PTA/OTA Modifiers – Coming January 1, 2020

In the CY 2019 Medicare Physician Fee Schedule Final Rule released last November, CMS established two new modifiers to identify services provided by a PTA or OTA as required by the Bipartisan Budget Act of 2018. These modifiers will be required beginning January 1, 2020 to indicate services provided “in whole or in part” by a therapist assistant. Services provided by an assistant will be paid at 85 percent of the Medicare Physician Fee Schedule beginning January 1, 2022.

The new modifiers are:

  • CQ: services provided in whole or in part by a PTA
  • CO: services provided in whole or in part by an OTA

In last year’s Final Rule, CMS also defined a de minimis standard for defining services provided “in whole or in part” by an assistant. The de minimis standard describes the minimum amount of a service that constitutes “in part.” Under this standard, a service is considered furnished by a PTA or OTA when more than 10 percent of the service is furnished by the assistant. This means, for example, that 1.5 minutes of a 15-minute unit of therapeutic exercise (CPT 97110) may be provided by a PTA without requiring the CQ modifier to be appended (and hence, without the service being subject to the 15 percent reduction in 2022). If the PTA provides more than 1.5 minutes, the modifier must be added.

This de minimis standard has raised many questions in the therapy industry about how to realistically comply with this requirement. We expect to see additional information and clarification about the de minimis standard and the implementation of these new modifiers in the CY 2020 Medicare Physician Fee Schedule Proposed Rule expected to be released in early July.

For more information on these payment differential modifiers and the payment reduction slated for January 1, 2022, visit APTA or PT in Motion.

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