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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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Site Updates

  • Monday 2/11/2019

    11 Feb 2019 2:28 PM | Zachary Edgar (Administrator)

    Updated Oregon's Medicaid Coverage of Physical and Occupational Therapy

    Updated Medicare Appeals

  • Just added full state surveys from Tennessee for PTs and OTs

    12 Dec 2018 10:38 AM | Zachary Edgar (Administrator)

    Tennessee Physical Therapy 

    Tennessee Occupational Therapy

    Topics covered: Scope of practice, continuing education, assistants, aides, reciprocity, modalities, unprofessional conduct, advertising, and more. 

  • 2019 Medicare Physician Fee Schedule Changed to Therapy Services

    27 Nov 2018 12:48 PM | Zachary Edgar (Administrator)

    Payment for Outpatient PT and OT Services Furnished by Therapy Assistants

    Beginning January 1, 2022, payment for services provided “in whole or in part” by a therapy assistant will be reduced to 85% of the Part B payment.

    This applies to outpatient therapy services and providers that submit institutional claims for therapy services such as outpatient hospitals, rehabilitation agencies, skilled nursing facilities, home health agencies and comprehensive outpatient rehabilitation facilities (CORFs). The reduced payment rate is not applicable to outpatient therapy services furnished by critical access hospitals.

    New PTA and OTA modifiers must be used beginning January 1, 2020.

    Modifiers for Therapist Services

    Revised GP modifier: Services fully furnished by a physical therapist or by or incident to the services of another qualified clinician – that is, physician, nurse practitioner, certified clinical nurse specialist, or physician assistant − under an outpatient physical therapy plan of care.

    Revised GO modifier: Services fully furnished by an occupational therapist or by or incident to the services of another qualified clinician – that is, physician, nurse practitioner, certified clinical nurse specialist, or physician assistant − under an outpatient occupational

    therapy plan of care.

    Modifiers for Therapy Assistant Services

    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.

    Therapists and Assistants Working Together

    The extent to which the modifiers apply to clinical scenarios in which the therapist and therapy assistant work together to furnish services collaboratively may be dependent on whether the therapy assistant’s services are furnished in the absence of the therapist, whose time could then no longer be attributed to that patient.

    CMS has finalizing a de minimis standard under which a service is furnished in whole or in part by a PTA or OTA when more than 10% percent of the service is furnished by the PTA or OTA. We anticipate addressing application of the therapy assistant modifiers and the 10% percent standard more specifically, including their application for different scenarios and types of services, in rulemaking for CY 2020.

    Functional Reporting Modifications

    Discontinued as of January 1, 2019

    Therapy KX Threshold Amounts

    Increase the CY 2018 KX modifier threshold amount of $2,010 by the CY 2019 MEI of 1.5 percent and rounding to the nearest $10.00 results in a CY 2019 KX threshold amount of $2,040 for PT and SLP services combined and $2,040 for OT services.

    The Targeted Medical Review Process

    CY 2019, the MR threshold is $3,000 for PT and SLP services combined and $3,000 for OT services. Under the established targeted review process, some, but not all claims exceeding the MR threshold amount are subject to review. For information on the targeted manual medical review process, go to https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare FFS-Compliance-Programs/Medical-Review/TherapyCap.html.


  • PT and OT Final Quality Measures for 2019

    12 Nov 2018 10:02 AM | Zachary Edgar (Administrator)

    Quality measures are reported for points toward an overall score.  The measures available to a PT or OT will be determined by the method of submitting data—claims or vendor. To earn a score in 2019, PTs and OTs who use a vendor will need to report on at least 6 quality measures. PTs and OTs using claims will have only 5 available measures and will need to report on all of them. 

    Measure Title: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

    Quality #: 128

    Measure Type: Process

    NQSD: Community/Population Health

    Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous 12 months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous 12 months of the current encounter. Normal Parameters: Age 18 years and older BMI ≥ 18.5 and < 25 kg/m2.

    Measure Title: Documentation of Current Medications in the Medical Record

    Quality #: 130

    Measure Type: Process

    NQSD: Patient Safety

    Percentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration.

    Measure Title: Pain Assessment and Follow-Up

    Quality #: 131

    Measure Type: Process

    NQSD: Communication and Care Coordination

    Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present.

    Measure Title: Functional Outcome Assessment

    Quality #: 182

    Measure Type: Process

    NQSD: Communication and Care Coordination

    Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies.

