The CO and CQ modifiers have been in use since 1/1/20, albeit in “practice mode.” Beginning 1/1/22, use of these modifiers translates to the dreaded 15% payment reduction for any therapy “services“ provided by an assistant that meet CMS’s definition of “in whole or in part.”
If this has been in place for the past 2 years, why all the fuss now?
CMS has revised the methodology for using the modifiers for 1/1/22. If you continue to use the “old way” you may be applying the payment reduction unnecessarily!
Make sure you are up to date on the revised information from CMS from the Final Rule.
The following will review the information SNF therapy professionals need to know:
WHAT?
- Therapy services provided by an assistant that meet the CMS definition of “in whole or in part” must be coded with the corresponding modifier
- CO for therapy services by an occupational therapy assistant
- CQ for therapy services by a physical therapist assistant
- A therapy service is a unit of service represented by a Current Procedural Terminology (CPT) code on the billing claim [service=CPT=unit]
- In whole is when the assistant provides the full service, either all the minutes of a single service/CPT/unit, or the full treatment with multiple services/CPT/units codes billed. The therapist did not contribute to the service/CPT/unit.
- In part is when the assistant provides a portion of a service/CPT/unit, separate from the therapist, such that the minutes for that portion of a service/unit exceed 10% of the total minutes for that service/CPT/unit. [ie: therapist and assistant separately each provide minutes of the same CPT]
- This 10% of a service/CPT is also known as the de minimis standard. There are specific examples, including billing scenario exceptions to this rule listed in the “HOW” section below
- De minimus standard is applied to each 15 minute unit of a service (not based on total units)
- De minimus is applicable only for a service/CPT/unit that is shared by the therapist and assistant, not for different services/CPTs/units
- Therapist and assistant each provide minutes for 97110. De minimus applies.
- Therapist and assistant each provide minutes to different codes. De minimus does not apply.
- Portions of a service/CPT/unit provided by the assistant (independent of the therapist) that do not exceed 10% of the total service/CPT/unit do not need the modifier
- Portions of a service provided by the assistant that exceed 10% of the total service/CPT/unit require the modifier
- Minutes that the therapist & assistant provide together toward the same service/CPT are counted as therapist minutes
- The CO/CQ modifier is needed to trigger the 15% payment reduction for the Current Procedural Terminology (CPT) code it is attached to. Without the modifier on the CPT code, CMS would not know if therapy was provided by the therapist or the assistant
WHEN?
- A payment reduction will go into effect for therapy service dates of January 1, 2022 and after
- Therapy billed to CMS in 2022 for dates of service in 2021 will not have payments reduced, though modifiers are required
WHERE?
For all outpatient therapy settings that bill Medicare Part B using the Physician Fee Schedule
Includes the following providers: Outpatient hospitals, rehabilitation agencies, skilled nursing facilities for Part B, home health agencies for Part B and CORFs
Does not include critical access hospitals because they are not paid using the Physician Fee Schedule
WHY?
- The Bipartisan Budget Act of 2018 (Act that repealed the therapy cap) amended the Social Security Act and required CMS to implement a payment reduction for PT and OT services provided by an assistant by 2022
- The requirement was a 15% payment reduction for the Part B payment Medicare is responsible for
- Medicare Part B will transition from reimbursing 100% of the 80% share, to reimbursing 85% of the 80% share. The 20% copay/coinsurance is not reduced.
- The CO/CQ modifier is needed to trigger the payment reduction for the CPT code it is attached to. Without the modifier, CMS would not know if therapy was provided by the therapist or the assistant
HOW?
- Therapy services are outlined on the billing claim by date of service, CPT code and units. Each therapy discipline has its own modifier to identify to CMS who provided the service. The modifier goes on the line with the CPT code.
- OT services = GO
- PT services = GP
- Speech services = GN
- The new CO/CQ modifiers will be used in addition to the therapy discipline modifier of GP or GO. When the CO/CQ modifier is used, the payment reduction for that CPT code will be applied.
There are 3 treatment scenario types. The first 2 are black and white in regards to the use of the CO/CQ modifier. The third requires further explanation and problem solving included below.
- CO/CQ modifier is applied to all CPT codes provided by an assistant for a date of service if the therapist did not contribute to the treatment. The 15% reduction would apply to each CPT code billed with the modifier attached.
