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According to the Centers for Medicare and Medicaid Services' (CMS') claims processing manual, all claims for outpatient rehabilitation therapy services must 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 and must include specific modifier(s) to distinguish the discipline of the plan of care under which the service is delivered to track and administer benefit limits set in place by Arizona Health Care Cost Containment System (AHCCCS) under AMPM 310-X.
The uniform coding requirement is specific to payment for physicians, non-physician practitioners (NPPs), physical therapist private practice (PTPP), occupational therapist private practice (OTPP), speech therapist private practice (SLPP), comprehensive outpatient rehabilitation facility (CORF), outpatient physical therapy (OPT), hospital, skilled nursing facility (SNF), and any others billing for physical therapy, speech-language pathology, or occupational therapy services that is provided and billed to Mercy Care programs.
The codes are as follows:
Modifier Codes
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.
96 Habilitative Services - When a service or procedure that may be either habilitative or rehabilitative in nature is provided for habilitative purposes, the physician or other qualified health care professional may add modifier 96 to the service or procedure code to indicate that the service or procedure provided was a habilitative service. Habilitative services help an individual learn skills and functioning for daily living that the individual has not yet developed, and then keep and/or improve those learned skills. Habilitative services also help an individual keep, learn, or improve skills and functioning for daily living.
97 Rehabilitative Services - When a service or procedure that may be either habilitative or rehabilitative in nature is provided for rehabilitative purposes, the physician or other qualified health care professional may add modifier 97 to the service or procedure code to indicate that the service or procedure provided was a rehabilitative service. Rehabilitative services help an individual keep, get back, or improve skills and functioning for daily living that have been lost or impaired because the individual was sick, hurt, or disabled.
Therapy Disposition Column Codes
Column Code 5 - These codes are “always therapy” services, regardless of who performs them. These codes always require a therapy modifier − GP, GO, or GN − to indicate that they're furnished under a physical therapy, occupational therapy, or speech-language pathology plan of care, respectively.
Column Code 7 - These HCPCS/CPT codes represent “sometimes therapy” services. However, these codes are “always therapy” services when furnished by a therapist and in this situation require the use of a therapy modifier − GP, GO or GN − in order to indicate the service is furnished under a physical therapy, occupational therapy, or speech-language pathology plan of care, respectively.
When these “sometimes therapy” codes are not considered therapy services, the therapy thresholds and therapy modifiers do not apply. Codes marked ‘7’ are not therapy services when:
- It is not appropriate to bill the service under a therapy plan of care, and
- They are billed by practitioners who are not therapists, e.g., physicians, clinical nurse specialists, nurse practitioners, physician assistants, and psychologists.
While this disposition designates that a particular HCPCS/CPT code will not of itself always indicate that a therapy service was rendered, these codes always represent therapy services when rendered by therapists or by practitioners who are not therapists in situations where the service provided is integral to an outpatient rehabilitation therapy plan of care. For these situations, these codes must always have a therapy modifier. For example, when the service is rendered by either a Doctor of Medicine or a nurse practitioner (acting within the scope of his or her license when performing such service), with the goal of rehabilitation, a therapy modifier is required. When there is doubt about whether a service should be part of a therapy plan of care, the contractor shall make that determination.
Column Code 9 - These evaluation and re-evaluation codes require a specific therapy modifier − GP, GO, or GN − to indicate when the evaluative service is furnished under a physical therapy, occupational therapy, or speech-language pathology plan of care, respectively.
In Addition to Modifiers GN, GO, and GP the provider will also need to define the type of service, one of the following modifiers is required:
96 Habilitative Services - When a service or procedure that may be either habilitative or rehabilitative in nature is provided for habilitative purposes, the physician or other qualified healthcare professional may add modifier 96 to the service or procedure code to indicate that the service or procedure provided was a habilitative service. Habilitative services help an individual learn skills and functioning for daily living that the individual has not yet developed, and then keep and/or improve those learned skills. Habilitative services also help an individual keep, learn, or improve skills and functioning for daily living.
97 Rehabilitative Services - When a service or procedure that may be either habilitative or rehabilitative in nature is provided for rehabilitative purposes, the physician or other qualified healthcare professional may add modifier 97 to the service or procedure code to indicate that the service or procedure provided was a rehabilitative service. Rehabilitative services help an individual keep, get back, or improve skills and functioning for daily living that have been lost or impaired because the individual was sick, hurt, or disabled.
In order to assist you with the appropriate coding detail, please click on the link to access the CY 2022 CMS Therapy Code List and Disposition table.
While the above has not been implemented for all lines of business yet, Mercy Care would like to give providers who bill for these services advance notice that billing these appropriate modifiers will be implemented in the near future. In order to avoid future claims from being denied, any claims that do not have appropriate modifiers may be denied for payment. We will provide you with additional information regarding this as we get closer to the implementation date.
As always, don't hesitate to contact your Mercy Care Provider Relations Representative with any questions or comments. You can find this Notice and all other provider notices on our Mercy Care website.
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