Humana PTA & OTA Modifiers

Humana is jumping on board...

              Beginning on January 1, 2020, CMS announced that any treatment code where the service was rendered by an assistant would require a designated modifier to be attached to it for billing purposes.

              The CQ modifier identifies outpatient physical therapy services provided in whole or in part by a physical therapist assistant (PTA) while the CO modifier identifies outpatient occupational therapy services provided in whole or in part by an occupational therapist assistant (OTA).

              Predictably, it looks as if commercial insurances will start following Medicare’s lead on this initiative. Humana has just announced their own claims payment policy outlining similar billing requirements and reimbursement for those same types of PT and OT services rendered in whole or in part by assistants effective January 1, 2020.

              At this stage, it seems as though this is simply about data collection as there is no mention of payment reductions within the next two years. However, it has been announced that effective for dates of service beginning January 1, 2022, Humana will allow a charge for an outpatient PTA or OTA service at 85% of the contracted rate or base maximum amount payable under the member’s plan if the treatment code in question appropriately requires a CQ or CO modifier.

              For more information on the new Humana policy, please click here.

              In order to maintain compliance within TheraOffice, you will want to navigate to the backstage menu using the gold button in the top-left corner of the software. Click on Manage, then Insurances, and then edit the insurance that requires these modifiers (in this case, Humana). You will want to check off the box labeled Assistant Modifiers located within the tab shown below.

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