- CO/CQ modifier is not applied to any CPT codes if the therapist and assistant jointly provided the therapy session (together for the full treatment), as the treatment would be deemed as provided by the therapist
- CO/CQ modifier would likely be applied if an assistant provides part of a treatment, or splits a treatment with the therapist. In this scenario, there are steps that must be followed to determine if each CPT code needs the CO/CQ modifier. This will depend on the distribution of the minutes provided between the assistant and therapist for either the same or different codes, and if the CPT codes billed are timed or untimed codes. Each CPT code is looked at independently to determine if the modifier is needed, based on the STEPS OUTLINED BELOW.
Here are the steps to follow as outlined by CMS for TIMED CPT CODES
First, determine minutes and units based on the current process…
Based on the total treatment time, determine how many 15-minute units can be billed.
| 1 unit: | ≥ 8 minutes through 22 minutes |
| 2 units: | ≥ 23 minutes through 37 minutes |
| 3 units: | ≥ 38 minutes through 52 minutes |
| 4 units: | ≥ 53 minutes through 67 minutes |
| 5 units: | ≥ 68 minutes through 82 minutes |
Based on the total number of units that can be billed, identify the CPT codes that will be billed, and minutes toward each code. If the therapist and assistant both contributed to the treatment (separately), list how time toward each CPT was spent by each. This will be needed to determine if the modifier is needed.
Therapy charting would look something like this…
- Total Treatment Minutes = 48 = Allows for 3 billable units
- Treatment consisted of :
- Assistant provided 7 minutes of 97110…
- Therapist provided 31 minutes of 97110…
- Therapist provided 10 minutes of 97116…
- Treatment consisted of :
Nothing new so far…..
Next, follow the steps outlined by CMS. If the steps are not followed, the modifier may be added or omitted in error, causing a potential billing nightmare down the road.
- Once CPT codes are established, identify the timed CPT codes that were provided for 15 minutes or more (if any). For now, ignore any with less than 15 minutes, even if 8 or more minutes were provided.
- Apply units to these codes. Identify any “left-over” minutes above the 15/30/45 minute mark
- In the example above, 2 units would be applied to 97110, with 1 left-over minute, no CO/CQ modifier needed
After STEP 1 is complete, identify any CPT codes that the therapist and assistant shared, providing minutes separately. Look at the minutes that have not already been assigned to a billed unit.
Assign units and modifiers based on these conditions:
- If 2 units of the same code remain to be billed, with therapist and assistant total time between 23-28 minutes:
- Bill 1 unit with the modifier for assistant minutes and 1 unit without the modifier for therapist minutes
- lf only 1 unit of the same code is left to bill and therapist and assistant each have provided minutes to that CPT, use the following to determine billing:
- Therapist provided 8 or more minutes, no modifier is needed for that CPT, even if the assistant provided 8 or more minutes (midpoint or 8-minute rule)
- Assistant provides 8 or more minutes of a CPT and the therapist provides less than 8 minutes of same CPT, modifier is needed (midpoint or 8-minute rule)
- Assistant and therapist each provide less than 8 minutes, the modifier is needed for that CPT
In the example above, there is 1 left-over minute by the therapist and 7 minutes by the assistant for 97110. Hold on to this information for STEP 3.
After completing STEP 1 and 2, identify any different CPT codes that the therapist and assistant provided separately. Assign remaining units and modifiers based on the following conditions:
- Of the remaining minutes for the different CPT codes, when 1 unit is left to bill, bill for the service that took the most time. Assign the CO/CQ modifier to the CPT provided by the assistant when the remaining minutes for the assistant are greater than that of the therapist.
- Tie-Breaker: If the remaining minutes for the CPT code provided by the therapist are the same as the CPT provided by the assistant, you may bill either CPT code, using the CO/CQ modifier if the CPT provided by the assistant is chosen.
In the example above, there is 1 unit left to bill after billing 2 units of 97110 without the modifier, and the CPT with the most time is required to be billed. The therapist provided 10 minutes of 97116. This is compared to the 7 minutes of 97110 provided by the assistant and 1 left-over minute by the therapist. Since 10 is greater than 7 and 1, the last unit is applied to 97116, without the CO/CQ modifier.
One could also argue that based on how the rule is written for STEP 2, the last unit to be billed should be 97110 with the modifier as “the assistant and therapist each provided less than 8 minutes.”. Though in this scenario, the therapist provided 41 minutes and could technically bill 3 units for the full treatment without the additional 7 minutes from the assistant. CMS has provided limited billing scenarios in the Final Rule and on the website below, and as more challenging scenarios are brought forward, it is likely that we will see more clarifications to the Rule.
