NEW Billing Modifier Requirements for Medicare Rehab Services

January 1st, 2020 will bring NEW Medicare Billing Modifier Requirements. Ashley Duggan, QRM’s VP of Medical Review and Clinical Compliance has provided a brief explanation and the source document reference for the changes.

The two items covered below include:

KX Modifier – ongoing requirement for identification of the Part B “threshold amount” being met. Updated amounts for 2020 are: $2080 for PT/ST combined as well as $2080 for OT per calendar year (1/1/20 re-sets to $0).

This modifier communicates that ongoing skilled therapy intervention is still medically necessary

PTA/ COTA NEW Modifiers will be required indicating services have been provided “in whole or in part” by an assistant. The GP and GO modifiers are remaining in place as well.

  • CQ: PTA (Example: 97110GPCQ)

  • CO: OTA (Example: 97535GOCO)

Please review the following information surrounding revision of modifiers for billing of rehab services for Medicare beneficiaries on or after January 1, 2020. Please consult payer specific guidelines for beneficiaries managed by other payers. Additional updates surrounding this guidance will be distributed as released.

Per CY 2020 Medicare Physician Fee Schedule Final Rule (placed on display at the Federal Register on November 1, 2019, published on November 15, 2019, and for which the comment period will close on December 31, 2019).

CMS clarified regulatory language pertaining to repeal of the prior therapy cap, as follows:

  • Utilization of “threshold amount” versus “limit”

  • Requirement for continued application of the KX modifier to substantiate medical necessity for PT/OT/SLP services provided in excess of the threshold amount

  • Establishment of the annual therapy threshold amount to include:

• $2080 for PT/SLP combined

• $2080 for OT

  • Continuation of manual medical review, on a targeted basis, for claims with PT/OT/SLP services billed in excess of $3000 until calendar year 2028, at which time the threshold will be indexed by the Medicare Economic Index (the MEI)

CMS also clarified requirements for application of modifiers for services provided by therapy assistants on claims with charges incurred on or after January 1, 2020, as follows:

  • Application of modifier CQ to reflect services provided in whole or in part by a PTA

  • Application of modifier CO to reflect services provided in whole or in part by an OTA

  • Expectation for application of modifiers CQ and CO when more than 10% of a service is provided in independent treatment by an assistant

  • Result of payment at 85% of the fee schedule beginning January 1, 2022

  • Requirement for application of the CQ and CO modifiers in addition to the currently reported GP and GO modifiers (used to designate discipline provision of a specific procedure code)

Let's Get to the Point:

Billing for January therapy services will require NEW modifier codes. Please share with your appropriate team members to avoid billing hold ups.