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Hot Topics: Understanding How to Use the Assistant Modifiers for Physical Therapists and Occupational Therapists in 2020

 

Summary

New modifiers to indicate when an assistant has performed at least 10% of services are required by Medicare for dates of service on or after January 1, 2020. This has no impact on payment for services until January 1, 2022. However, beginning on January 1, 2022, services with the assistant modifier will be reimbursed at 85% of the amount indicated by the Medicare Physician Fee Schedule.

What is the new Medicare rule for 2020 about services delivered "in whole or in part" by the physical therapist assistant (PTA) or occupational therapy assistant (OTA)? 

In the 2020 final rule, CMS made changes to their reimbursement policy for the use of physical therapy assistants and occupational therapy assistants. Starting with dates of service on or after January 1, 2020, when a PTA or OTA provides therapy services "in whole or in part", Medicare Part B claims must include a payment modifier.

What are the assistant modifiers for PTAs and OTAs?

These assistant modifiers are CQ for PTAs and CO for OTAs.

In 2020 is it mandatory to apply the assistant modifier if services are delivered "in whole or in part" by the physical therapist assistant (PTA) or occupational therapy assistant (OTA)?

Yes. It is required to begin using the assistant modifiers for dates of service on or after January 1, 2020. It impacts reimbursement beginning January 1, 2022.

Starting in 2022, how much will Medicare pay for services delivered "in whole or in part" by a PTA or OTA?

For dates of service on or after January 1, 2022, services provided "in whole or in part" by an assistant will be paid at 85 percent of the Medicare Physician Fee Schedule.

Medicare established a de minimis standard for defining services provided "in whole or in part" by an assistant. What is this de minimis standard?

In the 2019 PFS final rule, CMS finalized a 10% "de minimis" standard under which a service is considered to be furnished "in whole or in part" by a PTA or OTA and thus require the modifier. 

When do you apply the assistant modifier for services performed " in whole or in part" by a PTA or OTA?

The assistant modifier will be applied when the assistant treats independently from the therapist and performs greater than 10% of the total time for a service. If the therapist and the assistant perform the same service concurrently, the assistant modifier does not apply.

Does the Medicare rule about using an assistant apply to all Medicare part B patients, or is the rule only for treatment in an outpatient setting?

The assistant modifiers are required for all outpatient services, including private practice, physician offices, rehab agencies, CORFs, SNF Part B, HHA Part B and hospital outpatient. It is not applicable to Critical Access Hospitals, which are paid on the basis of cost.

Does this rule apply to services provided by a physical therapy aide?

No. Services performed by a PT aide are not billable to Medicare, so the assistant modifier rule does not apply.

therapist and practice owner looking at report
Learn five take-aways from the 2020 Final Rule.

How does Clinicient Insight support the new Medicare assistant modifier rule?

To help with compliance, the Clinicient Insight system will automatically apply the assistant modifier to support Medicare requirements.

How does Clinicient help therapists manage other Medicare requirements?

Clinicient's therapy-specific EMR and billing system can help ease compliance to Medicare regulations. Among the many features that support Medicare compliance are:

  • Single system for EMR and billing
  • Therapy-specific chart templates
  • Workflow prompts, alerts and notifications
  • Goal tracking and process reporting
  • Pre-audit at visit sign off
   

Where can I learn more about the assistant modifier rules for PTAs and OTAs?

Always refer to the source documentation and Department of Health & Human Services (DHHS) Centers for Medicare and Medicaid Services (CMS) for more information.

Clinicient also has a series of blogs and webinars covering assistant modifiers and other 2020 Medicare updates.

 

IMPORTANT NOTICE: The information provided herein is intended to be general in nature. It is not offered as legal or insurance related advice, and is not a complete description, or meant, or intended, to replace or be interpreted as specific, of Medicare requirements. Although every effort has been made to ensure the content herein is correct, we assume no responsibility for its accuracy. Contact Department of Health & Human Services (DHHS) Centers for Medicare and Medicaid Services (CMS) for more information.