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:
How Does CMS Interpret What is a Service
Will the GP and GO Modifiers Still be Required
Will the New Modifiers Apply to Services Provided Incident-to a Physician
Will the New Modifiers Apply to Outpatient Therapy Provided in a Critical Access Hospital
What is “In Whole” or “In Part”
How will CMS Apply the de minimis Standard
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.