    Measure Title: Functional Status Change for Patients with Knee Impairments

    Quality #: 217

    Measure Type: Patient Reported Outcome

    NQSD: Communication and Care Coordination

    A patient-reported outcome measure of risk-adjusted change in functional status for patients aged 14 years+ with knee impairments. The change in functional status (FS) is assessed using the Knee FS patient reported outcome measure (PROM) (©Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey).

    Measure Title: Functional Status Change for Patients with Hip Impairments

    Quality #: 218

    Measure Type: Patient Reported Outcome

    NQSD: Communication and Care Coordination

    A patient-reported outcome measure of risk adjusted change in functional status for patients 14 years+ with hip impairments. The change in functional status (FS) is assessed using the Hip FS patient-reported outcome measure (PROM) (©Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey).

    Measure Title: Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments

    Quality #: 219

    Measure Type: Patient Reported Outcome

    NQSD: Communication and Care Coordination

    A patient-reported outcome measure of risk adjusted change in functional status for patients 14 years+ with foot, ankle and lower leg impairments. The change in functional status (FS) assessed using the Foot/Ankle FS patient-reported outcome measure (PROM) (©Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey).

    Measure Title: Functional Status Change for Patients with Low Back Impairments

    Quality #: 220

    Measure Type: Patient Reported Outcome

    NQSD: Communication and Care Coordination

    A patient-reported outcome measure of risk adjusted change in functional status for patients 14 years+ with low back impairments. The change in functional status (FS) is assessed using the Low Back FS patient reported outcome measure (PROM) (©Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level by to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey).

    Measure Title: Functional Status Change for Patients with Shoulder Impairments

    Quality #: 221

    Measure Type: Patient Reported Outcome

    NQSD: Communication and Care Coordination

    A patient-reported outcome measure of risk adjusted change in functional status for patients 14 years+ with shoulder impairments. The change in functional status (FS) is assessed using the Shoulder FS patient reported outcome measure (PROM) (©Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey).

    Measure Title: Functional Status Change for Patients with Elbow, Wrist or Hand Impairments

    Quality #: 222

    Measure Type: Patient Reported Outcome

    NQSD: Communication and Care Coordination

    A patient-reported outcome measure of risk adjusted change in functional status (FS) for patients 14 years+ with elbow, wrist or hand impairments. The change in FS is assessed using the Elbow/Wrist/Hand FS patient reported outcome measure (PROM) (©Focus on Therapeutic Outcomes, Inc.) The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey).

    Measure Title: Functional Status Change for Patients with General Orthopedic Impairments

    Quality #: 223

    Measure Type: Patient Reported Outcome

    NQSD: Communication and Care Coordination

    A patient-reported outcome measure of risk-adjusted change in functional status (FS) for patients aged 14 years+ with general orthopedic impairments (neck, cranium, mandible, thoracic spine, ribs or other general orthopedic impairment). The change in FS is assessed using the General Orthopedic FS PROM (patient reported outcome measure) (©Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey).


  • Medicare 2019 Final Physician Fee Schedule

    6 Nov 2018 11:53 AM | Zachary Edgar (Administrator)

    Discontinue Functional Status Reporting Requirements for Outpatient Therapy

    Since January 1, 2013 as required by the Middle Class Tax Relief and Jobs Creation Act of 2012, all providers of outpatient therapy services have been required to include functional status information on claims for therapy services. CMS implemented a system that collects data using non-payable HCPCS G-codes and modifiers to describe a patient’s functional limitation and severity at periodic intervals during outpatient therapy services. In response to the Request for Information on CMS Flexibilities and Efficiencies that was issued in the CY 2018 PFS proposed rule, CMS received comments requesting burden reduction related to the functional status reporting requirements.

    The data from the functional reporting system was to be used to aid CMS in recommending changes and reforming of Medicare payment for outpatient therapy services that were subject to the statutory therapy caps. Going forward, the functional status reporting data that would be collected may be even less purposeful because the Bipartisan Budget Act of 2018 repealed the therapy caps while imposing protections to ensure therapy services are furnished when appropriate. As a result, CMS is finalizing our proposal to discontinue the functional status reporting requirements for services furnished on or after January 1, 2019. 

    Outpatient Physical Therapy and Occupational Therapy Services Furnished by Therapy Assistants

    The Bipartisan Budget Act of 2018 requires payment for services furnished in whole or in part by a therapy assistant at 85 percent of the applicable Part B payment amount for the service effective January 1, 2022. In order to implement this payment reduction, the law requires us to establish a new modifier by January 1, 2019 and CMS details our plans to accomplish this in the final rule. 

