Physical, Occupational, and Speech Therapy Modifiers

Policy ID: NDRP-GC-032

Section: General Coding

Effective Date: January 01, 2024

Last Reviewed: November 15, 2023

Applies To: Commercial and Medicaid Expansion

Description

This policy provides direction on Blue Cross Blue Shield of North Dakota (BCBND) coding and billing requirements for professional and outpatient facility Physical, Occupational and Speech Therapy services.

Term

Definition

Physical Therapy

The treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery.

Occupational Therapy

A form of therapy for those recuperating from physical or mental illness that encourages rehabilitation through the performance of activities required in daily life.

Speech Therapy

The treatment of communication impairment and swallowing disorders. Speech therapy services involve the use of special techniques to facilitate the development and maintenance of human verbal communication and swallowing through assessment, diagnosis, and rehabilitation.

Policy

Effective January 1, 2024, BCBSND will reject claims for physical, occupational and speech therapy services if modifiers are not appended appropriately.

Modifier

Definition

Services delivered under an outpatient physical therapy plan of care

Services delivered under an outpatient occupational therapy plan of care

Services delivered under an outpatient speech language pathology plan of care

Physical Therapy

Physical therapy (PT) is a medically prescribed treatment for physical disabilities or impairments that result from disease, injury, congenital anomaly, and/or prior therapeutic intervention. PT employs the use of therapeutic exercise and other interventions that focus on locomotion, strength, endurance, balance, coordination, joint mobility, flexibility, and the functional activities of daily living.

The Current Procedural Terminology (CPT) physical medicine and rehabilitation codes, as well as other services that require supervised/constant attendance modalities, wound therapy, testing, assessments, evaluations, and re-evaluation services may be submitted by a physical therapist.

An Evaluation and Management (E/M) service performed by a physical therapist may be reported separately if the patient’s condition requires significant separately identifiable services, above and beyond the usual preservice and post-service work associated with the procedure performed.

Billing Rules

Professional Claims: Each line of service billed by a Physical Therapist must include modifier GP.
Outpatient Facility Claims: Each line of service billed with revenue code 042X must be billed with the GP Modifier.

Occupational Therapy

Occupational Therapy (OT) is the treatment of neuromusculoskeletal and psychological dysfunction, caused by disease, trauma, congenital anomaly, or prior therapeutic process, using specific tasks or goal-directed activities designed to improve functional performance of the individual. OT services emphasize useful and purposeful activities to improve neuromusculoskeletal function and to provide training in activities of daily living.

The CPT physical medicine and rehabilitation codes, as well as other services such as splints, strapping, testing, assessments, evaluations and re-evaluation services may be submitted by an occupational therapist.

An E/M service performed may be reported separately if the patient’s condition requires significant separately identifiable services, above and beyond the usual pre-service and post-service work associated with the procedure performed.

Billing Rules

Professional Claims: Each line of service billed by an Occupational Therapist must include modifier GO.
Outpatient Facility Claims: Each line of service billed with revenue code 043X must be billed with the GO Modifier.

Speech Therapy

Speech-Language Pathologist should use appropriate CPT codes for their speech therapy services and for evaluation and treatment of swallowing dysfunction.

If a speech evaluation is done over a period of two days and only one report is generated upon completion of the evaluation, submit the evaluation code only once with the date of service the evaluation was completed.

Billing Rules:

Professional Claims: Each line of service billed by a Speech-Language Pathologist must include modifier GN.
Outpatient Facility Claims: Each line of service billed with revenue code 044X must be billed with the GN Modifier.

Limitations and Exclusions

While reimbursement is considered, payment determination is subject to, but not limited to:

Group or Individual benefit
Provider Participation Agreement
Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, payment integrity edits and medical necessity.
Mandated or legislative required criteria will always supersede.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

Cross Reference

History

Date

Updates

11/15/2023

Created Physical, Occupational, and Speech Therapy Modifiers

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