Section 53107 of the Bipartisan Budget Act (BBA of 2018) added a new section 1834(v) of the Social Security Act which requires CMS, through the use of new modifiers, to make a reduced payment for occupational therapy and physical therapy services furnished in whole or in part by occupational therapy assistants (OTAs) and physical therapist assistants (PTAs) at 85 percent of the otherwise applicable Part B payment for the service effective January 1, 2022.  Section 1834(v)(2) of the Act requires that: (a) by January 1, 2019, CMS must establish a modifier to indicate that a therapy service was furnished in whole or in part by an OTA or PTA; and, (b) beginning January 1, 2020, each claim for a therapy service furnished in whole or in part by an OTA or PTA must include the modifier.  Section 1834(v)(3) requires CMS to implement these amendments through notice and comment rulemaking.  CMS has implemented these amendments through the annual physician fee schedule (PFS) rulemaking process for CY 2019 and CY 2020.  See CY 2019 PFS final rule, 83 F.R. 59654-59660 (Nov. 23, 2018); CY 2020 PFS final rule and 84 F.R. 62702-62707 (Nov. 15, 2019).

The information in the below Background Section is found in Chapter 5, Medicare Claims Processing Manual (MCPM), section 20.1 - Discipline Specific Outpatient Rehabilitation Modifiers – All Claims.

 

Background: 

 

CMS has established two modifiers, CQ and CO, to indicate services furnished in whole or in part by a PTA or OTA, respectively.

The modifiers are defined as follows:

• CQ modifier: Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant
• CO modifier: Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant

Effective for claims with dates of service on and after January 1, 2020, the CQ and CO modifiers are required to be used, when applicable, for services furnished in whole or in part by a PTA or OTA on the claim line of the service, along with the respective GP or GO therapy modifier, to identify those services furnished in whole or in part by a PTA or OTA under a physical therapy or occupational therapy plan of care.

For those practitioners submitting professional claims who are paid under the physician fee schedule (PFS), the CQ/CO modifiers apply to services of physical and occupational therapists in private practice (PTPPs and OTPPs).

The CQ and CO modifiers must be used when applicable for all outpatient therapy services for which payment is made under section 1848 (the PFS) or section 1834(k) of the Social Security Act (the Act).  As such, the modifiers are required to be used for therapy services furnished by providers that submit institutional claims, including the following provider types: outpatient hospitals, rehabilitation agencies, skilled nursing facilities, home health agencies and comprehensive outpatient rehabilitation facilities (CORFs). However, the CQ and CO modifiers are not applicable to claims from critical access hospitals or other providers that are not paid for outpatient therapy services under the PFS or section 1834(k) of the Act.

The CQ modifier must be reported with the GP therapy modifier and the CO modifier with the GO therapy modifier. Claims with modifiers not so paired will be rejected/returned as unprocessable.

 

CY 2022 Rulemaking

The regulations for determining when the CQ/CO assistant modifiers apply are located at §§ 410.60(a)(4) and 410.59(a)(4) for outpatient physical and occupational therapy services, respectively; and at § 410.105(d)(3) for CORF physical and occupational therapy services.  The regulations were revised through CY 2022 PFS rulemaking.  Each policy is outlined below. We require that claims for services furnished in whole or in part by a PTA or an OTA must include the CQ or CO modifier, respectively, when:

• the PTA/OTA furnishes all of the minutes of a service independent of the respective physical therapist (PT) or occupational therapist (OT); or
• the PTA/OTA furnishes a portion of a service (or unit of service) separately from the part that is furnished by the PT/OT, such that the minutes for that portion of a service (or unit of a service) furnished by the PTA/OTA exceed 10 percent of the total minutes for that service (or unit of a service) ─ except in the specific cases that are outlined below.  (See the two bulleted items below titled Apply the De Minimis Standard Policy for more detailed information.)   

This 10 percent standard is also known as the de minimis standard ─ it was finalized during CY 2020 PFS rulemaking, and its non-application to certain billing scenarios was revised in the CY 2022 final rule (discussed below).

