrataPT, not by clinic staff. If you want to adjust the enforcement level for a specific payer, contact your Customer Success Manager.
Referring Provider Requirement
Medicare does not require patients to have a physician referral for physical therapy under direct access laws — but it does require a referring provider NPI on every Medicare claim. This is a billing requirement, not a clinical one. StrataEMR enforces this: if a Medicare patient’s case lists “Direct Access” as the referral source without a specific physician selected, you will see the error “A referrer must be specified when billing Medicare” when attempting to complete a document. To resolve this: add the certifying physician to the patient’s case info as the referring provider. This is the physician who will sign the Plan of Care — they don’t need to have sent the patient to you, but Medicare requires their name and NPI on the claim.Note: The certifying physician must sign and date the Plan of Care within 30 days of the initial therapy visit. StrataEMR generates a fax task at evaluation completion to facilitate this. The Plan of Care must be re-certified within 90 calendar days. See Plan of Care for the full physician signature workflow.
Medicare Advantage vs. Medicare Supplement
“Medicare” covers two very different coverage types that require different handling in StrataEMR: Medicare Advantage (Replacement Plan) A private insurance plan that replaces traditional Medicare. The payer is the Advantage plan (for example, Blue Cross Medicare Advantage or AARP Medicare Advantage), not Medicare itself. Enter the Advantage plan as the primary payer. Do not add Medicare as a secondary — Medicare is not involved in the claim. Medicare Supplement (Medigap) A secondary policy that covers costs not paid by traditional Medicare Part B — typically coinsurance and deductibles. Enter traditional Medicare as the primary payer and the supplement plan as secondary. A common error is entering a Medicare Advantage plan as a secondary policy alongside traditional Medicare. If a patient’s primary payer is a Medicare Advantage plan, remove the Medicare MBI from the secondary field. Keeping both will cause claim routing errors. If you’re unsure which type a patient has, the benefit verification summary will indicate whether the coverage is a replacement plan or a supplement.Medicare Coinsurance and Patient Collections
Traditional Medicare covers 80% of the allowed amount for covered therapy services. The remaining 20% is the patient’s responsibility — unless a supplement plan covers it. StrataEMR calculates the expected patient responsibility based on the payer’s coinsurance rate. For many Medicare patients, this generates a collection task showing a balance due (commonly around $20 per visit on a standard visit rate). If the patient has a supplement that covers the 20%, or your practice’s policy is to waive Medicare coinsurance, you can enter $0 in the preferred collection amount field to prevent collection tasks from generating for that patient.Note: A payer-level setting that automatically sets the preferred collection amount to $0 for all Medicare patients is available. Contact your StrataPT Customer Success Manager to discuss whether this is appropriate for your practice’s billing workflow.
Related
- Plan of Care — Certification periods, physician signature workflow, and POC fax return process
- Benefit Verification — How StrataEMR verifies Medicare benefits and what the verification summary includes
- Authorization Management — Managing authorization requirements for Medicare Advantage plans
- Policy Overview — Entering and managing payer policies, including Medicare and supplement coverage