Occupational Therapy Assistant Modifier Required in 2020
The Balanced Budget Act of 2018 called for a payment adjustment when a patient is seen by a therapy assistant rather than a therapist. The Centers for Medicare & Medicaid Services (CMS) has laid the groundwork for implementing this change in the Medicare Physician Fee Schedule (MPFS) over the past 2 years. In the CY2020 MPFS final rule, CMS clarified and finalized the new therapy assistant payment modifiers. Although the 15% payment reduction does not go into effect until 2022, the modifier requirement goes into effect for claims for services provided on or after January 1, 2020.
The modifiers CO (occupational therapy assistant) and CQ (physical therapist assistant) are required in addition to the GO and GP modifiers when a service is performed under a therapy plan of care.
The modifiers are to be applied when the de minimis standard is met by an assistant. CMS defines the de minimis standard as providing greater than 10% of a therapeutic service. The standard only applies to skilled therapeutic services, not unskilled services that could be performed by an aide.
In the CY2020 final rule, CMS walked back some of the requirements that were discussed in the proposed rule after significant advocacy by AOTA and other therapy stakeholders resulted in CMS receiving more than 9,000 comments.
Here is what you need to know about the OTA modifier changes in the final rule:
1) Concurrent Services: CMS acknowledged that it is not appropriate to reduce payment when an OT and an OTA are working concurrently on the same patient. The OTA modifier will only apply to time where the OTA is performing the service independently.
2) Units of Service Furnished Separately: CMS acknowledged that it is more appropriate to apply the OTA modifier at the unit level rather than at the service level. The OTA modifier calculation will apply to untimed codes and to timed codes at the 15-minute unit level. For example, when the OTA performs 15 minutes of 97530 and the OT performs 30 minutes, the modifier should be applied to one 15-minute unit of 97530 rather than to all three units.
3) Administrative Burden: CMS acknowledged that an additional documentation requirement would result in undue administrative burden. CMS reminded practitioners that the documentation should be sufficient to support the codes billed and the units applied to the modifier.
Here are a few scenarios that show how the modifier is applied.
Scenario 1
An occupational therapist performs therapeutic activities, 97530, for 25 minutes. The occupational therapy assistant (OTA) then takes the patient and performs an additional 25 minutes of therapeutic activities.
97530
97530-CO x 2
In this example, a total of 50 minutes of therapeutic activities was performed. The occupational therapist performed one 15-minute unit alone, so no modifier is needed. For the second unit, the occupational therapist performed 10 minutes and the OTA performed 5 minutes. Because 5 minutes is greater than 10% of the 15-minute unit, the modifier is required for the 15 minute unit. The OTA performed the third 15-minute unit in its entirety, requiring the modifier.
Scenario 2
An occupational therapist performs an evaluation, 97166. The OTA provides assistance during the evaluation, but the therapist never leaves, performing the entire service. The OTA then takes the patient and performs 15 minutes of therapeutic activities, 97530.
97166
97530-CO
In this example, the therapist performs the evaluation and is present for the entire service. Even though the OTA was present, no modifier is required for concurrent services. The modifier is required for 97530 because the OTA performed the entire service independently.
Scenario 3
An occupational therapist performs cognitive intervention with a patient for 14 minutes. The OTA then comes in and completes the activity for another minute, then takes the patient and performs 21 minutes of self-care.
97129
97535-CO
In this example, the occupational therapist performed 14 minutes of a 15-minute cognitive intervention service. One minute is less than 10% of the unit of service, so no modifier is needed. The OTA performed 21 minutes of self-care. Using the 8-minute rule, only 1 unit of service can be billed. The CO modifier would apply because the OTA completed the entire unit of service.
Certain scenarios remain unclear based on inconsistencies in the application of the 8-minute rule versus the de minimis standard. CMS will be providing additional guidance on its website on how to apply these modifiers. AOTA will also be releasing a video resource on our website prior to January 1, 2020.