PT Modifier Insights: Enhancing Coding for Clinics

PT Modifier for Physical and Occupational Therapists

Modifiers are a vital part of medical coding. There are many different modifiers that can be used with both CPT and HCPCS codes.
Modifier 33 can be appended to a CPT code when the physician performs preventive services. This allows patients to waive their co-pay and deductible for the service. For example, a patient may come in for a screening colonoscopy and the physician finds a polyp that needs to be removed.

GP Modifier: Essential for Plan of Care

If a patient requires physical therapy services, it’s important to have all medical records properly documented. This ensures that your clinic is reimbursed for the services provided, and it also prevents any potential problems down the road. One of the most important pt modifiers is the GP modifier, which indicates that the services were delivered under a plan of care. When the GP modifier is used, it should be appended to all CPT codes that require it. Typically, this includes revenue code 042X (physical therapy), 043X and 044X (occupational therapy) and 045X (speech-language pathology). In addition to this, the GP modifier can also be applied to the following CPT codes:

Modifier GP is appropriate when the physician or physical therapist provides the services under an outpatient physical therapy care plan. This means that the physician is aware of the patient’s needs and has a plan of care in place for him or her to follow. This plan of care must be approved by Medicare to ensure reimbursement for the services.

A GP modifier is also required for Orthopedic physical therapy, which aids in the treatment of injuries on muscles, bones, tendons, fascia, and ligaments. These conditions can be treated through manual therapy, mobility training, strength training, and different mobilizations.
The GP modifier is also applicable to Wound care therapy, Decongestive therapy, and Vestibular therapy. These therapies can help drain accumulated fluids and improve blood circulation, and they can be used to treat conditions such as lymphedema and inner ear disorders.

While a GP modifier is appropriate for all of these services, it’s best to only use it when it’s necessary. Otherwise, it may raise red flags for Medicare, which can make your clinic more susceptible to an audit. It’s also important to note that if you do use the GP modifier, you must document that it’s medically necessary for the continued therapy. This will help ensure that you don’t waste Medicare funds and that your patients receive the services they need. This is why it’s essential to start documenting reasons for a GP modifier as soon as you anticipate needing to use it.


CQ Modifier: Reimbursement for PTA and OTA Services

Starting in 2022, CMS will reduce reimbursement for any timed service that is reported with modifier CQ (for PTAs) or CO (for OTAs). The CQ and CO modifiers must be used whenever outpatient physical therapy services are furnished in whole or in part by a PTA or OT. This includes physical therapist private practices, skilled nursing facilities, home health agencies, and comprehensive outpatient rehabilitation facilities.

When billing timed treatment codes, it’s important to determine the number of billable minutes for each unit of service based on the 8 minute rule. Then, you’ll need to determine if the PTA furnished more than 10% of each unit independently from the PT. This is known as the de minimis standard and is what qualifies a claim to be submitted with the CQ or CO modifier.

For example, assume a PT performs one round of therapeutic exercise and then passes the patient to an assistant to complete another round of therapy. This is a total of 30 minutes of exercise, or two units of 97110. When billing these units, the PT should add the CQ modifier since they spent more than 10 percent of the total time furnishing the service.

However, if the assistant only provided 10 minutes of independent time for each unit of therapy, then the PT should not apply the CQ modifier. The therapist could instead simply add the GP modifier to both units of 97110 to reflect their corresponding 15-minute lengths of service.

Similarly, if a physician performs a screening colonoscopy and then converts it to a diagnostic procedure with a polypectomy, the coder should append modifier 33 to both services. However, if the physician also performs a digital prostate exam at this same visit that is billed as a screening but later converts to a diagnostic service, they should only apply modifier -33 to the digital prostate exam.
While it’s not common to use these new modifiers together, there are some cases in which this will be appropriate. For example, a physician performs a screening colonoscopy followed by a diagnostic TURB and should apply both modifiers to the procedure. For more billing help, see some success stories in the industry.


KX Modifier: Indicating Therapy Threshold for Medicare

Modifier KX is a Medicare therapy modifier that is used when patients reach the physical or occupational therapy threshold. Once the patient has reached this threshold, it’s imperative that you use the KX modifier on your claim to indicate that continued services are medically necessary. If you do not add this modifier, your claims may be denied by Medicare or other third-party payers.If you use this modifier, it should be applied to all the PT lines on your claim, even those that are below the cap. This will ensure that all of your PT services are paid for. You should also make sure that your documentation clearly demonstrates why the KX modifier should be applied. If you routinely apply this modifier to all PT patients who are close to the cap, it will be seen as an abuse practice by MACs and will likely trigger an inquiry into your billing processes.

When billing HCPCS codes that require the KX pt modifier, it should be appended after the professional discipline GP modifier. This will usually appear in field 24 D of the CMS 1500 Claim form. In some cases, the payer may provide their own claims forms and might require a different location for adding these.

For example, if you’re billing for an advanced colorectal screening (CPT code 99408), the Medicare KX modifier should be added in the box labeled “modifier” located in field 24 D of the CMS 1500 Claim Form. It should be placed after the professional discipline GP modifier and before the CPT code for the test.

When applying the KX modifier, it should only be applied when the patient has reached the physical or occupational therapy threshold for the year. If you use this is for all patients who are close to the limit, it will be seen as an abuse of the system and could result in your claims being audited by Medicare. Additionally, if you are using this pt modifier before the patient has reached the threshold, it’s important to make sure that you have strong and thorough documentation in place to justify why the KX modifier should be applied.

GA Modifier: Waiver of Liability Statement

The GA Modifier is a pt modifier that indicates the provider has provided a waiver of liability statement issued as required by payer policy to a beneficiary. It can be applied to CPT codes when the provider is aware that Medicare is likely to deny an otherwise covered service due to a lack of medical necessity and has not been given the opportunity to obtain a signed ABN from the member prior to providing the item or service. The GA HCPCS modifier must be appended to the appropriate code on a claim form and may not be used with the GX, GY, or GZ modifiers.

It’s important for providers to understand the intricacies of these modifiers, and how they relate to each other. This will help them confidently ensure accurate billing, enhance communication with payers, and uphold financial transparency with patients. With a firm grasp on these billing modifiers, providers can accurately bill Medicare claims and ensure that their patients are receiving the best care possible.

As with all other Medicare modifiers, it’s critical for healthcare professionals to apply them correctly to ensure accurate reimbursement and avoid any unnecessary delays or denials. However, many misconceptions have emerged surrounding the use of these modifiers. In some cases, these myths are simply untrue, but others can have a serious financial impact on the provider if not adhered to properly.For example, a common myth is that the GA modifier indicates a service is a maintenance service. This is not true, and it is also not a good idea to use the GA modifier when a provider has a signed ABN on file. In this scenario, the provider should use the -AT modifier instead.
In addition, it’s important for providers to understand the difference between payment and informational modifiers. While a payment pt modifier has an impact on the reimbursement of a claim, informational modifiers provide valuable information to the payer and are not subject to the same rules. This includes the GX, GA, and GY modifiers. For any assistance on this topic, reach out to us.