What are the New Documentation Requirements CMS is Proposing

CMS is proposing a new documentation requirement effective with dates of service on and after January 1, 2020 to support the application or non-application of the CQ/CO modifier for each service furnished that day. In the proposed rule, CMS provides the following examples:

This content is for Gold Members only. Please log in above or Register

Lets now take a look at some case scenarios and see when and when not the CQ/CO modifiers would be required per the proposed rule Also, keep in mind that the scenarios could change when the final rule is released in early November 2019.

Evaluations and Reevaluations

This content is for Gold Members only. Please log in above or Register

When Multiple Units of the Same 15-Minute Time-Based CPT Code are Billed

Many times, providers of outpatient therapy services bill multiple units of the same 15-minute CPT code for services rendered to a Medicare beneficiary. I will provide several examples of how the CQ/CO modifier will or will not apply. I will use therapeutic exercise (CPT code 97110) for my examples. In addition, this is where the CMS interpretation of service will cause financial issues for providers of outpatient physical and occupational therapy.

This content is for Gold Members only. Please log in above or Register

When Different 15-Minute Time-Based CPT Codes are Provided

I will provide several examples when the PT/OT and PTA/OTA are providing different interventions and procedures to a Medicare beneficiary that are described by different CPT codes.

This content is for Gold Members only. Please log in above or Register

Group Therapy (CPT Code 97150)

I will provide several examples when the PT/OT and PTA/OTA are providing group therapy in which a Medicare beneficiary is a participant.

This content is for Gold Members only. Please log in above or Register

To access the proposed rule regarding the PTA/OTA modifiers, click

This content is for Gold Members only. Please log in above or Register

I hope you found this article helpful. Thank you for being a Gold Member!

 

9 Comments

  1. Texas currently uses the UB modifier for assistant visits which is reimbursed at 70% of the U5 modifier. Does this mean the new modifier will further reduce that rate? ( 85% of the 70%)
    thanks

    • I assume you are talking about Texas Medicaid requiring the UB modifier? If so, Medicaid and Medicare are not the same. The new CQ and CO modifiers are for traditional Medicare outpatient therapy visits.

  2. Will this apply to pediatric only clinics? We do not take Medicaid directly but have a few patients with Medicaid that are billed through a HMO.

  3. We share chargemasters in our Therapy Service line for our organization and we have two billing facilities – one that is critical access and one that is not. Even though the critical access will not require the modifiers reporting and reduced payment will not apply to those claims 2021, do you know if we can voluntarily submit the modifiers on the critical access claims?

  4. Might you clarify, you state the CQ/CO modifier would be appended in addition to the GP/GO modifier to the CPT codes on the claim form, but page 384 of the CMS-1693-P that is linked to your article states” …modifiers would be used instead of the GP and GO modifiers that are currently used”. Thank you.

    • Here is the exact language from page 40559 of the proposed rule: In the CY 2019 PFS final rule, we clarified that the CQ and CO modifiers are required to be used when applicable for services furnished on or after January 1, 2020, on the claim line of the service alongside the respective GP or GO therapy modifier to identify services furnished under a PT or OT plan of care. What page number are you referring to?

      • Also, on page 40564, it states: As specified in the CY 2019 PFS final rule, we also note that the CQ or CO modifier
        is to be applied alongside the corresponding GP or GO therapy modifier that is required on each claim line of service for physical therapy or occupational therapy services. Beginning for dates of service and after January 1, 2020, claims missing the corresponding GP or GO therapy modifier will be rejected/returned to the therapist or therapy provider so they can be corrected and resubmitted for processing.
        As discussed in the CY 2019 PFS proposed and final rules (see 83 FR 35850 and 83 FR 59654), we established that the reduced payment rate under section 1834(v)(1) of the Act for the outpatient therapy services furnished in whole or in part by therapy assistants is not applicable to outpatient therapy services furnished by CAHs, for which payment is made under section 1834(g) of the Act. We would like to take this opportunity to clarify that we do not interpret section 1834(v) of the Act to apply to outpatient physical therapy or occupational therapy services furnished by CAHs, or by other providers for which payment for outpatient therapy services is not made under section 1834(k) of the Act based on the PFS rates.

Leave a Reply

Your email address will not be published. Required fields are marked *

Post comment

This site uses Akismet to reduce spam. Learn how your comment data is processed.

Go to Top