Medicare requires the CQ modifier be added to claims for PTA services and the CO modifier be added to claims for COTA services. Medicare is requiring these modifiers because PTA and COTA services will be paid at 88% of PT and OT rates for dates of services starting on 1/1/2022.2
UHC, Tricare and Humana also require the CQ/CO modifiers. Humana is reducing PTA/COTA payments by 15%. UHC and Tricare have not announced whether PTA/COTA payment rates will be cut.
The determination of when the CQ/CO modifier is required can get complex if both the therapist and assistant are treating a patient during the same visit. This explanation is a simplified version of the rules that should cover most every situation in day-to-day practice.
The following explanation applies to traditional Medicare patients. Keep in mind that Medicare applies the “total time rule” requires the minutes of all types of timed codes to be combined to determine the total number of billable timed units.
- Therapist treats for entire visit. No CQ/CO modifier.
- Assistant treats for entire visit. Add CQ modifier for PTA or CO modifier for COTA.
- Therapist treats patient for 30 minutes. If a patient is seen by the therapist for the first 30 minutes and an assistant sees the patient for the rest of the visit, the therapist can charge two units without the CQ/CO modifier and any other units charged by the assistant require the CQ/CO modifier
- Other visits. For other visits when both a therapist and assistant treat a patient, first determine how many total units are billable per Medicare “total time rule” and then assign units using the following steps:
- Step 1: When a provider furnishes 15-29 minutes of a code, assign one unit to that provider. When multiples of 15 minutes are furnished, e.g., 30 minutes (assign two units) and 45 minutes (assign three units), etc. When any of these procedures, i.e., full 15-minute increments, are provided by an assistant, the CQ/CO modifiers apply. (See Example C below)
- Step 2: Same code. If the therapist and assistant separately provide additional minutes of the same code(s), assign the code as follows:
- If the therapist provided 8 or more minutes of that last unit, it is assigned to the therapist.3
- If the therapist provided less than 8 minutes of the last unit, it is assigned to the assistant and requires the CQ/CO modifier. (See Examples A and B below)
- If there are two timed units left to bill and the therapist and assistant separately provided 9-14 minutes of the same code, assign one to the therapist and the other unit to the assistant. (See Example E)
- Step 3: Different codes. If remaining minutes are provided by both the therapist and assistant for different codes, compare the remaining minutes furnished by the therapist for the one code with the remaining minutes furnished by the assistant for the other code. If the therapist’s minutes are equal to or more than the assistant’s minutes, bill for the therapist’s code without the CQ/CO modifier. Otherwise, bill for the assistant’s code with the CQ/CO modifier. (See Examples F and G below.)
Example A
PTA – 10 minutes of 97110
PT – 5 minutes of 97110
Total = 15 minutes – qualifies to bill one 15-minute unit
Explanation: Bill one unit of 97110 with the CQ modifier because the therapist did not provide at least 8 minutes and the assistant provided more minutes than the therapist.
Example B
PTA – 5 minutes of 97110
PT ─ 6 minutes of 97110
Total = 11 minutes – qualifies to bill one 15-minute unit (8 minute through 22 minutes).
Explanation: Bill one unit of 97110 with the CQ modifier because the therapist did not provide at least 8 minutes and the assistant provided more minutes than the therapist. (If the PT provided at least 8 minutes, the 8-minute rule is met and no CQ modifier would be required.)
Example C
PTA – 5 minutes 97110
PT ─ 30 minutes 97110
Total = 35 minutes – 2 units can be billed
Explanation: Apply Step 1 to assign two units of 97110 to the therapist because the therapist provided two complete 15-minute units of therex.4
Example D
PTA-22 minutes of 97110
PT – 23 minutes of 97110
Total = 45 minutes ─ qualifies to bill three 15-minute units
Explanation: Apply Step 1 to bill one unit of 97110 with the CQ modifier because the PTA provided 15 full minutes with 7 minutes remaining. Apply Step 1 to the PT’s 23 minutes to bill one unit of 97110 without the assistant modifier with 8 minutes remaining. Apply the 8-minute rule to assign the third and final unit of 97110 to the therapist because the therapist had 8 or more minutes remaining (23-15=8).
Example E
PT – 12 minutes of 97110
PTA-14 minutes of 97110
PT – 20 minutes of 97140
Total = 46 minutes – qualifies to bill three units
Explanation: Apply Step 1 to assign one unit of 97140 to the therapist because the therapist provided 15 full minutes of one unit with 5 minutes remaining. Two units of 97110 remain to be billed and the PT and the PTA each provided 9-14 minutes independent of each other. In this “two remaining units” billing scenario, one unit is assigned to the assistant and the other unit is, assigned to the therapist.5
Example F
PTA – 19 minutes of 97110
PT ─ 10 minutes of 97140
Total = 29 minutes – two units can be billed
Explanation: Apply Step 1 to assign one unit of 97110 to the PTA because the PTA performed a full 15-minute unit, with 4 minutes remaining. The remaining minutes are for different codes, so bill the code with the greater number of minutes. Because the PT’s 10 minutes of 97140 is greater than the PTA’s 4 remaining minutes of 97110, bill one unit of 97140 without the CQ modifier.
Example G
OTA-11 minutes of 97535
OT – 11 minutes of 97530
Total = 22 minutes ─ qualifies to bill one unit
Explanation: Because two different services were furnished for an equal number of minutes – the “tie breaker” scenario applies, and the unit can be assigned to the therapist.
References:
1. From https://www.cms.gov/medicare/therapy-services/billing-examples-using-cqco-modifiers-services-furnished-whole-or-part-ptas-and-otas).
2. Medicare’s portion of the payment is 85% of the PT/OT rate but the patient’s coinsurance is not reduced so the “blended” payment for PTA/COTA services is at 88% of the PT/OT rate.
3. Once the PT/OT meets or exceeds the 8-minute mark, for the final unit in a billing scenario, it does not matter how many minutes the PTA/OTA furnishes for the same service/code – that final unit is billed without a CQ/CO assistant modifier.
4. Record the 5 minutes of service by the PTA with the total time for the treatment session (per standard documentation rules), even though the time is not billable.
5. The PT’s 5 remaining minutes of 97140 are counted toward the total timed minutes of treatment that day (per our standard documentation protocol) but are not billable in this scenario.
