In a recent MLN Matters article, the Centers for Medicare & Medicaid Services (CMS) published revisions to editing of Part B “Always Therapy” services, identifying outpatient therapy (OPT) services that must always be accompanied by a discipline-specific therapy modifier. CMS states that Change Request (CR) 10176, intended for therapists, physicians, and certain other practitioners billing MACs for therapy services provided to Medicare beneficiaries, “contains no new policy. Instead, the guidelines presented in the CR improve the enforcement of longstanding, existing instructions.”
The modifiers and their designated therapy services are as follows:
GP = physical therapy
GO = occupational therapy
GN = speech-language pathology services
OPT services can be furnished as either “always” or “sometimes” therapy. An annual update of this list is published by Medicare on the agency’s Therapy Services Billing page.
On professional claims, each code designated as “always therapy”:
- Must always be furnished under an SLP, OT, or PT plan of care, regardless of who furnishes them; and, as such,
- Must always be accompanied by one of the GN, GO, or GP therapy modifiers.
In addition, several “always therapy” codes have been identified as discipline-specific – requiring the GN modifier for six codes, the GO modifier for four codes, and the GP modifier for four codes, as illustrated below.
Codes requiring the “GN” therapy modifier:
- 92521: Evaluation of speech fluency
- 92522: Evaluation speech production
- 92523: Speech sound lang comprehend
- 92524: Behavral quality analys voice
- 92597: Oral speech device eval
- 92607: Ex for speech device rx 1hr
Codes requiring the “GO” therapy modifier:
- 97165: Ot eval low complex 30 min
- 97166: Ot eval mod complex 45 min
- 97167: Ot eval high complex 60 min
- 97168: Ot re-eval est plan care
Codes requiring the “GP” therapy modifier:
- 97161: Pt eval low complex 20 min
- 97162: Pt eval mod complex 30 min
- 97163: Pt eval high complex 45 min
- 97164: Pt eval est plan care
The following “Always Therapy” HCPCS codes require a GN, GO, or GP modifier, as appropriate: (Descriptors for these codes can be found here.)
Providers should expect the following:
- MACs will return/reject claims which contain an “always therapy” procedure code, but do not also contain the appropriate discipline-specific therapy modifier of GN, GO, or GP.
- MACs will also return/reject claims if any service line on the claim contains more than one occurrence of a GN, GO, or GP therapy modifier.
- MACs who are returning/rejecting such claims will use Group Code CO and Claim Adjustment Reason Code (CARC) 4 on the related remittance advice.
Scrutiny of these instructions will begin January 2, 2018. To read the full MLN Matters article, click here.