Modifiers 96 and 97: What are They and When To Use Them
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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Does this apply to outpatient hospital based facilities?
Yes!
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
You would if the insurance carrier is requiring the use of that modifier.
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.
Yes, insurance carriers can apply this to private practices.
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?
Modifiers 96 and 97 do apply to the private practice setting if they are required by the insurance carrier.
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
Carol
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.
What kind of provider types can use the 96/97 modifiers? Is this strictly use for PT/OT provider types?
I only focus on PT, OT and SLP so I know those modifiers can apply to those 3 disciplines.
What modifiers do I use for PT outpatient? I have used the GP CQ and both have denied by Humana.
If a child has Autism and is actively receiving speech therapy, would this fall under 96 or 97
You would need to determine what type of therapy you are providing.
What CPT code do I have to use the 97 modifier on in outpatient setting. Modalities or just the exercise and activities?
If modifier 97 required, would be required on all CPT codes.