Discipline Specific Outpatient Rehabilitation Modifiers - All

20.1 - Discipline Specific Outpatient Rehabilitation Modifiers - All Claims (Rev. 11129, Issued: 11-22-21, Effective: 01-01-22, Implementation: 01-03-22) Modifiers are used to identify therapy services whether or not financial limitations are in effect. When limitations are in effect, the CWF tracks the financial limitation based on the presence of therapy modifiers. Providers/suppliers must continue to report one of these modifiers for any therapy code on the list of applicable therapy codes except as noted in §20 of this chapter. Consult §20 for the list of codes to which modifiers must be applied. These modifiers do not allow a provider to deliver services that they are not qualified and recognized by Medicare to perform. The claim must include one of the following modifiers to distinguish the discipline of the plan of care under which the service is delivered: • GN Services delivered under an outpatient speech-language pathology plan of care; • GO Services delivered under an outpatient occupational therapy plan of care; or, • GP Services delivered under an outpatient physical therapy plan of care. This is applicable to all claims from physicians, nonphysician practitioners (NPPs), PTPPs, OTPPs, SLPPs, CORFs, OPTs, hospitals, SNFs, and any others billing for physical therapy, speech-language pathology or occupational therapy services as noted on the applicable code list in §20 of this chapter. Modifiers GN, GO, and GP refer only to services provided under plans of care for physical therapy, occupational therapy and speech-language pathology services. They should never be used with codes that are not on the list of applicable therapy services. For example, respiratory therapy services, or nutrition therapy services shall not be represented by therapy codes which require GN, GO, and GP modifiers. Contractors edit institutional claims to ensure the following: • that a GN, GO or GP modifier is present for all lines reporting revenue codes 042X, 043X, or 044X. • that no more than one GN, GO or GP modifier is reported on the same service line. • that revenue codes and modifiers are reported only in the following combinations: o Revenue code 42x (physical therapy) lines may only contain modifier GP o Revenue code 43x (occupational therapy) lines may only contain modifier GO o Revenue code 44x (speech-language pathology) lines may only contain modifier GN. • that discipline-specific evaluation and re-evaluation HCPCS codes are always reported with the modifier for the associated discipline (e.g. modifier GP with a HCPCS code for a physical therapy evaluation). Contractors return to the provider institutional claims that do not meet one or more of these conditions. CMS has established two modifiers, CQ and CO, for services furnished in whole or in part by physical therapist assistants (PTAs) and occupational therapy assistants (OTAs). The modifiers are defined as follows: • CQ modifier: Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant • CO modifier: Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant Effective for claims with dates of service on and after January 1, 2020, the CQ and CO modifiers are required to be used, when applicable, for services furnished in whole or in part by PTAs and OTAs on the claim line of the service alongside the respective GP or GO therapy modifier, to identify those PTA and OTA services furnished under a PT or OT plan of care. For those practitioners submitting professional claims who are paid under the PFS, the CQ/CO modifiers apply only to services of physical and occupational therapists in private practice (PTPPs and OTPPs); and not to the therapy services furnished by or incident to the services of physicians or nonphysician practitioners (NPPs) ‒ including nurse practitioners (NPs), physician assistants (PAs), and clinical nurse specialists (CNSs) ‒ because PTAs and OTAs do not meet the qualifications and standards of physical or occupational therapists, as required by §§ 410.60 and 410.59, respectively. However, the CQ and CO modifiers do apply to claims from physician or NPP groups when a PTPP or OTPP has reassigned their benefits to the group and their NPI appears as the rendering provider of the therapy service(s) on the claim. For providers submitting institutional claims and paid at PFS rates for their outpatient PT and OT services, the CQ and CO modifiers apply to the following providers: outpatient hospitals, rehabilitation agencies, skilled nursing facilities, home health agencies and CORFs. However, the CQ and CO modifiers are not applicable to claims from critical access hospitals because they are paid on a reasonable cost basis, or from other providers for which payment for PT and OT services is not made under the PFS rates. The CQ modifier must be paired to the GP therapy modifier and the CO modifier with the GO therapy modifier. Claims not so paired will be rejected/returned as unprocessable. For dates of service, on and after January 1, 2022, claims billed with a CQ or CO modifier to indicate the services were furnished in whole or in part by a PTA or OTA are paid at an amount equal to 85 percent of the otherwise applicable Part B payment that’s based on the MPFS. The 15 percent reduction is taken last, e.g., after the MPPR (and other reductions where applicable) and right before sequestration. This reduction is taken from the paid amount, i.e., the actual amount paid not the MPFS allowed amount. Regulations for the payment of therapy claims and the policy for assigning the therapy assistant modifiers (CO and CQ) for services provided in whole or in part by OTAs and PTAs are found at §§ 410.59(a)(4) and 410.60(a)(4) for outpatient occupational and physical therapy services, respectively and at § 410.105(d) for CORF OT and PT services.