Beginning in 2020, Medicare is requiring claims to include new modifiers showing when therapy is provided by a PTA or COTA. The PTA modifier is CQ and the COTA modifier is CO. (The GP, GO and KX modifiers will continue to be required.)
This is important because beginning in 2022, Medicare will apply a 15% discount to payments for therapy that is provided, in whole or in part, by a PTA or COTA. The CQ and CO modifiers will trigger the 15% discount.
At the end of July, CMS issued proposed regulations on when these modifiers need to be added. The following is an explanation of these proposed regulations. This explanation will be updated when the regulations are finalized.
As a practical matter, if your therapists and assistants each have their own schedules and do not both treat the same patient on a DOS, this is simple. If a therapist provides all of the therapy on a DOS, the CQ/CO modifier is not required. If an assistant provides all of the therapy on a DOS, the CQ or CO modifier will be required. If your therapists and assistants do not share patients on the same DOS, you do not need to read further.
This only becomes complicated if the same Medicare patient is treated on the same DOS by both a therapist and assistant which should be avoided if at all possible. As a general rule, if a therapist and assistant both participate in providing the same procedure on the same DOS, the CQ or CO modifier needs to be added to that procedure if the minutes of service provided by the assistant are more than 10% of the total minutes for that service. CMS has illustrated this rule in the following examples:
Scenario 1: One type of procedure provided by therapist and assistant
- The therapist and assistant each separately furnish minutes of therapeutic exercise (97110) in different time frames with the therapist providing 7 minutes and the assistant providing 7 minutes for a total of 14 minutes. One billable unit of 97110 is reported on the claim with the CQ or CO modifier because the 7 minutes of service provided by the assistant exceeded 10% of the 14-minute total service time.
- The therapist and assistant each separately furnish minutes of 97110 in different time frames with the therapist providing 20 minutes and the assistant providing 25 minutes for a total of 45 minutes. Three units of 97110 are reported on the claim with a CQ or CO modifier because the 25 minutes furnished by the assistant exceeds 10% of the 45-minute total service time.
Scenario 2: Two or more different types of procedures provided by therapist and assistant
- The therapist furnishes 20 minutes of neuromuscular reeducation (97112) and the assistant furnishes 8 minutes of 97110 for a total of 28 minutes. Under Medicare’s total time rule, 2 procedures are billable-1 unit of 97112 and 1 unit of 97110. The 1 unit of 97112 is billed without the CQ or CO modifier because the therapist furnished all minutes of that service independently. The CQ or CO modifier would apply to 97110 because the assistant furnished all minutes of that service independently.
- The therapist furnishes 32 minutes of 97112 and 12 minutes of 97110 and the assistant furnishes 14 minutes of 97110 and 12 minutes of self-care (97535). This totals 70 minutes of timed code treatment time which permits 5 billable units allocated as 2 units of 97112, 2 units of 97110 and 1 unit of 97535. The 2 units of 97112 would be billed without a CQ/CO modifier because all 32 minutes of that service were furnished independently by the therapist. The 2 units of 97110 would be billed with the CQ/CO modifier because the assistant’s 14 minutes of service were greater than 10% of the 26 total minutes for 97110. The 1 unit of 97535 would be billed with the CQ/CO modifier because the assistant independently furnished all minutes of that service.
- The therapist independently furnishes 12 minutes of 97112 and the assistant independently furnishes 8 minutes of 97535 and 7 minutes of 97110. The total treatment time of 27 minutes allows for 2 units to be billed-1 unit of 97112 and 1 unit of 97535. The 1 unit of 97112 would be billed without the CQ/CO modifier because it was furnished independently by the therapist and the 1 unit of 97535 would be billed with the CQ/CO modifier because it was independently furnished by the assistant.
Supervised Modalities. The CQ/CO modifier must be attached to claims for supervised modalities if the minutes of service provided by the assistant exceed 10% of the total minutes for the service.
Documentation. CMS is proposing to require documentation to back up addition of the CQ/CO modifier. For example, the daily note could state “Code 97110: CQ/CO modifier applied-PTA wholly furnished) or “Code 97530: CQ/CO modifier not applied-PTA minutes less than 10% standard.”). We expect that the documentation requirements will be refined in the final regulations to be issued later this year.