Physical Therapy/Occupational Therapy/Speech Therapy

Outpatient OT and PT Services Billing Guide

Outpatient Occupational and Physical Therapy Coverage

Table of Contents

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CMS References

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LCDs and Billing and Coding Articles

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CMS MLN Matters®

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Certifying Physician/NPP

  • For outpatient therapy services, providers should report the NPI of the physician/NPP certifying the therapy plan of care in the Attending Physician field on institutional claims for outpatient therapy services. In cases where different physicians/NPPs certify the OT, PT or SLP plan of care, report the additional NPI in the Referring Physician field (loop 2310F) on institutional claims for outpatient therapy services
  • For Part B claims, the certifying physician/NPP is considered a referring provider and such providers must follow the instructions in CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.1.1 for reporting the referring provider on a claim.

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Therapy Plan of Care/Modifiers

  • The LCD for outpatient physical and occupational therapy services describes the coverage limits of outpatient physical and occupational therapy services under Medicare Part B, billed to either the Medicare Fiscal Intermediary, Part A, Medicare Carrier, or Part B MAC when services are provided under a therapy plan of care. The claim must include one of the following modifiers to distinguish the discipline of the plan of care under which the service is delivered:
    • GO ‒ Services delivered under an outpatient occupational therapy plan of care; or,
    • GP ‒ Services delivered under an outpatient physical therapy plan of care.
  • The modifiers are applicable to all claims from physicians, NPPs, PTPPs, OTPPs, CORFs, ORFs, outpatient hospital departments, SNFs billing under Medicare Part B, HHAs (when not rendered under a home health plan of care, but rendered under a therapy plan of care), and any other billing for PT or OT services. However, physical therapists may only report modifier GP and OT may only report modifier GO.

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Physical Therapy Assistants/Occupational Therapy Assistants

  • Since a beneficiary’s incurred expenses for PT and OT services are tracked and accrued to different KX modifier and medical review threshold amounts (established via section 50202 of the BBA of 2018), CMS established two modifiers, CQ and CO, for services furnished in whole or in part by PTAs and OTAs, respectively, through CY 2019 PFS rulemaking. 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
  • In the CY 2019 PFS final rule and in CY 2020 PFS rulemaking, CMS clarified that the CQ and CO modifiers are required to be used, when applicable, for services furnished in whole or in part by PTAs and OTAs on and after 1/1/ 2020, on the claim line of the service alongside the respective GP or GO therapy modifier, to identify those PTA and OTA services furnished under a PT or OT plan of care.
  • In the CY 2020, CMS established a de minimis standard for such services, which means that portions of a service furnished by the PTA/OTA independent of the physical therapist/occupational therapist, as applicable, that do not exceed 10 percent of the total service are not subject to the payment reduction; while portions of a service furnished by the PTA/OTA independent of the therapist that exceed 10 percent of the total service, or unit of service, must be reported on the claim with the CQ/CO modifier, alongside of the corresponding GP/GO therapy modifier. Portions of services provided by the PTA/OTA together with the PT/OT are counted as services provided by the PT or OT.
  • In the CY 2022 PFS final rule, the de minimis policy that requires the CQ/CO modifier to be on claims when the PTA/OTA provides more than 10 percent of a unit of service for other time intervals than the 15-minute one was finalized.
    • More than 10 percent of an untimed service, or
    • More than 10 percent of a 15 minute timed unit of service

Note: This includes the 20-minute time increment of the new codes for remote therapeutic monitoring services.

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Diagnosis Coding

  • The diagnosis should be specific and as relevant as possible to the problem being treated. In many cases, both a medical diagnosis (obtained from the physician/NPP) and an impairment-based treatment diagnosis are relevant.
  • Bill the most relevant diagnosis. As always, when billing for therapy services, the ICD-10 code that best relates to the reason for the treatment shall be on the claim, unless there is a compelling reason.
    • For example, when a patient with diabetes is being treated for gait training due to amputation, the preferred diagnosis is abnormality of gait (which characterizes the treatment). Where it is possible, in accordance with state and local laws and the contractors LCDs, avoid using vague or general diagnoses.
    • When a claim includes several types of services, or where the physician/NPP must supply the diagnosis, it may not be possible to use the most relevant therapy code in the primary position. In that case, the relevant code should, if possible, be on the claim in another position.
  • Codes representing the medical condition that caused the treatment are used when there is no code representing the treatment. Complicating conditions are preferably used in nonprimary positions on the claim and are billed in the primary position only in the rare circumstance that there is no more relevant code.

Revised 1/25/2024