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CMS (Finally) Posts Billing Examples Using the PTA and OTA Modifiers

CMS (Finally) Posts Billing Examples Using the PTA and OTA Modifiers

The Bipartisan Budget Act of 2018 required CMS to establish two new modifiers to indicate services provided in whole or in part by PTAs and OTAs, and, in January 2022, to begin paying for these services at 85% of the fee schedule rate. These modifiers, CQ and CO, became effective January 1, 2020. CMS updated information in the Medicare Claims Processing Manual, Chapter 5, Section 20.1 describing modifier application, but until now, had not released specific examples.

CMS describes a 4-step process to determining whether the CQ/CO modifier applies:

  1. Identify the timed HCPCS codes furnished for 15 minutes or more.
  2. Identify services for which the PT/OT and PTA/OTA provided minutes of the same HCPCS code.
  3. Identify services where the PT/OT and PTA/OTA furnish services of two different timed HCPCS codes.
  4. Identify the different HCPCS codes where the PT/OT and the PTA/OTA each independently furnish the same number of minutes.

And, then CMS describes two methods, the “Simple Method” and the “Percentage Method”, for calculating the 10% de minimis standard. While the math may be “simple,” no doubt therapists will rely on their EMR and billing software to follow the steps and perform the calculations behind the scenes.

The complete article and examples can be found here.

Holly Hester

Holly Hester is Casamba’s Senior Vice President of Compliance & Education, as well as the Compliance Officer. She provides regulatory guidance and interpretation, clinical programming and content development, education and training steerage, and compliance support for the company. As a physical therapist for more than 20 years, Holly has multi-venue clinical and management experience, giving her a unique perspective on the integration of compliance and training with therapy service delivery and clinical practice.
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