Page 46 - OPTA Access Spring 2020

Payment Policy Report Berni Willis – OPTA Payment Policy Specialist
THIS YEAR BEGINS WITH IMPORTANT CHANGES
New modifier requirements:
CQ / CO - This modifier is applied using the de minimis standard of 10% of care that is provided by a PTA: 30 minutes is 3 minutes; 20 minutes is 2 minutes, etc . It is possible that the PTA can assist in care and bill with and without the CQ in the same visit . For example: .
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1. Therapeutic Exercise for 20 minutes (1 unit) - Equally the PTA and PT provide the same time. The claim would require the CQ applied to the allowed 1 unit. (97110 GP CQ)
2. Therapeutic Exercise for 40 minutes (3 units) - PTA provides 15 minutes of care / PT provides 25 minutes. CQ is applied to 1 unit and NO CQ for 2 units. Why? Per CPT guidelines- 15-minute timed unit.
A Your bill would include 2 units of 97110 GP and 1 unit of 97110 GP CQ . Two lines of 97110 in the same claim .
At this time, the CQ modifier is only required by traditional Medicare and Humana insurances .
Please check with your payers as the year progresses for any updates .
In addition to these new modifiers, there is an increased usage in modifiers 96 (Habilitative Care) 97 (Rehabilitative Care) XE, XS, XP & XU (alternative to 59) and GP modifier. I am mentioning the GP modifier specifically as we are used to using it only with Medicare . However, many commercial payers require this modifier as well. The GP modifier means "all therapy ." Watch for updates from your payers requiring their usage .
Authorizations requirements are continuing to pop up on multiple payers . First, it is very important to remember, if you have primary, secondary and tertiary payers, with the same patient, the authorization rules are all independent from one another; you must follow each . The top three payers (United Healthcare Medicaid, Anthem and Humana) are all now requiring authorizations from third party sources . Please follow the OPTA Payment Policy News (found
under Resources) to stay current with ever- changing authorization requirements .
Other new edits announced include that you
can no longer provide Therapeutic Activities on the same day of an evaluation. No modifier will allow you to get paid for both . Additionally, when providing manual therapy on the same day of
the initial evaluation, if the manual therapy is provided independent of the evaluation, you must add a 59 modifier for payment. (97140 GP 59)
Merit-Based Incentive Payment System (MIPS) 2020 - MIPS only applies to the providers that are in the private practice setting and this includes off-site hospital clinics . The hospital has established the clinic as a private practice with CMS . If you submit your claims on a UB04 the answer is you are not required . Be sure to check your eligibility!
As I mentioned earlier, be sure to watch for updates on the OPTA website > Resources > Payment Policy News .
For more information, contact OPTA at:
opt@ohiopt.org.