modifier

Beginning with dates of service on and after January 1, 2020, the Centers for Medicare and Medicaid Services (CMS) will require providers of outpatient physical therapy and occupational therapy services to append a modifier to CPT code(s) on the claim form when that service was provided in whole or in part by a physical therapist assistant (PTA) or an occupational therapy assistant (OTA). Click HERE to access my answers to some of the more frequently asked questions on the new PTA and OTA modifiers.

In this article, I will provide 14 scenarios and the answer how to correctly bill for that scenario based on the information we have as of today. Keep in mind that answers to any of the scenarios may change once CMS issues further guidance and scenarios on the application of the CQ and CO modifiers.

Scenario 1

The physical therapist (PT) performs a moderate complexity evaluation (CPT code 97162) or the occupational therapist (OT) performs a low complexity evaluation (CPT code 97165).

Scenario 1 Answer

Scenario 2

PT or OT spends 10 minutes determining the placement of the electrodes, parameters of the electrical stimulation, answering patient questions and pushing start. The electrical stimulation runs for 10 minutes.

Scenario 2 Answer

Scenario 3

PT or OT spends 10 minutes providing therapeutic exercise and then the PTA or OTA provides an additional 10 minutes of therapeutic exercise.

Scenario 3 Answer

Scenario 4

PT or OT spends 25 minutes providing therapeutic exercise and then the PTA or OTA provides an additional 15 minutes of therapeutic exercise.

Scenario 4 Answer

Scenario 5

PT or OT spends 25 minutes providing therapeutic exercise and then the PTA or OTA provides an additional 20 minutes of therapeutic exercise.

Scenario 5 Answer

Scenario 6

PT or OT spends 15 minutes providing manual therapy and then the PTA or OTA provides 20 minutes of therapeutic exercise.

Scenario 6 Answer

Scenario 7

PT or OT spends 7 minutes providing manual therapy and then the PTA or OTA provides 15 minutes of therapeutic exercise.

Scenario 7 Answer

Scenario 8

PT or OT spends 10 minutes providing manual therapy and then the PTA or OTA provides 10 minutes of therapeutic exercise.

Scenario 8 Answer

Scenario 9

PT or OT spends 32 minutes providing manual therapy and then the PT or OT provides 12 minutes of therapeutic exercise and then the PTA or OTA provides 14 minutes of therapeutic exercise

Scenario 9 Answer

Scenario 10

The PT and PTA working together provides 15 minutes of gait training to a Medicare beneficiary.

Scenario 10 Answer

Scenario 11

The PT provides 20 minutes of therapeutic exercise (CPT code 97110) and 15 minutes of neuromuscular reeducation (CPT code 97112). The PTA then provides 20 minutes of manual therapy (CPT code 97140)

Scenario 11 Answer

Scenario 12

A Medicare patient is under “Observation Status” in the hospital setting. In the morning, the PT performs a 25 minute moderate complexity evaluation and also provides 17 minutes of gait training (CPT code 97116). In the afternoon, the patient is seen by a PTA and the PTA provides 10 minutes of therapeutic activities focused on bed  mobility and sit to stand transfers (CPT code 97530) and 15 minutes of gait training (CPT code  97116). The patient is then discharged home and the hospital bills the PT services to the Medicare program as outpatient physical therapy.

Scenario 12 Answer

Scenario 13

The PTA provides 18 minutes of therapeutic exercise followed by 12 minutes of manual therapy and then finished with a 10 minute ultrasound.

Scenario 13 Answer

Scenario 14

The OTA provides 10 minutes of paraffin bath followed by 18 minutes of manual therapy and then finished 20 minutes of therapeutic activities.

Scenario 14 Answer

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