For CY 2022, in response to stakeholders concerns and to promote appropriate care, CMS finalized a policy for which the de minimis standard is not applicable:

• When determining the final 15-minute unit of a multiple unit billing scenario, the PT/OT meets the Medicare billing requirements for the 15-minute timed service without the minutes furnished by the PTA/OTA by providing more than the 15-minute midpoint (that is, 8 minutes or more, which is also known as the “8-minute rule”).  In these cases, that final unit is billed without the CQ/CO modifier; and any minutes that the PTA/OTA furnishes in these cases would not matter for billing Medicare. (See Example #D below.)

CMS identified another scenario, defined by a finite number of cases, in which the de minimis standard is not applied.

• When there are two remaining units remaining to be billed, in which the PT/OT and the PTA/OTA each provide between 9 and 14 minutes of the same service for which the total time is at least 23 minutes and no more than 28 minutes. In these 13 cases, one unit is billed with the CQ/CO modifier for the minutes furnished by the PTA/OTA, and the other unit is billed without the CQ/CO modifier.  The full complement of PT:PTA or OT:OTA time splits is:  9:14, 10:13, 10:14, 11:12, 11:13, 11:14, 12:12, 12:13, 12:14, 13:12, 13:13, 13:14, and 14:14.  (See Example #E below.)

Finally, in the CY 2022 PFS final rule, CMS revised the de minimis policy to include a “different time interval” in addition to the 15-minute one.

• This was done to accommodate the two new codes for Remote Therapeutic  Monitoring (RTM) Services, CPT codes 98980 and 98981, which represent full 20-minute codes:  98980 is for the first full 20 minutes of RTM treatment management services in a month, and 98981 is for additional 20-minute increments of RTM treatment management services.  (See Example #I below.)  

Billing Examples/Scenarios:

For purposes of the below examples, assume the following:    

• Services furnished by the PT together with the PTA or by the OT together with the OTA are considered to be performed by the PT/OT.
• Services or minutes/portions of services performed by the PTA/OTA are independent of those performed by the PT/OT.
• In the below examples (except Examples #H and #I for group therapy and RTM services, respectively) all services are for those therapy HCPCS/CPT codes that are described by 15-minute increments).

 

General Policy Rules

To determine how many 15-minute units can be billed in a single treatment day for a beneficiary:

• Apply the usual method used by your clinic/office as this policy has not changed, and
• Check the chart in IOM Pub. 100-04, MCPM, Chapter 5, section 20.2.C. The chart describes how to count minutes for timed codes defined by 15-minute units.  

More about Calculating the De Minimis:

There are two methods for calculating the de minimis:  the “simple” method and the “percentage” method.

•     Simple Method:  For instances where the de minimis is applicable, once Step 1 is applied for each service (if applicable), where there are remaining minutes for the same service provided by the PTA/OTA and the PT/OT, add these together, divide that total by 10, then round to the nearest integer to get the 10 percent de minimis standard for that service.  Then, add 1 minute to get the PTA/OTA minute floor. The CQ/CO modifier applies when the PTA/OTA minutes meet or exceed this floor number.

•     Percentage Method:  After Step 1 is applied, determine if there are remaining minutes provided by the PTA/OTA and the PT/OT for the same service.  If so, divide the remaining PTA/OTA time by the total time (PTA/OTA minutes + PT/OT minutes for the same service).  Then multiply by 100 to get the percentage and round to the nearest integer. Where this number is greater than 10 percent (11 percent or more), the CQ/CO modifier applies. 

 

To Determine Whether the CQ/CO Modifier Applies:

• Step 1.  Identify the 15-minute Timed HCPCS/CPT Codes Furnished for 15 Minutes or More.

List the code numbers of each of the services furnished along with the number of minutes in total done by the PT, PTA, OT, or OTA.  When a PT, PTA, OT, or OTA provides at least 15 minutes and less than 30 minutes of a service on a single treatment day, assign 1 unit; when multiples of 15 minutes are furnished, e.g., 30 minutes (assign 2 units) and 45 minutes (assign 3 units), etc.  This needs to be the first step whenever it is applicable to the billing scenario.  When any of these services, i.e., full 15 minute increments, are provided by PTAs/OTAs, the CQ/CO modifiers apply. (See Example #C for discussion when Step 1 is not taken, resulting in incorrect billing.)  

