Get to Know the 2020 Therapy Assistant Modifiers You Need to Use

Get to Know the 2020 Therapy Assistant Modifiers You Need to Use

Modifiers CO and CQ are now required when an assistant provides 10 percent or more of the timed service.

The Balanced Budget Act of 2018 called for a payment adjustment when a patient is seen by a therapy assistant rather than a therapist. The Center for Medicare & Medicaid Services (CMS) has laid the groundwork for the implementation of this change in the Medicare Physician Fee Schedule (MPFS) over the last two years.

In the 2020 MPFS final rule, CMS clarified and finalized the new therapy assistant payment modifiers. Although the 15 percent payment reduction does not go into effect until 2022, the modifier requirement goes into effect for claims with dates of service on or after Jan. 1, 2020.

In the 2020 MPFS final rule, CMS conceded to some of the requirements that were discussed in the proposed rule after receiving over 9,000 comments. CMS finalized a new policy stating that the modifier will only be applicable when the assistant performs the service independently, not concurrently with a therapist. CMS also lowered the 10 percent de minimis standard to per unit of service rather than per CPT® code and removed the proposed additional documentation requirements for reporting why the modifier was or was not used.

Here’s a detailed look at the requirements.  

New Therapy Modifier Requirements

Modifiers CO Outpatient physical therapy services furnished in whole or in part by an occupational therapy assistant and CQ Outpatient physical therapy services furnished in whole or in part by a physical therapy assistant are required in addition to modifiers GO Services delivered under an outpatient occupational therapy plan of care and GP Services delivered under an outpatient physical therapy plan of care when a service is performed under a therapy plan of care. CO and CQ are payment modifiers, so they should be applied first.

Apply the modifiers when an assistant meets the de minimis standard. CMS defines the de minimis standard as providing greater than 10 percent of a therapeutic service. The standard applies to skilled therapeutic services performed independently by a therapy assistant only; it does not apply to unskilled services that could be performed by an aide.

Coding Scenarios

Let’s look at some scenarios for when you may apply the new modifiers. 

Scenario 1

An occupational therapist performs therapeutic activities, one-on-one with the patient, for 25 minutes. The occupational therapy assistant (OTA) then takes the patient and performs an additional 25 minutes of service.

97530 Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes

97530-CO x 2

In this example, a total of 50 minutes of therapeutic activities is performed. The occupational therapist performed one 15-minute unit alone, so no modifier is needed for one unit. For the second unit, the occupational therapist performed 10 minutes and the OTA performed five minutes. Five minutes is greater than 10 percent of the 15-minute unit, so the modifier is required. The OTA performed the third 15-minute unit in its entirety, requiring the modifier.

Scenario 2

A physical therapist performs a physical therapy evaluation of high complexity. The physical therapist assistant (PTA) assists during the evaluation, but the therapist never leaves, performing the entire service. The PTA then takes the patient and performs 15 minutes of therapeutic exercises.

97163  Physical therapy evaluation: high complexity, requiring these components: …. Typically, 45 minutes are spent face-to-face with the patient and/or family

97110-CQ  Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility

In this example, the therapist performs the evaluation and is present for the entire service. Even though the PTA was present, no modifier is required for concurrent services. The modifier is required for 97110 because the PTA performed the entire service independently.

Scenario 3

The PTA sets up the patient on electrical stimulation, which takes six minutes, and adjusts the stimulation level halfway through the treatment, which takes two minutes. The physical therapist finishes the modality with the patient and then assesses the patient, which takes eight minutes.

97014-CQ Application of a modality to 1 or more areas; electrical stimulation (unattended)

In this instance, the supervised modality is an untimed code. However, for the purposes of applying the modifier, time must be tracked and added. The PTA performed eight minutes of a 16-minute service. Eight minutes is more than 10 percent of the service, so the modifier is required.

Scenario 4

An occupational therapist performs cognitive intervention with a patient for 14 minutes. The OTA then comes in and completes the activity for another minute before taking the patient to perform 21 minutes of self-care.

97129  Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing, and sequencing tasks), direct (one-on-one) patient contact; initial 15 minutes

97535-CO  Self-care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes

In this example, the occupational therapist performed 14 minutes of a 15-minute cognitive intervention service. One minute is less than 10 percent of the unit of service, so no modifier is needed. The OTA performed 21 minutes of self-care. Using the eight-minute rule, you can only bill one unit of service. Modifier CO applies because the OTA completed the entire unit of service.

Certain scenarios remain unclear based on inconsistencies in the application of the eight-minute rule versus the de minimis standard. CMS will be providing additional guidance on its website as to the application of these modifiers. Additional guidance can also be found from The American Occupational Therapy Association and American Physical Therapy Association.

Monica Wright
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About Has 1 Posts

Monica Wright, CPC, CPMA, CPCO, is the manager of Coding and Payment Policy for the American Occupational Therapy Association (AOTA) and has a master's in health administration. Wright is a member of the Annapolis, Md., local chapter.

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