Rule is two years in the making
For the past two years, the Centers for Medicare & Medicaid Services (CMS) has laid the groundwork for implementing a change mandated by The Balanced Budget Act of 2018 calling for a payment adjustment when a patient is seen by a therapy assistant rather than a therapist.
In the CY2020 MPFS final rule, CMS clarified and finalized the new therapy assistant payment modifiers. While the 15 percent payment reduction does not go into effect until 2022, the modifier requirement is now in effect for claims for services provided on or after January 1, 2020.
The modifiers CO (occupational therapy assistant) and CQ (physical therapist assistant) are required in addition to the GO and GP modifiers when a service is performed under a therapy plan of care.
The modifiers are to be applied when the ‘de minimis’ standard is met by an assistant. CMS defines the de minimis standard as providing greater than 10% of a therapeutic service. The standard only applies to skilled therapeutic services, not unskilled services that could be performed by an aide.
In the CY2020 final rule, CMS walked back some of the requirements that were discussed in the proposed rule after significant advocacy by AOTA and other therapy stakeholders resulted in CMS receiving more than 9,000 comments.
Here is what you need to know about the OTA modifier changes in the final rule:
1) Concurrent Services: CMS acknowledged that it is not appropriate to reduce payment when an OT and an OTA are working concurrently on the same patient. The OTA modifier will only apply to time where the OTA is performing the service independently.
2) Units of Service Furnished Separately: CMS acknowledged that it is more appropriate to apply the OTA modifier at the unit level rather than at the service level. The OTA modifier calculation will apply to untimed codes and to timed codes at the 15-minute unit level. For example, when the OTA performs 15 minutes of 97530 and the OT performs 30 minutes, the modifier should be applied to one 15-minute unit of 97530 rather than to all three units.
3) Administrative Burden: CMS acknowledged that an additional documentation requirement would result in undue administrative burden. CMS reminded practitioners that the documentation should be sufficient to support the codes billed and the units applied to the modifier.