• Applying the “8-minute Rule.”  Identify Services for Which the PT/OT and PTA/OTA Provide Minutes of the Same HCPCS/CPT Code.

After applying Step 1, where it is applicable, identify any minutes (including remaining minutes from Step 1) performed by a PT/OT and PTA/OTA for the same service/code.  If determining whether the CQ/CO modifier is applicable for the final 15-minute unit, check to see if the PT/OT furnished 8 minutes or more of that last unit.  If so, the last unit is billed without the CQ/CO modifier because the PT/OT provided enough minutes on their own to satisfy the Medicare billing criterion for an exception to the de minimis policy.  Once the PT/OT meets or exceeds the 8-minute mark, for the final unit in a billing scenario, it does not matter how many minutes the PTA/OTA furnishes for the same service/code – that final unit is billed without a CQ/CO assistant modifier.  In these cases, any minutes that the PTA/OTA furnishes for the final unit would not matter for purposes of billing Medicare. (See Example #D)   

After applying Step 1, where it is applicable, and determining the final unit of a billing scenario, compare the minutes for the same 15-minute service/code provided by the PT and PTA (or the OT and OTA).  Here are 2 times the de minimis policy is applicable to that final 15-minute unit:

• Applying the De Minimis Standard Policy – Cases When the CQ/CO Modifier is Applied to Services Defined by 15-minute Increments. 
  • When the PTA/OTA furnishes 8 minutes or more of a service and the PT/OT provides less than 8 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.
    (See Examples #A and #B below.)

• Applying the De Minimis Standard Policy – Cases When the CQ/CO Modifier is Applied to “Untimed” HCPSC/CPT Codes that Can Only be Billed with One Unit. 

The de minimis policy is applicable when the PT and the PTA or the OT and the OTA each independently provide minutes of the same untimed service, including:  supervised modalities, evaluations and re-evaluations, group therapy, and certain RTM codes discussed in Example #I below.  In these cases, either the simple or percentage method (see above) can be used to determine if the PTA/OTA furnished more than 10 percent of the service.  If so, the CQ/CO modifier is appended to the claim for that unit of service.  (See Example #H for group therapy)

•  Instances Where There are Two 15-minute Remaining Units Left to Bill and the PT/OT and PTA/OTA Each Provide Between 9 and 14 Minutes with a Total Time of at Least 23 Minutes and No More than 28 Minutes.   

This finalized policy applies in a limited number of cases where there are two 15-minute units of therapy remaining to be billed for the same service.  For these limited cases, we are allowing one 15-minute unit to be billed with the CQ/CO 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 when the total time is at least 23 minutes and no more than 28 minutes. (See Example #E below)

• Billing for the Service with the Most Time. Identify Services Where the PT/OT and PTA/OTA Furnish Services of Two Different 15-minute Timed HCPCS/CPT Codes.

After applying Step 1 for each service and determining there is only one unit left to bill, compare the remaining minutes furnished by the PT/OT for the one service with the remaining minutes furnished by the PTA/OTA for the different service.  Bill for the service that took the most time. That is, assign the CQ/CO modifier to the service provided by the PTA/OTA when the time he/she spent is greater than the time spent by the PT/OT performing the different service.  The CQ/CO modifier does not apply when the minutes spent delivering a service by the PT/OT are greater than the minutes spent by the PT/OTA delivering a different service.  (See Example #F below.)

• Tie-Breaker.  Identify the Different HCPCS/CPT Codes Where the PT/OT and the PTA/OTA Each Independently Furnish the Same Number of Minutes.  Once Step 1 is completed for each service (when applicable) and determining there is only one unit left to bill, the remaining minutes for each service – one provided by the PT/OT and the other provided by the PTA/OTA ─ are the same, either service may be billed, but not both.  If the service provided by the PT/OT is billed, the CQ/CO modifier does not apply.  However, if the service provided by the PTA/OTA is billed, the CQ/CO modifier does apply. (See Example #G below.)   

 

BILLING EXAMPLES

Example #A:

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).

Billing 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.  Using the percentage method, divide the PTA’s 10 minutes by the total 15 minutes of the service (10 PTA + 5 PT = 15 minutes) to get 0.66, then multiply the result X 100 = 66 percent. 

