New Modifiers to Distinguish Rehabilitative & Habilitative Therapy
Effective for dates of service on and after January 1, 2018, there will be 2 new modifiers that providers 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 will not replace the existing modifier for habilitative services.
The 2 new modifiers are:
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Do you know which insurance carriers will require us to distinguish between the two types of service?
The difficult part for providers of therapy services will be determining which insurance carriers may require the use of the new modifiers in 2018. This will be insurance carrier specific. I would recommend you carefully review your explanation of benefits and electronic remittance advice’s for line item denials due to a particular modifier missing from the CPT code on the claim form. This could be an indication that a particular insurance carrier is requiring the new modifier.
How do we know when these modifiers “may be required”?
The difficult part for providers of therapy services will be determining which insurance carriers may require the use of the new modifiers in 2018. This will be insurance carrier specific. I would recommend you carefully review your explanation of benefits and electronic remittance advice’s for line item denials due to a particular modifier missing from the CPT code on the claim form. This could be an indication that a particular insurance carrier is requiring the new modifier.
Does this modifier apply to all outpatient rehab settings, including hospital outpatient?
You would have to check with insurance carriers to see if any of them will use the new modifiers.
So ran into a situation with Excellus BCBS of Rochester. They are telling us per the AMA that the 96 modifier is replacing the SZ modifier effective 1/1/18 and we have to use the 97 modifier for rehabilitative services. Has anyone ran into this for other carriers?
What each insurance carrier decides to do with the new modifiers will be insurance carrier specific.
If a carrier does require this modifier, would we append 97 to each code on the claiim. For example, 97110 GP 97 (Gp showing physical therapy in first modifier column and 97 showing rehab in the 2nd modifier column) for each cpt code billed? Thank you in advance. (I ask because we have denials stating incorrect modifier used and we are billing as we always have with just GP)
If an insurance carrier requires the new modifiers, then they would be appended to each CPT code on the claim form in addition to any other modifiers that may be required. Most insurance carriers do not require the GP, GO and GN therapy specific modifiers.
Hi Rick,
Our updates must be rusty. We have been putting GP/GO on all our claims for all payers for years now. Can you shed some light on when that may have stopped being a billing rule for most insurance carriers. Some carriers we also still bill “incident to” aka UHC and AETNA. Thank you.
The GP, GO and GN modifiers were for traditional Medicare Part B and not all insurance carriers. Some insurance companies adopted them, but most did not.
Ok, thank you. Our practice just puts them on every payer. I did not know this.
Does Medicare require the new modifiers?
The Centers for Medicare and Medicaid Services has not published any transmittals stating they are requiring the new modifiers.
When using the modifiers, is there a specific order on the billing claim? For instance, we always use the GN/GO/GP, then would the 96/97 follow?. The situation is more enhanced when the 59 is used and finally if G codes and their modifiers are billed as well. Any clarification would be appreciated.
Most insurance companies do not dictate the order of the modifiers on the claim form.
Would the 96/97 be used on the evaluation or just treatment?
If required by the insurance carrier, would be on all CPT codes billed during that episode of care.