CMS to Require New Modifiers in Calendar Year 2020
Effective with dates of service beginning on and after January 1, 2020, the Centers for Medicare and Medicaid Services (CMS) will require 2 new modifiers be appended to CPT codes on the claim form when those services are provided “in whole” or “in part” by a physical therapist assistant (PTA) or an occupational therapy assistant (OTA). To make matters worse, beginning with dates of service on and after January 1, 2022, services that contain one of the two modifiers appended to them on the claim form will be paid at 85% of the normal rate of the Medicare allowed amount for that service.
In this article, I will provide what the 2 new modifiers are, define “in whole” or “in part”, explain new documentation requirements CMS is proposing to support the use of or non-use of the new modifiers and provide examples of when the new modifiers would be and would not be required to be appended to CPT codes on the claim form. In addition, I will discuss whether the new modifiers will apply to services that are furnished by, or incident to the services of, physicians or nonphysician practitioners (NPPs) including nurse practitioners, physician assistants, and clinical nurse specialists as well as if these new modifiers will apply to outpatient physical and occupational therapy provided in a critical access hospital.
What are the New Modifiers
The 2 modifiers that will be required to be appended to a CPT code(s) when an intervention or service is provided “in whole” or “in part” by a PTA or OTA are as follows:
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How Does CMS Interpret What is a Service The content here is for members only log in here or sign up. Will the GP and GO Modifiers Still be Required The content here is for members only log in here or sign up. Will the New Modifiers Apply to Services Provided Incident-to a Physician The content here is for members only log in here or sign up. Will the New Modifiers Apply to Outpatient Therapy Provided in a Critical Access Hospital The content here is for members only log in here or sign up. What is “In Whole” or “In Part” The content here is for members only log in here or sign up. How will CMS Apply the de minimis Standard The content here is for members only log in here or sign up. How Will CMS Determine if the 10% de minimis Standard is Exceeded In the proposed rule, CMS offers 2 ways to determine if the 10% de minimis standard has been exceeded. The content here is for members only log in here or sign up.
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.
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.
CMS is implementing the new modifiers for traditional Medicare beneficiaries. Medicaid is not the same as Medicare.
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?
I would not recommend you do that.
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.
Hi Rick,
Does it matter which modifier (GP or CQ) goes in the first box? Or does it not matter as long as they are both there?
Thanks!
CMS has not stated the order. I would go GPCQ unless told otherwise by your Medicare Administrative Contractor.