When Should I Use the New PTA and OTA Modifiers
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
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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
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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
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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
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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
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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
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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
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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
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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
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Scenario 10
The PT and PTA working together provides 15 minutes of gait training to a Medicare beneficiary.
Scenario 10 Answer
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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
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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
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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
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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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I hope you found these scenarios helpful. Thank you for being a Gold Member! We appreciate your business and loyalty!
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How can you append a CO or CQ modifier to an evaluation charge when evaluation is out of the scope of practice of the assistant. The assistant can assess progress after a therapist has evaluated and set up a plan of care but they can’t do the evaluation. I would be afraid to append an assistant to an evaluation code.
That is an example CMS provided. If a PTA or OTA does not gather any information independently of the PT or OT, then the CQ or CO modifier would never be required. My opinion only, not a good example from CMS.
https://www.cms.gov/Medicare/Billing/TherapyServices/downloads/61004ptartc.pdf
PTAs are skilled health care workers who provide services under the direction and
supervision of PTs and implement certain aspects of treatment plans that are outlined by
PTs. PTAs are not permitted to perform evaluations, assessment procedures, or certain
complex procedures; nor do they design plans of care or develop treatment plans.
Accordingly, PTAs do not possess an independent “scope of practice” as do PTs. Each
State’s PT practice act defines the physical therapy “scope of practice” as belonging
solely to the PT, who is legally responsible for all of the services, including the services
of PTAs, provided under his or her supervision.
Again, this is an example provided by CMS in the July 29, 2019 proposed rule. If you have concerns, I would recommend you contact CMS as well as APTA and AOTA.
This is just another example of how out of touch CMS is with the realities of what therapists do!
Actually, do not blame CMS on this one. Blame your U.S. Senator and Representative as they are the ones that did this to you.
If a PTA does the entire treatment, do the GP and CQ codes go on the same line on the bill or do they have to go on separate line.
GP and CQ are both attached to the applicable CPT code(s) on the claim form.
Any update on scenerio 5 and if the 3rd unit requires the CQ modifier?
Still waiting for CMS to release their scenarios.
During the time the APTA was trying to get clarification of the scenarios there was an effort to exclude clinics in rural areas. Do you know if this ever went through or did CMS ignore the difficulty rural clinics are having obtaining PT’s?
I am not aware of that effort. Rural clinics are not excluded.
To my understanding, as currently written, the new CQ and/or CO changes DO NOT apply when billing incident to. Is this correct ? Thanks
The services of a PTA or OTA can’t be billed incident to a physician. That is illegal.
Did CMS release the scenarios for the CQ and CO modifiers yet?
No!
Quick question in regards to the CQ modifier when a PTA is treating a patient that has Medicare as their primary insurance and Tricare for Life as their secondary insurance. I know that PTA’s are not allowed to treat Tricare patients, but what about when Tricare for Life is their secondary? The claim would be automatically crossed over to Tricare for Life after Medicare paid and if they were treated by a PTA, the CQ modifier would be on the crossed over claim that TFL sees. Not sure if there are any restrictions. I’ve searched the website and cannot find any information on this with them and wasn’t sure if you had heard of anything regarding this?
A PTA or OTA can’t treat TRICARE patients whether TRICARE is primary or secondary.
Do the CQ/CO modifiers apply when Medicare is secondary?
If submitting the claim to the Medicare program, yes.
Was there CMS confirmation of the correct billing of Scenario 5? Thank you!
CMS has yet to provide clarification on this scenario.