Modifiers

Everything you need to know to use the correct modifier when billing occupational therapy services

Billing modifiers are used to provide additional details about a service or procedure performed by healthcare providers such as occupational therapy practitioners (OTPs). They can be used to:

• Indicate that a service or procedure has been altered by a specific circumstance
• Add information or change the description of a service
• Report when not all the services in a bundle are performed
• Specify unique circumstances, exceptions, or special considerations related to the service rendered

Several modifiers commonly appended to claims for occupational therapy services provided by occupational therapists (OTs) and occupational therapy assistants (OTAs) are listed below.

Modifier 59: Distinct Procedural Service

Modifier 59 is used to identify procedures/services that are not normally reported together on the same day, but are appropriate under the circumstances. Modifier 59 does not apply to all codes. Certain situations require the modifier to clarify that two services that would typically be considered part of the same service should both be allowed, because in this instance they are performed as two separate and distinct interventions.

Each payer will decide which codes require a modifier or allowed to be billed together on the same date. For Medicare, consult the Medicare NCCI Procedure to Procedure (PTP) Edits or the Medicare Administrative Contractor (MAC) website. For the national Medicaid edit file, consult the Medicaid NCCI Edit files. Note that presence of a code pairing on the National Medicaid file doesn’t necessarily indicate that the code is covered by a specific state's Medicaid program. Private insurances may utilize the national edit files or a previous version. Because of variances in which file is utilized by individual payers, OTPs should consult payer policies to determine if a code pair is allowed and requires modifier assignment.

Points to remember:

• Modifier 59 should only be used when the two 15-minute timed services are performed sequentially. The time spent must be clearly documented as separate and distinct, and cannot overlap.
• For example, if you spent 7 minutes on therapeutic activities (CPT 97530) and 10 minutes on wheelchair management (97542), only one 15-minute unit could be billed. But if you spent 15 minutes on therapeutic activities and then an additional, separate 15 minutes on wheelchair management, you would bill both codes and modifier 59 would be appropriate.

Modifier GO

Modifier GO indicates that a service was performed under an outpatient occupational therapy plan of care. It should be used on every service performed under an OT plan of care billed to Medicare, Humana, United Healthcare, etc. (Practitioners should confirm modifier requirements with the payer.)

Modifier CO

Modifier CO is required whenever an OTA independently performs more than 10% of a service for payers applying the OTA payment differential policy such as Medicare Part B, Tricare, or Humana. There are several scenarios where the modifier would apply:

1. When the OTA performs the entire service or unit of service.
2. When an OTA performs more than 10% of a service independently. This works out to be more than 1.5 minutes of a 15-minute unit.
3. When the OTA performs more than 10% of an untimed service independently. This will require keeping track of the time spent during an untimed service. This modifier signified a 15% payment reduction beginning in 2022.

Several private insurance agencies and state Medicaid programs have implemented this policy over the past several years. OTPs should consult individual payer policies to determine whether the OTA differential applies to OTA services provided in their setting.

Modifier KX

The KX modifier indicates that a specific discipline's therapy services exceed the annual threshold amount set by Medicare Part B (and some Medicare Advantage plans) but continue to be medically reasonable and necessary. This is a cumulative threshold that takes into account not just the current episode of care but all preceding OT episodes within the calendar year. Using this modifier is an indication that the practitioner is aware that the threshold has been exceeded, but the therapy services continue to be medically necessary and documentation is present in the record to support the ongoing OT services.

Modifier GA

Modifier GA is used to let Medicare know that an Advanced Beneficiary Notice (ABN) is on file for the service because the service is not believed to be covered by Medicare in these circumstances.

Modifiers 95 and GT

Modifier 95 and Modifier GT are both used to indicate that a synchronous telehealth service was rendered via a real-time audio and video telecommunications system. The payer will determine which modifier they prefer.

Modifier 93

Modifier 93 is used to indicate that a synchronous telehealth service was provided using audio-only communication technology. Note that individual payers will have specific policies regarding the availability of audio-only telehealth. OTPs should consult specific payer policies for details.