Bill as Follows:  Bill 1 unit of 97110 with the CQ modifier because the PTA provided more than 10 percent of the service in a case where the de minimis standard applies.   

 

Example #B:

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).

Billing 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.  Using the percentage method, divide the PTA’s 5 minutes by the total 11 minutes (5 PTA + 6 PT = 11 minutes) to get 0.45, then multiply the result X 100 = 45 percent in a case where the de minimis standard applies.   

Bill as Follows:  Bill 1 unit of 97110 with the CQ modifier because the PTA provided more than 10 percent of the service.    

 

Example #C

PTA – 5 minutes 97110

PT  ─ 30 minutes 97110

Total = 35 minutes – 2 units can be billed (23 minutes through 37 minutes). 

Billing Analysis:  

Apply Step 1:  Bill two (2) units of 97110 without the CQ modifier because the PT furnished 2 complete 15-minute units of therapeutic exercise.  Record the 5 minutes of service by the PTA with the total time for the treatment session (per standard documentation protocol), even though the time is not billable. 

Bill as Follows: Bill two (2) units of 97110 without the CQ modifier because the PT provided 2 full 15-minute units. 

Note:  If, in this scenario, the PT/PTA did not follow “Step 1” of the general rule, it would result in one or both units of 97110 being mistakenly billed with a CQ modifier as described below:

• Simple method:  Divide the 35 total minutes by 10 = 3.5, round to 4.0 minutes, then add 1 minute = 5 – CQ modifier is billed incorrectly.    
• Percentage method:  Divide the PTA’s 5 minutes by the total time (35 minutes) ─ 5 divided by 35 = 0.14 X 100 = 14 percent.  The PTA’s 5 minutes would be incorrectly billed with the CQ modifier in this scenario. 

 

Example #D:

PTA-22 minutes of 97110

PT – 23 minutes of 97110

Total = 45 minutes ─ qualifies to bill 3 15-minute units (38 minutes through 52 minutes).

Billing Analysis: 

●  Apply Step 1 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 1 to the PT’s 23 minutes and bill one unit without the assistant modifier with 8 minutes remaining. 

●  Apply the 8-minute rule to the third and final unit of 97110 to bill without the CQ assistant modifier because the therapist provided enough minutes (8 or more minutes) without the PTAs minutes to bill the final unit. 

Bill as Follows:  Bill 1 unit of 97110 with the CQ modifier because the PTA provided a full 15-minute unit, and bill 2 units of 97110 without the CQ modifier – 1 unit for the full 15-minute unit provided by the PT and 1 unit because the 8-minute rule is applied to the final unit.     

 

Example #E

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)

Billing Analysis: 

●  Apply Step 1 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 of 97110 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 this “two remaining units” billing scenario, 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 toward the total timed minutes of treatment that day (per our standard documentation protocol), but are not billable in this scenario.

Bill as Follows:  Bill 1 unit of 97140 without the CQ modifier because the PT provided a full 15-minute unit. Then, for the 2 remaining units of 97110:  bill 1 unit of 97110 with the CQ modifier and 1 unit of 97110 without the CQ modifier because the PT:PTA ratio of 12:14 minutes qualifies as one of the 13 instances for applying the “Two Remaining Units” Billing Rule discussed above.

 

Example #F

PTA – 19 minutes of 97110

PT   ─ 10 minutes of 97140

Total = 29 minutes – two units can be billed (23 minutes through 37 minutes).  

Billing Analysis: 

●  Apply Step 1: Bill 1 unit of 97110 with the CQ modifier because the PTA performed a full 15 minute unit, with 4 minutes remaining.

●  The remaining minutes are for different services, so, bill the service with the greater number of minutes.  Since the PT’s 10 minutes of 97140 (manual therapy) is greater than the PTA’s 4 remaining minutes of 97110 (therapeutic exercise), bill 1 unit of 97140; the CQ modifier does not apply because the PT provided the 97140 service. 

Bill as Follows: Bill 1 unit of 97110 with the CQ modifier because the PTA performed a full 15-minute unit, with 4 minutes remaining.  Then bill 1 unit of 97140 without the CQ modifier because the PT’s time of 10 minutes is greater than the PTA’s time of 4 minutes for a different service.  

