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:

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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

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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.

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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.

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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.

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

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6 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?

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