Billing Examples for CO/CQ Modifier Use
Use the STEPS ABOVE to work through the following billing examples:
- Total Treatment Minutes = 35 = Allows for 2 billable units
- Treatment consisted of :
- Assistant: 5 minutes of 97110
- Therapist: 30 minutes of 97110
- STEP 1: Bill 2 units of 97110 without the modifier as the therapist provided 2 complete 15 minutes units
- *Note that using the “old method” prior to changes made in the Final Rule, a modifier would have been applied to both units because the assistant provided greater than 10% of the service/CPT
- STEP 2 and 3: Not applicable
- Treatment consisted of :
- Total Treatment Minutes = 46 = Allows for 3 billable units
- Treatment consisted of:
- Therapist: 12 minutes of 97110
- Therapist: 20 minutes of 97140
- Assistant: 14 minutes of 97110
- STEP 1: Bill 1 unit of 97140 without modifier for the 15 minutes provided by the therapist (5 minutes left-over)
- STEP 2: Bill 1 unit of 97110 without modifier; Bill 1 unit of 97110 with modifier
- STEP 3: Not applicable
- Treatment consisted of:
- Total Treatment Minutes = 29 = Allows for 2 billable units
- Treatment consisted of:
- Assistant: 19 minutes of 97110
- Therapist: 10 minutes of 97140
- STEP 1: Bill 1 unit of 97110 with modifier for the 15 minutes provided by the assistant (4 minutes left-over)
- STEP 2: Not applicable
- STEP 3: Bill 1 unit of 97110 without modifier, as the 10 minutes provided by the therapist are greater than the 4 left-over minutes provided by the assistant
- Treatment consisted of:
Here are the steps to follow as outlined by CMS for UNTIMED CPT CODES
- Untimed CPT codes include: group therapy, evaluations and re-evaluations, supervised modalities, and certain Remote Therapeutic Monitoring (RTM) codes
- The 10%, or de minimis policy, is applied when the therapist and assistant each independently provide minutes of the same untimed service/CPT/code
- Determine total time spent for untimed code, outlining minutes spent by therapist and assistant
- Determine if the assistant contribution to the untimed code exceeds 10% of the total time for that code by using either method:
- (Assistant minutes + therapist minutes) / Assistant minutes x 100 = %
- (Therapist minutes + Assistant minutes) / 10 , round to nearest integer, add 1
- If 10% is exceeded, the modifier is required on the untimed CPT code
- If Group Therapy is billed, 97150, and 10% is exceeded, all residents in the group will have the modifier added to the untimed group code
- If the assistant contributes minutes to the evaluation or re-evaluation by gathering data, etc., those minutes would count toward the 10% determination
Resources for Therapy Professionals
Best practice is to make sure you understand the requirements for the CO/CQ modifier use. Take a proactive approach to understand the application of the modifier, as a true understanding will be key for how you assign treatments to therapists and assistants going forward, to ensure the payment reduction is not triggered if not needed.
If therapists and assistants are each providing treatment to the same resident, the need for the modifier can’t be determined until all the billing is entered for a discipline. Don’t rely on your therapy software to do the work!
Points to ponder as this all sinks in:
- Should therapists and assistants provide therapy to the same resident on the same day?
- If sharing a resident on a given day, should therapists and assistants use the same CPT codes, or stick to separate and distinct codes?
- Should the treatment CPT breakdown for therapists and assistants be determined ahead of time?
- Should “minimum minute thresholds” be set for services/CPTs for therapists or assistants?
- Is it more or less cost effective to have assistants provide group therapy? The answer may surprise you!
- How will your therapy scheduling change?
- How will your documentation change?
- How will you support your billing choices in your documentation so that a reviewer can come to the same determination regarding modifier use?
Of most importance, make sure your facility has a process in place to review Part B coding and billing to ensure the modifiers are used appropriately. Don’t rely on therapy software to get it right! A manual review is recommended due to the complexity of each billing scenario.
The following resources provide more in-depth information on the topic:
CMS Billing Examples Test yourself with more CMS billing examples.
Medicare Claims Processing Manual – Chapter 5 Review the therapy unit section to ensure you are billing Part B appropriately.
Medicare Part B Changes for 1/1/22 – SNF Summary
If you have a therapist / assistant treatment scenario you want assistance with to determine the modifier breakdown, send it to our Just Ask Q&A – Montero Therapy & MDS Resource Team and we will work it out together!
In Your Corner,
Dolores Montero, PT, DPT, RAC-CT, RAC-CTA
SNF Therapy & MDS Compliance Team