(Medicare Claims Processing Manual)

The contractor shall use the following remittance advice messages and asso ciated codes when adjusting payment under this policy.  The CARC below is not included in the CAQH CORE Business Scenarios.   Group Code: CO  CARC: 59  RARC: N/A  MSN: 30.1  20 - HCPCS Coding Requirement  (Rev. 1850, Issued: 11- 13-09, Effective: 01- 01-10, Implementation: 01 -04-10)  A.  Uniform Coding   Section 1834(k)(5) of the Act requires that all claims for outpatient rehabilitation therapy services and all comprehensive outpatient rehabilitation facility (CORF) services be reported using a uniform coding system.  The current Healthcare Common Procedure Coding System/Current Procedural Terminology is used for the reporting of these services.  The uniform coding requirement in the Act is specific to payment for all CORF services and outpatient rehabilitation therapy services -  including physical therapy, occupational therapy, and speech -language pathology -  that is provided and billed to Medicare contractors.  The Medicare physician  fee schedule (MPFS) is used to make payment for these therapy services at the non facility rate.   Effective for claims submitted on or after April 1, 1998, providers that had not previously reported HCPCS/CPT for outpatient rehabilitation and CORF service s began using HCPCS to report these services.  This requirement does not apply to outpatient rehabilitation services provided by:    Critical access hospitals, which are paid on a cost basis, not MPFS;    RHCs, and FQHCs for which therapy is included in the al l-inclusive rate; or    Providers that do not furnish therapy services.   The following providers of services must bill the A/B MAC (A)  for outpatient rehabilitation services using HCPCS codes:    Hospitals (to outpatients and inpatients who are not in a covered Part A stay) ;     Skilled nursing facilities (SNFs) (to residents not in a covered Part A stay and to nonresidents who receive outpatient rehabilitation services from the SNF);    Home health agencies (HHAs) (to individuals who are not homebound or otherwise are not receiving services under a home health plan of care (POC).     Comprehensive outpatient rehabilitation facilities (CORFs); and    Providers of outpatient physical therapy and speech- language pathology services (OPTs), also known as rehabilitation agencies (previously termed outpatient physical therapy facilities in this instruction).   Note 1. The requirements for hospitals and SNFs apply to inpatient Part B and outpatient services only.  Inpatient Part A services are bundled into the respective prospective payment system payment; no separate payment is made.   Note 2.  For HHAs, HCPCS/CPT coding for outpatient rehabilitation services is required only when the HHA provides such service to individuals that are not homebound and, therefore, not under a home health plan of care.   The following practitioners must bill the A/B MAC (B)  for outpatient rehabilitation therapy services using HCPCS/CPT codes:    Physical therapists in private practice (PTPPs),    Occupational therapists in private practice (OTPPs),    Speech -language pathologists in private practice (SLPPs),    Physicians, including MDs, DOs, podiatrists and optometrists, and   Certain nonphysician practitioners (NPPs), acting within their State scope of practice, e.g., nurse practitioners and clinical n urse specialists.   Providers billing to intermediaries shall report:   The date the therapy plan of care was either established or last reviewed (see 220.1.3B ) in Occurrence Code 17, 29, or 30.    The first day of treatment in Occur rence Code 35, 44, or 45.  B.  Applicable Outpatient Rehabilitation HCPCS Codes   The CMS identifies the codes listed at: http://www.cms.hhs.gov/TherapyServices/05_Annual_Therapy_Update.asp#TopOfPage   as therapy services, regardless of the presence of a financial limitation.  Therapy services include only physical therapy, occupational therapy and speech -language pathology services.  Therapist means only a physical therapist, occupational therapist or speech -language pathologist. Therapy modifiers are GP for physical therapy, GO for occupational therapy, and GN for speech- language pathology.   When in effect, any financial limitation will also apply to services represented unless otherwise noted on the therapy page on the CMS Web site.  C.  Additional HCPCS Codes   Some HCPCS/CPT codes that are not on the list of therapy services should not be billed with a modifier.  For example, outpatient non- rehabilitation HCPCS codes G0237, G0238, and G0239 should be billed without therapy modifiers.  These HCPCS codes describe services for the improvement of respiratory function and may represent either incident to services or respiratory therapy services that may be appropriately billed in the CORF setting.  When the services described by these G -codes are provided by physica l therapists (PTs) or occupational therapists (OTs) treating respiratory conditions, they are considered therapy services and must meet the other conditions for physical and occupational therapy.  The PT or OT would use the appropriate HCPCS/CPT code(s) in the 97000 -  97799 series and the corresponding therapy modifier, GP or GO, must be used.  Another example of codes that are not on the list of therapy services and should not be billed with a therapy modifier includes the following HCPCS codes:  95860, 95861, 95863, 95864, 95867, 95869, 95870, 95900, 95903, 95904, and 95934.  These services represent diagnostic services -  not therapy services; they must be appropriately billed and shall not include therapy modifiers.  Other codes not on the therapy code li st, and not paid under another fee schedule, are appropriately billed with therapy modifiers when the services are furnished by therapists or provided under a therapy plan of care and where the services are covered and appropriately delivered (e.g., the therapist is qualified to provide the service).  One example of non- listed codes where a therapy modifier is indicated regards the provision of services described in the CPT code series, 29000 through 29590, for the application of casts and strapping.  Some of these codes previously appeared on the therapy code list, but were deleted because we determined that they represented services that are most often performed outside a therapy plan of care. However, when these services are provided by therapists or as an integral part of a therapy plan of care, the CPT code must be accompanied with the appropriate therapy modifier.  