AOTA Practice Resource for Coding & Billing: How to Apply the Medicare OTA Modifier

With the release of the Medicare Physician Fee Schedule final rule, AOTA now has final guidance on when and how the OTA modifier is applied for occupational therapy services (a PTA modifier follows the same rules for physical therapy services). Many of the Centers for Medicare and Medicaid Services’ (CMS’) modifier reporting policies have been in effect for the past 2 years, but the final rule provides some modifications. This is important because CMS will base reimbursement for OTA services on correct application of the modifier beginning on January 1, 2022. In addition, commercial payers and Medicaid plans may establish policies to follow Medicare’s rules, so preparing for appropriate application of the modifier now can support future advocacy and proper billing.

The biggest modification in the final rule comes with how the 8-minute rule is applied to the last unit of service. CMS acknowledged AOTA and APTA’s arguments that it did not make sense to apply the modifier to a situation where the OT is allowed to bill a unit of service independently (i.e., if 8 minutes of a final unit are performed). Therefore, if an OT performs 8 minutes of the final unit of service, no modifier is required. The minutes the OTA performs of the last unit count as total time for the date of service, but do not count towards billing. CMS also finalized that the calculation is done per unit of service billed.

Let’s take a closer look at the requirements.

The Modifier Applies When

  • OTA performs entire 15-minute unit of service independently
  • OTA performs more than 10% of a 15-minute unit (see below for when the 8-minute rule applies)
  • OTA performs 8 minutes or more of final unit of service
  • OTA independently performs more than 10% of an untimed service independently.

The Modifier Does NOT Apply When

  • Services are performed concurrently with an OT
  • The tasks are non-therapeutic
  • Total time spent by OTA does not reach more than 10% of untimed service
  • Total time spent by OTA does not reach more than 10% of a 15-minute unit
  • OT performs 8 or more minutes of the final unit of service.

How do I calculate time for the modifier?

  1. Add total visit time to determine how many units can be billed under the 8-minute rule.
  2. Determine how much time the OTA spent on each unit of service.
  3. For the last unit, calculate if the OT treatment time exceeded the 8-minute rule.
  4. For untimed codes, multiply the total time spent by 10% to determine if OTA treatment time exceeded it. The untimed codes are: 97165, 97166, 97167, 97168, 97150, 92610, 92526, 96110, and 96127, supervised modalities

Clinical Scenarios

1. OT performs a low complexity evaluation. After evaluation, the OTA takes the client and performs 12 minutes of self-care training.

Bill:
97165
97535-CO

No modifier is required for the evaluation because the OT performed the entire service. If the OTA assisted with assessments, then that time would have to be calculated to see if it exceeded 10%. The modifier is required for the intervention because the OTA performed 100% of the service independently.

2. OT spends 15 minutes working on cognitive function. The OTA works jointly with the OT in ADL training for 30 minutes. The OT leaves while the OTA performs ADL training for another 15 minutes.

Bill:
97129
97535 x 2 units
97535-CO

No modifier is needed for the cognitive intervention the OT performed independently. The OT and OTA worked jointly for 30 minutes on self-care, so no modifier is needed for those 2 units. The OTA performed one 15-minute unit of self-care independently, which would require the modifier.

3. OT provides orthotics training for 12 minutes. The OTA demonstrates work integration training using the orthotic for 8 minutes.

Bill: 97760

In this example, the total time spent was 20 minutes, so under the 8-minute rule, only 1 unit may be billed. Using the 8-minute rule, the OT performed 12 minutes, which is enough time to bill the unit independently. The time spent by the OTA need not be considered for billing.

4. OT provides self-care for 23 minutes. The OTA provides self-care for an additional 22 minutes.

Bill:
97535 x 2 units
97535-CO

In this scenario, 45 minutes of self-care were rendered, so 3 units are billable. For the first 2 units, the OT and the OTA each performed 1 full 15-minute unit, so 1 unit would require the modifier. For the last unit, the OT performed 8 minutes and the OTA performed 7 minutes.

5. OT performs 97530 for 11 minutes, and the OTA performs 97530 for 11 minutes.

Bill: 97530

Using the 8-minute rule, only 1 unit can be billed for 22 minutes. Because the OT provided more than 8 minutes of the service, no modifier is needed.

6. OT performs 10 minutes of group therapy. The OTA takes over and performs another 8 minutes.

Bill: 97150-CO

In this case, group therapy is an untimed service. To calculate for the modifier, total time must be considered. In this scenario, the OTA performed more than 10% of the service, so the modifier is required.

Download a printable handout and watch a video to provide additional guidance on applying the modifier.

Advertisement