Do the CQ and CO Modifiers Apply to All Federal Insurances
Language in the Bipartisan Budget Act of 2018 instructed the Secretary of Health and Human Services (HHS), by January 1, 2019, to establish a modifier to indicate (in a form and manner specified by the Secretary), in the case of an outpatient physical therapy service or outpatient occupational therapy service furnished in whole or in part by a PTA or OTA, that the service was furnished by a PTA or OTA.
The CQ and CO modifiers were created by the Secretary of HHS and became effective with dates of service on and after January 1, 2020 for traditional Medicare outpatient therapy services. Beginning with dates of service on and after January 1, 2022, CPT codes that contain the CO or CQ modifier will be paid at 85% of what a physical therapist or an occupational therapist would be paid for providing the exact same services under the Medicare Physician Fee Schedule.
In this article, I will answer the following questions:
The CQ/CO modifiers are applicable to outpatient physical and occupational therapy services provided in all settings accept critical access hospitals (CAHs). Settings where the CQ/CO modifiers will be applicable include:
- Private Practice, both therapist and physician owned
- Skilled Nursing Facilities providing Part B therapy services
- Home Health Agencies providing Part B therapy services in a beneficiaries home
- Comprehensive Outpatient Rehabilitation Facilities
- Rehabilitation Agencies
- Hospital outpatient therapy departments
For hospitals, keep in mind that if a Medicare beneficiary has exhausted all of their Part A days or they do not meet the criteria for an inpatient admission and they received physical and/or occupational therapy services and those services are being billed to your Medicare contractor separately, this would be considered outpatient therapy services as well and the new CQ/CO modifiers could be applicable.
The same is also true for Medicare beneficiaries in the emergency department or under “Observation Status”, have physical and/or occupational therapy, do not get admitted to the hospital and are discharged home. If the physical and/or occupational therapy services are not part of the ambulatory payment classification and are being billed separately to your Medicare contractor, this would be considered outpatient therapy services as well and the new CQ/CO modifiers could be applicable.
The reason CAHs are not included is CAHs are not reimbursed under the Medicare Physician Fee Schedule. They are paid on a cost-ratio basis.
No since critical access hospitals are not reimbursed under the Medicare Physician Fee Schedule, rather, are paid on a cost-ratio basis.
The Bipartisan Budget Act of 2018 and the requirements for the new CQ/CO modifiers applies only to traditional Medicare and does NOT apply to Medicare Advantage plans, state Medicaid programs, managed Medicaid programs or any other insurance carrier(s). This does not mean any insurance carrier(s) can’t decide to implement these modifiers in 2020 or in subsequent years.
No! The Bipartisan Budget Act of 2018 applies only to the traditional Medicare program and for outpatient therapy services reimbursed under the Medicare Physician Fee Schedule. This does not mean that any federal insurance carrier(s) can’t decide to implement these modifiers in 2020 or in subsequent years. For example, TRICARE implemented the CQ and CO modifiers effective in 2020.
All material posted on our website is the intellectual property of Gawenda Seminars & Consulting, Inc. and can’t be used, reproduced, or posted as your own material without the prior written approval of Gawenda Seminars & Consulting, Inc.
This article is not intended to and does not serve as legal advice or as consultative services, but is for general information purposes only.
Check Our Past Webinars!
Leave a Reply
Your email address will not be published. Required fields are marked *This site uses Akismet to reduce spam. Learn how your comment data is processed.
Hi Rick
Thanks for the free article!
My understanding is that Aetna has implemented a reduction for PTA and OTA. Can you confirm this?
https://gawendaseminars.com/aetna-implements-assistant-payment-reduction/