CMS is proposing to revise the de minimis standard established to determine whether services are provided “in whole or in part” by PTAs or OTAs. Specifically, CMS is proposing to revise the de minimis policy to allow a timed service to be billed without the CQ/CO modifier in cases when a PTA/OTA participates in providing care to a patient with a physical therapist or occupational therapist (PT/OT), but the PT/OT meets the Medicare billing requirements for the timed service without the minutes furnished by the PTA/OTA by providing more than the 15-minute midpoint (also known as the 8-minute rule).
Under this proposal, any minutes that the PTA/OTA furnishes in the scenarios described above would not matter for purposes of billing Medicare. In addition to cases where one remaining unit of a multi-unit therapy service to be billed, this revision to the policy would apply in a limited number of cases where more than one unit of therapy, with a total time of 24-28 minutes is being furnished. For these limited cases, CMS is proposing to allow one 15-minute unit to be billed with the CQ/CO assistant modifier and one 15-minute unit to be billed without the CQ/CO modifier in billing scenarios where there are two 15-minute units left to bill when the PT/OT and the PTA/OTA each provide between 9 and 14 minutes of the same service.
Overall, the de minimis standard would continue to be applicable in the following scenarios:
- When the PTA/OTA independently furnishes a service, or a 15-minute unit of a service “in whole” without the PT/OT furnishing any part of the same service.
- In instances where the service is not defined in 15-minute increments including: supervised modalities, evaluations/reevaluations, and group therapy.
- When the PTA/OTA furnishes eight minutes or more of the final unit of a billing scenario in which the PT/OT furnishes less than eight minutes of the same service.
- When both the PTA/OTA and the PT/OT each furnish less than eight minutes for the final 15-minute unit of a billing scenario.
PTA - 10 minutes of 97110
PT – 5 minutes of 97110
Total = 15 minutes – qualifies to bill one 15-minute unit (8 minute to 22 minutes).
Analysis: Bill one unit of 97110 with the CQ modifier because the PTA provided 8 minutes or more and the PT provided less than 8 minutes. The de minimis standard applies in these cases.
PTA - 5 minutes of 97110
PT - 6 minutes of 97110
Total = 11 minutes – qualifies to bill one 15-minute unit (8 minute through 22 minutes).
Analysis: Bill one unit of 97110 with the CQ modifier because the PTA and the PT both provided less than 8 minutes. In this case, the PT provided 6 minutes and the PTA furnished 5 minutes independent of each other. The de minimis standard applies in these cases.
PTA-22 minutes of 97110
PT – 23 minutes of 97110
Total = 45 minutes ─ qualifies to bill three 15-minute units (38 minutes through 52 minutes).
Apply Step One of the general policy rules and bill one unit of 97110 with the CQ modifier because the PTA provided 15 full minutes with 7 minutes remaining.
Apply Step One to the PT’s 23 minutes and bill one unit without the assistant modifier with 8 minutes remaining.
The third unit of 97110 is billed without the assistant modifier because the therapist provided enough minutes (8 or more minutes) without the PTAs minutes to bill the final unit.
PT – 12 minutes of 97110
PTA-14 minutes of 97110
PT – 20 minutes of 97140
Total = 46 minutes – qualifies to bill three units (38 minutes through 52 minutes)
Apply Step One of the general policy rules and bill one unit of 97140 without the CQ modifier because the PT provided 15 full minutes of one unit with 5 minutes remaining.
Two units remain to be billed and the PT and the PTA each provided between 9 and 14 minutes independent of one another with a total time between 23 and 28 minutes – in these “two remaining unit” scenarios, one unit is billed with the CQ modifier for the PTA and the other unit is billed without it for the PT.
The PT’s 5 remaining minutes of 97140 are counted towards the total timed minutes but are not billable in this scenario.
OTA-11 minutes of 97535
OT – 11 minutes of 97530
Total = 22 minutes ─ qualifies to bill one (1) unit (8 minutes through 22 minutes)
Since two different services were furnished for an equal number of minutes – the “tie breaker” scenario applies. Either code 97530 by the OT or code 97535 by the OTA can be billed in accordance with a billing example. Either one unit of 97530 is billed without the CO modifier or one unit of 97535 is billed with the CO modifier.
Example #F: Untimed code – 1 unit is billed for all untimed codes including evaluations, reevaluations, supervised modalities, and group therapy.
OTA – 20 minutes 97150 independent of the OT
OT ─ 20 minutes 97150 independent of the OTA
Total = 40 minutes of Group Therapy = 1 unit of 97150 is billed for each group member
One unit of group therapy 97150 is billed with the CO modifier because the OTA provided more than the 10 percent time standard in this example. Either method can be used to determine if the OTA’s time exceeded the 10 percent time standard for this clinical scenario, see below:
The simple method: First add the OTA’s 20 minutes to the OT’s 20 minutes to get 40, then divide by 10 to get 4.0 and add 1 to equal 5 minutes. The OTA’s 20 minutes is equal to or greater than 5 minutes so the CO modifier is required on the claim.
The percentage method: Divide the number of minutes that an OTA independently furnished a service by the total number of minutes the service was furnished as a whole – 20 divided by 40 equals 0.50. Then multiple by 100 to get 50 percent, which is greater than 10 percent. The CO modifier is applied to 97150.
Tie breaker: The tie breaker does not apply in this scenario because the example does not contain two different timed codes described in 15-minute intervals. For “tie breaker” see Example #F above.
Fed. R. 2021 -14973