NOTE:  The above lists of HCPCS/CPT codes are intended to facilitate the contractors ability to pay claims under the MPFS.  It is not intend ed to be an exhaustive list of covered services, imply applicability to provider settings, and does not assure coverage of these services.     20.1 - Discipline Specific Outpatient Rehabilitation Modifiers - All Claims  (Rev. 11129, Issued: 11- 22-21, Effective : 01-01-22, Implementation: 01- 03-22)  Modifiers are used to identify therapy services whether or not financial limitations are in effect. When limitations are in effect, the CWF tracks the financial limitation based on the presence of therapy modifiers. P roviders/suppliers must continue to report one of these modifiers for any therapy code on the list of applicable therapy codes except as noted in 20 of this chapter. Consult 20 for the list of codes to which modifiers must be applied. These modifiers do not allow a provider to deliver services that they are not qualified and recognized by Medicare to perform.   The claim must include one of the following modifiers to distinguish the discipline of the plan of care under which the service is delivered:    GN Services delivered under an outpatient speech -language pathology plan of care;    GO Services delivered under an outpatient occupational therapy plan of care; or,    GP Services delivered under an outpatient physical therapy plan of care.   This is applicable to all claims from physicians, nonphysician practitioners (NPPs), PTPPs, OTPPs, SLPPs, CORFs, OPTs, hospitals, SNFs, and any others billing for physical therapy, speech -language pathology or occupational therapy services as noted on the applicable code list in 20 of this chapter.   Modifiers GN, GO, and GP refer only to services provided under plans of care for physical therapy, occupational therapy and speech -language pathology services. They should never be used with codes that are not  on the list of applicable therapy services. For example, respiratory therapy services, or nutrition therapy services shall not be represented by therapy codes which require GN, GO, and GP modifiers.   Contractors edit institutional claims to ensure the fo llowing:   that a GN, GO or GP modifier is present for all lines reporting revenue codes 042X, 043X, or 044X.    that no more than one GN, GO or GP modifier is reported on the same service line.   that revenue codes and modifiers are reported only in the following combinations:  o Revenue code 42x (physical therapy) lines may only contain modifier GP  o Revenue code 43x (occupational therapy) lines may only contain modifier GO  o Revenue code 44x (speech -language pathology) lines may only contain modifier GN.      that discipline -specific evaluation and re -evaluation HCPCS codes are always reported with the modifier for the associated discipline (e.g. modifier GP with a HCPCS code for a physical therapy evaluation).   Contractors return to the provider institutional claim s that do not meet one or more of these conditions.  CMS has established two modifiers, CQ and CO, for services furnished in whole or in part by physical therapist assistants (PTAs) and occupational therapy assistants (OTAs). The modifiers are defined as f ollows:    CQ modifier:  Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant    CO modifier:  Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant   Effectiv e for claims with dates of service on and after January 1, 2020, the CQ and CO modifiers are required to be used, when applicable, for services furnished in whole or in part by PTAs and OTAs on the claim line of the service alongside the respective GP or GO therapy modifier, to identify those PTA and OTA services furnished under a PT or OT plan of care.    For those practitioners submitting professional claims who are paid under the PFS, the CQ/CO modifiers apply only to services of physical and occupationa l therapists in private practice (PTPPs and OTPPs); and not to the therapy services furnished by or incident to the services of physicians or nonphysician practitioners (NPPs)  including nurse practitioners (NPs), physician assistants (PAs), and clinical nurse specialists (CNSs)  because PTAs and OTAs do not meet the qualifications and standards of physical or occupational therapists, as required by  410.60 and 410.59, respectively.  However, the CQ and CO modifiers do apply to claims from physician or NPP groups when a PTPP or OTPP has reassigned their benefits to the group and their NPI appears as the rendering provider of the therapy service(s) on the claim.   For providers submitting institutional claims and paid at PFS rates for their outpatient PT and OT services, the CQ and CO modifiers apply to the following providers:  outpatient hospitals, rehabilitation agencies, skilled nursing facilities, home health agencies and CORFs.  However, the CQ and CO modifiers are not applicable to claims from criti cal access hospitals because they are paid on a reasonable cost basis, or from other providers for which payment for PT and OT services is not made under the PFS rates.   The CQ modifier must be paired to the GP therapy modifier and the CO modifier with the GO therapy modifier. Claims not so paired will be rejected/returned as unprocessable.     For dates of service, on and after January 1, 2022, claims billed with a CQ or CO modifier to indicate the services were furnished in whole or in part by a PTA or OTA are paid at an amount equal to 85 percent of the otherwise applicable Part B payment that s based on the MPFS.  The 15 percent reduction is taken last, e.g., after the MPPR (and other reductions where applicable) and right before sequestration. This reduction is taken from the paid amount, i.e., the actual amount paid not the MPFS allowed amount.   Regulations for the payment of therapy claims and the policy for assigning the therapy assistant modifiers (CO and CQ) for services provided in whole or in part by OTAs and PTAs are found at  410.59(a)(4) and 410.60(a)(4) for outpatient occupational and physical therapy services, respectively and at  410.105(d) for CORF OT and PT services.    20.2 - Reporting of Service Units With HCPCS  (Rev. 3670, Issued: 12- 01-16, Effective: 01- 01-17, Implementation: 01- 03-17)  A.  General