Modifiers
Everything you need to know to use the correct modifier when billing occupational therapy services
Modifier 59
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.
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 and 10 minutes on self-care, 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 self-care, you would bill both codes and modifier 59 would be appropriate.
Modifier GO
Modifier GO Indicates that the service was performed under a therapy plan of care. It should be used on every service performed under a therapy plan of care billed to Medicare, Humana, and United Healthcare, etc. (Practitioners should confirm modifier requirements with the payer.)
Modifier CO
Modifier CO is required whenever an OTA performs more than 10% of a service independently for Medicare, Tricare, and Humana, etc.(Practitioners should confirm modifier requirements with the payer.) There are several scenarios where the modifier would apply:
- When the OTA performs the entire service or unit of service.
- 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.
- 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.
Modifier KX
The KX modifier is meant to be placed on all services that exceed the Medicare yearly therapy threshold ($2,150 for the year 2022). Using this modifier is an indication that the practitioner is aware the threshold has been exceeded, but the therapy services continue to be medically necessary.
Modifier GA
Modifier GA is used to let Medicare know that an ABN is on file for the service because the service is not believed to be covered by Medicare in these circumstances.
Modifier 95 and GT
Modifiers 95 and GT are both used to indicate synchronous telehealth services. The payer will determine which modifier they prefer.
AOTA Practice Resource for Coding & Billing: How to Apply the Medicare OTA Modifier
Proper Use of Modifiers 59 & –X{EPSU}