Beware: Medicare Is Enforcing the Use of Modifiers for “Always Therapy” Services

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Physical therapists, physicians, and other qualified healthcare professionals who bill Medicare Administrative Contractors (MACs) for therapy services provided to Medicare beneficiaries continue to incorrectly bill for Part B “always therapy” services. For this reason, the Centers for Medicare & Medicaid Services released Change Request 10176, which requires the MACs to enforce the longstanding requirement to report the appropriate therapy modifier for the service so it can be accurately applied to the therapy cap. Therefore, effective January 2, 2018, the Medicare professional claims processing system will implement newly created edits that will return claims when “always therapy” codes and the associated modifiers are improperly reported.
Following are some frequently asked questions that pertain to this reporting requirement.
Q: Is there a therapy cap for each outpatient therapy service?
A: No. There are 2 therapy caps. One cap is for physical therapy (PT) and speech-language pathology (SLP) services combined. Another cap is for occupational therapy (OT) services.
Q: How does Medicare know which type of therapist performed the service?
A: All outpatient therapy services furnished by therapists in private practice must append 1 of 3 therapy modifiers to their claims, regardless of whether the services are designated as “always therapy” or “sometimes therapy:”
Because the GN, GO, and GP therapy modifiers are specific to the SLP, OT, or PT plan of care, respectively, only 1 of these modifiers is allowed.
Q: When outpatient therapy services are furnished by physicians and certain nonphysician practitioners, that is, physician assistants, nurse practitioners, and certified nurse specialists, should they use the therapy modifiers on their claims?
A: To accrue incurred expenses to the correct therapy cap, each code designated as “always therapy” (1) must always be furnished under an SLP, OT, or PT plan of care, regardless of who furnishes them, and (2) must always be accompanied by 1 of the 3 therapy modifiers.
The “always therapy” codes in Figure 1 require a GN, GO, or GP modifier as appropriate. The contractor will return professional claims reporting any of the 42 codes whenever the appropriate therapy modifier is missing.
In addition, several “always therapy” codes are discipline specific. See Figure 2 for the SLP-specific codes that require the GN modifier to indicate the service is furnished under an SLP plan of care. The contractor will return professional claims reporting any of the 6 codes whenever the GN therapy modifier is missing.
See Figure 3 for the OT-specific codes that require the GO modifier to indicate the service is furnished under an OT plan of care. The contractor will return professional claims reporting any of the 4 codes whenever the GO therapy modifier is missing.
See Figure 4 for the PT-specific codes that require the GP modifier to indicate the service is furnished under a PT plan of care. The contractor will return professional claims reporting any of the 4 codes whenever the GP therapy modifier is missing.
It may be clinically appropriate for physicians and nonphysician practitioners to furnish outpatient therapy services that have been designated “sometimes therapy.” In these cases, a therapy plan of care is not required, and the therapy modifiers are not required on claims. EXCEPTION: the codes designated as “sometimes therapy” always represent therapy services rendered by therapists or practitioners who are not therapists when the service provided is integral to an outpatient rehabilitation therapy plan of care. In these situations, these codes must always be reported with a therapy modifier. For example, when the service is rendered by either a physician or a nurse practitioner (acting within the scope of his/her license when performing such service), with the goal of rehabilitation, a therapy modifier is required.
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