    CMS is finalizing our proposal to establish two new modifiers – one for Physical Therapy Assistants (PTA) and another for Occupational Therapy Assistants (OTA) – when services are furnished in whole, or in part by a PTA or OTA. However, CMS is finalizing the new modifiers as “payment” rather than as “therapy” modifiers, based on comments from stakeholders. These will be used alongside of the current PT and OT modifiers, instead of replacing them, which retains the use of the three existing therapy modifiers to report all PT, OT, and Speech Language Pathology services, that have been used since 1998 to track outpatient therapy services that were subject to the therapy caps. CMS is also finalizing a de minimis standard under which a service is furnished in whole or in part by a PTA or OTA when more than 10 percent of the service is furnished by the PTA or OTA, instead of the proposed definition that applied when a PTA or OTA furnished any minute of a therapeutic service. The new therapy modifiers for services furnished by PTAs and OTAs are not required on claims until January 1, 2020. 


  • Medicare Proposed 2019 Physician Fee Schedule

    3 Oct 2018 2:04 PM | Zachary Edgar (Administrator)

    Outpatient PT and OT Services Furnished by Therapy Assistants

    The Bipartisan Budget Act of 2018 requires payment for services furnished in whole or in part by a therapy assistant at 85 percent of the applicable Part B payment amount for the service effective January 1, 2022. In order to implement this payment reduction the law requires CMS to establish a new modifier by January 1, 2019 and detail CMS's plans to accomplish this in the proposed rule.

    CMS is proposing to establish two new therapy modifiers – one for PT Assistants (PTA) and another for OT Assistant (OTA) – when services are furnished in whole or in part by a PTA or OTA. These are to be used in conjunction with the three existing therapy modifiers that have been used since 1998 to track outpatient therapy services that were subject to the therapy caps. The new therapy modifiers for services furnished by PTAs and OTAs are not required on claims until January 1, 2020.


  • Updates to North Carolina Medicaid

    18 Sep 2018 2:54 PM | Zachary Edgar (Administrator)

    Prior Approval changes to NC Medicaid coverage for adults.

    Removal of diagnosis specific coverage and replaced with general prior authorization requirement and service limit:

    Prior approval is required at the start of all treatment services. 

    Detailed information and instructions for registering and submitting requests is available on The Carolinas Center of Medical Excellence (CCME) website https://www.medicaidprograms.org/NC/ChoicePA The provider shall submit a request to DHHS utilization review contractor to start the approval process. Please note that approval, if granted, is for medical approval only and does not guarantee payment or ensure beneficiary eligibility on the date of service. 

    The first prior approval request within a calendar year shall be for no more than three therapy treatment visits and one month. The PA review vendor will authorize these three treatment visits to begin as early as the day following the submission of the PA request. Any subsequent PA may be obtained for up to 12 therapy treatment visits and six months. A beneficiary can receive a maximum of 27 therapy treatment visits per calendar year across all therapy disciplines combined (occupational therapy, physical therapy and speech/language therapy). 

    Each reauthorization request must document the efficacy of treatment.


  • Massachusetts Physical Therapy

    20 Aug 2018 4:08 PM | Zachary Edgar (Administrator)

    Content added:

    Massachusetts Medicaid Coverage of Physical and Occupational Therapy 

    MA PT Scope of Practice

    MA PT Direct Access and Referrals

    MA PT Supervision and Delegation

    MA PT Assistants

    MA PT Aides

    MA PT Students

    MA PT Temporary Permits

    MA PT License Exemptions

    MA PT Licensure by Endorsement

    MA PT License Reinstatement 

    MA PT Documentation 

    MA PT Identification and Notifications

    MA PT Facilities 

    MA PT Board Fees

    Mass Medicaid and Workers Comp Fee Schedules 


  • Florida OT Updates

    14 Aug 2018 4:09 PM | Zachary Edgar (Administrator)


  • California Physical Therapy

    13 Aug 2018 3:09 PM | Zachary Edgar (Administrator)

    Content added 8/13/2018

    California Medicaid Coverage of PT and OT

    CA PT Continuing Education

    CA PT Scope of Practice

    CA PT Electromyography

    CA PT Topical Medications

    CA PT Direct Access and Referrals 

    CA PT Assistants

    CA PT Aides

    CA PT Students

    CA PT and PTA Graduates 

    CA PT Documentation 

    CA PT Advertising

    CA PT Unprofessional Conduct

    CA PT Board Fees

    CA Fee Schedules



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