What are Modifiers 96 and 97?
Effective for dates of service on and after January 1, 2018, there were 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. As we are now 4 years into the use of these new modifiers, we are starting to see some insurance carriers require the use of either Modifier 96 or 97 to be appended to the CPT code(s) on the claim form in addition to any other required modifiers.
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Hi Rick. Would physical therapy for post operative TKA’s, THA’s, etc be considered “Modifier 97: When a service or procedure rehabilitative in nature is provided for rehabilitative purposes?”
My opinion only is a new TKA would be rehabilitative.
We received our first claim rejection from Humana where they are requiring one of these modifiers, and it appears that the modifier should be attached to all CPTs (except the evaluation codes). Is this accurate?