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The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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Medicare Modifiers FAQs

See our Billing section for more guidance.

Which modifiers have to appended to all therapy claims?

GP: Physical therapy services.

GO: Occupational therapy services.

GN: Speech therapy services.

When does the KX modifier need to be added to the claim?

In 2022 the KX modifier threshold is $2,150 for PT and SLP services combined.  And $2,150 for OT services.

This applies the all therapy services during the year, not just the services provided by the billing therapist.

By appending the KX modifier, the provider is attesting that the services billed:

    • Are reasonable and necessary services that require the skills of a therapist; and
    • Are justified by appropriate documentation in the medical record,; and
    • Qualify for an exception using the automatic process exception.

When do the CO/CQ modifiers need to be added to claims? 

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

Medicare required that claims for services furnished in whole or in part by a PTA or an OTA must include the CQ or CO modifier, respectively, when:

    • The PTA/OTA furnishes all of the minutes of a service independent of the respective physical therapist (PT) or occupational therapist (OT); or
    • The PTA/OTA furnishes a portion of a service (or unit of service) separately from the part that is furnished by the PT/OT, such that the minutes for that portion of a service (or unit of a service) furnished by the PTA/OTA exceed 10 percent of the total minutes for that service (or unit of a service) ─ except in the specific cases that are outlined below. 

Reference

Medicare Therapy Services available at https://www.cms.gov/medicare/billing/therapyservices

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