 

Example #G

OTA-11 minutes of 97535

OT – 11 minutes of 97530

Total = 22 minutes ─ qualifies to bill one (1) unit (8 minutes through 22 minutes)

Billing Analysis:  The de minimis standard does not apply when different services are provided by the OT and the OTA or the PT and the PTA.  Since two different services were furnished for an equal number of minutes – the “tie breaker” scenario applies (see examples in the MCPM, Chapter 5, section 20.2.C that are designed for when services are provided by just one professional ─ either the PT or PTA or the OT or the OTA).  Either one unit of 97530 is billed without the CO modifier or one unit of 97535 is billed with the CO modifier.

Bill as Follows:  Bill 1 unit of 97535 with the CO modifier because the OTA provided this service, or, bill 1 unit of 97530 without the CO modifier for the OT’s service.    

 

Example #H: Untimed code – 1 unit is billed for all untimed codes including evaluations, reevaluations, supervised modalities, group therapy, and 2 RTM codes (98975 and 98980), as noted below. 

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

Billing Analysis:  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 the simple or percentage method can be used to determine if the OTA’s time exceeded the 10 percent time standard for this clinical scenario. Using the percentage method:  Divide the OTA’s 20 minutes by the total time of 40 minutes (20 OTA + 20 OT 20 = 40 minutes) equals 50 percent – which exceeds the 10 percent time standard.

Bill as Follows:  CPT code 97150 is billed with a CO modifier (for each patient) because the OTA’s minutes represents 50 percent of the total time for the group therapy services.   

 

Example #I:  Remote Therapeutic Monitoring (RTM) Services

Billing Scenario:  The PT and PTA independently provide a total of 47 minutes of RTM treatment management services during the 30-day period, defined by codes 98980 (for the first 20 minutes) and 98981 for each additional full 20-minute increment. 

●  For purposes of billing CPT code 98980:  The first 20 minutes of RTM treatment management services were furnished by the PT.  Therefore, CPT code 98980 is billed without a CQ modifier.

Billing Analysis:  Even though CPT code 98980 represents the initial 20 minutes of RTM service for a 30-day period, it’s treated as an untimed code for purposes of billing Medicare since only 1 unit can be billed.  

Bill as Follows:  CPT code 98980 is billed without a CQ modifier because the PT furnished the first 20 minutes the RTM service in the 30-day period.   

 ●  For purposes of billing CPT code 98981:  From the remaining 27 minutes, total up the minutes provided by the PT and/or by the PTA ─ with 17 minutes furnished by the PTA and 10 minutes furnished by the PT.  Twenty-seven minutes qualifies for billing one 20-minute unit of 98981.  So, subtract out the minutes provided by the PT and/or PTA from the final 7 minutes of the 30-day period of RTM services since there is no partial billing.  In this scenario, the PTA furnished all the minutes of the last 7 minutes so they are subtracted from the 17 minutes, resulting in 10 minutes.  The billing scenario follows: 

PTA ─ 10 minutes of  98981

PT  ─  10 minutes of  98981

Total = 20 minutes of 98981 (qualifies to bill one 20-minute unit) 

Billing Analysis:  The 20 total minutes of additional time allows one full 20-minute unit of CPT code 98981 to be billed:  The one 20-minute unit is billed with a CQ modifier because the PTA’s 10 minutes is greater than 10 percent of the 20-minute total.  Using the percentage method where 10 (PTA’s minutes) divided by 20 total minutes (10 PTA + 10 PT = 20 minutes) equals 0.50 X 100 = 50 percent which is greater than the 10 percent standard of 2 minutes.

Bill as Follows:  Bill 1 unit of code 98981 with the CQ modifier for one 20-minute unit because the PTA’s 10 minutes exceeds the 10 percent time standard. 

Note about RTM Set-Up Code 98975 and the 2 Device codes 98976 and 98977: 

• The two device codes, CPT codes 98976 and 98977, are not subject to the de minimis standard, and they are billed only once per the episode of care. 
• CPT code 98975, for the initial set up and patient education on use of the device is subject to the de minimis policy as an untimed code.  Therefore, if the PTA or OTA provides more than 10 percent of the service, the CQ/CO modifier is applied to the 1 unit of CPT code 98975.