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New Medicare PTA and OTA Modifiers - General Rule

Key Dates

January 2020: PTA (CQ) and OTA (CO) modifiers must be used when services are provided “in whole or in part” by therapy assistants.  

January 2022: Payment for services provided “in whole or in part” by a therapy assistant will be reduced to 85% of the Part B payment.

Applicability

The modifiers must be used for all outpatient therapy services and providers that submit Part B claims:

    • Private practice;
    • Physicians’ offices;
    • Outpatient hospitals;
    • Rehabilitation agencies;
    • Skilled nursing facilities;
    • Home health agencies (will be addressed by CMS at a later date); and
    • Comprehensive outpatient rehabilitation facilities (CORFs).

Critical access hospitals will not be subject to the reduced payment rate but may still need to use the modifiers. 

The New Modifiers

PTA Modifier CQ: Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant.

OTA Modifier CO: Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant.

Key Changes in the Final Rule

  1. When the PT/OT is involved for the entire duration of the service and the PTA/OTA provides skilled therapy alongside the therapist, the CQ/CO modifier isn't required.
  2. When the same service is furnished separately by the PT/OT and the PTA/OTA, the ten (10%) percent standard will apply to each fifteen (15) minute unit, not the total time that was spent on the service.
  3. CMS will not require additional information about time and the application of the modifiers to treatment notes.

Application of the Modifiers

When the modifiers apply

Services wholly furnished by PTAs or OTAs without physical or occupational therapists.

When at least 10% of a service or unit of a service is provided by a PTA or OTA without a therapist.

When the modifiers do not apply

When therapists exclusively furnish services without the involvement of PTAs/OTAs.

When therapists furnish a service with an assistant and provide care to the patient for the entire duration of the service. 

Reference

84 FR 40482

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