Modifiers 96 and 97: What are They and When To Use Them

March 4, 2019
Rick Gawenda

Effective for dates of service on and after January 1, 2018, there were 2 new modifiers that providers of outpatient physical, occupational and speech therapy may be required to use with some insurance carriers, such as Affordable Care Act (ACA) compliant plans, to distinguish whether the service provided was rehabilitative in nature or habilitative in nature. The new modifiers replaced the SZ modifier for habilitative services, unless instructed otherwise by an insurance carrier.

The 2 new modifiers that became effective January 1, 2018 are Modifier 96 and Modifier 97. What are the definitions of each modifier and when would you use each modifier for outpatient therapy services?

Modifier 96:

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  1. So if we do 3 procedures on a patient and it is rehabilitative would we put the modifier 97 on a 3 codes or would we only put on the primary code? Thanks

  2. Does this apply to private based clinics? We have never used the SZ modifier and already have two insurance companies denying stating we have to use the 96 and or 97 modifier.

  3. We are a outpatient physical therapy company that bills in clinic setting.
    Does modifier 96 and 97 apply to this as well? The only two modifiers we’ve used is GP and 59. We’ve noticed the payer Humana has informed us to bill one of these two modifiers. If so, should one of the two be applied to all CPT codes?

    1. Modifiers 96 and 97 do apply to the private practice setting if they are required by the insurance carrier.

    2. Hi Geneva
      We are having the same issue with Humana denying for invalid modifier 96-97 should be added.
      Did you find out which one we would use?

      Thank You

  4. Humana has confirmed the use of 96 or 97 modifier is required for some, not all plans.
    UHC co-4 denials for incorrect or missing modifier. he said UHC reps just received an email that the claims were processed in error starting on date of service 05/16/2019 and that providers do not have to call on these because UHC will reprocess any claims denied with CO-4 denials.

  5. What kind of provider types can use the 96/97 modifiers? Is this strictly use for PT/OT provider types?

  6. What CPT code do I have to use the 97 modifier on in outpatient setting. Modalities or just the exercise and activities?