Check out my video update and explanation of the OTA Modifier or read the article below. Both are full of information! Note: CMS did provide more clarity on how to split charges if OT and OTA treat a patient in the same session which I explain in this article. See the CMS summary for more information.
To learn more about how to implement the OTA Modifier, please view this article. Keep reading to learn more about the SMART Act!
11/10/2021 Update:
CMS published the final 2022 Physician Fee Schedule which confirms that the OTA modifier will be implemented Jan 1, 2022 without any major changes from the proposed rule. View a summary of this rule here.
10/9/2021 Update:
AOTA announced that the House recently introduced legislation to address the OTA modifier issue and supervision requirements. The “Stabilizing Medicare Access to Rehabilitation and Therapy Act” – SMART Act – is sponsored by Rep. Jason Smith (R-MO) and Rep. Bobby Rush (D-IL).
This legislation would…
- Delay the OTA/PTA Modifier Payment Reduction implementation, which is scheduled for January 1, 2021
- Exempts rural and underserved areas from the OTA/PTA reduction
- Standardizes supervision requirements for Medicare beneficiaries by removing the burdensome “direct supervision” requirements for OTAs/PTAs under Medicare Part B.
Continue with the article below to learn more about the OTA modifier and what it means for your practice!
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The Story Behind the OTA Modifier
The Occupational Therapy Assistant (OTA) Payment modifier was implemented in 2020 for all Medicare Part B patients and private health insurance companies. That modifier was a precursor to a scheduled 15% reduction in reimbursement for services billed by OTA or a Physical Therapy Assistant (PTA) under Medicare Part B.
What you can do: Send a comment to CMS! AOTA makes it super easy and already has a comment letter template ready to go. Don’t forget to add your story on this rule will impact you and your practice. That’s what makes CMS pay attention. Comments are due September 13, 2021. Additionally, AOTA signed on to the letter asking for relief from Congress (see above for updates)
Also, sign Up for AOTA’s 3-day Grassroots Advocacy Learning Intensive – AOTA’s virtual annual Hill Day. Fingers crossed, I can meet you all in DC for next year’s.
What is the OTA Payment Modifier
The OTA Payment Modifier was passed as part of the 2018 Balanced Budget Act. This Act also permanently eliminated the hard therapy cap, which haunted the therapy profession for over 30 years. CO modifiers are for OTAs, and CQ modifiers are for PTAs. The modifiers were created in CY 2019 Physician Fee Schedule (PFS) final rule (83 FR 59654 through 59661). GO is the modifier for OTs and GQ is the modifier for PTs.
Medicare Part B implemented the OTA payment modifier in 2020, but it does not yet carry the payment reduction. Section 1834(v)(1) of the Social Security Act requires the 15% payment reduction implementation on January 1, 2022. This 15% reduction is for services provided “in whole or in part” by an OTA or PTA.
Since Medicare beneficiaries have a 20% copay for outpatient services, Medicare will reimburse 85% of the 80%, and Medicare beneficiaries will still have a 20% copay. So, the equation is (0.20 + (0.80*0.85), equalling 88% of payment. When CMS releases the final rule in the fall of 2021, we will have more clarity on exactly how to implement this regulation.
When to Use the OTA Payment Modifier and What it Means for Your Practice
The OTA and PTA modifiers should be used when the OTA or PTA provides 10% or more of the billed treatment unit or provides the entire visit. CMS guidelines best explain the math on how to calculate 10%. AOTA also laid out helpful scenarios specific to occupational therapy.
The OTA payment reduction does not necessarily mean that we have seen the end of assistants billing Medicare Part B. Assistants still have a vital role in these settings. Assistants support caseload volumes by allowing therapists to engage in more evaluations and thus bringing more patients into a clinic. Assistants have a great deal of talent and care to bring to the outpatient setting.
Why the OTA Payment Modifier Exists
As stated above, the mandate for CMS to implement an OTA payment modifier was passed by Congress as part of the Balanced Budget Act (BBA) of 2018. When the therapy cap repeal was included in the BBA, the measure was given a ‘score’ by the Congressional Budget Office (CBO). The CBO determined that removing the therapy cap would cost taxpayers over $6 billion over the next decade.
To partially pay for this $6 billion estimated spending increase, Congress agreed behind closed doors to include the assistant payment reduction in the BBA of 2018. AOTA and APTA were not aware of this added amendment until the bill passed. The justification for this reduction is to place OTs and OTAs on par with how CMS reimburses physicians compared to nurse practitioners and physicians assistants.
AOTA continues to advocate for action on the OTA payment modifier, including delaying implementation and exclusions for rural and underserved populations as these populations rely more on assistants for care. Be sure to attend AOTA’s advocacy intensive to advocate for occupational therapy services.
Resources:
- AOTA – Delay the OTA Payment Differential: Join AOTA to Advocate & Make Your Voice Heard
- CMS – Revisions to Payment Policies under the Medicare Physician Fee Schedule, Quality Payment Program, and Other Revisions to Part B for CY 2022 (CMS-1751-P)
- CMS – Medicare Program: CY 2022 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Provider Enrollment Regulation Updates; Provider and Supplier Prepayment and Post-Payment Medical Review Requirements (CMS-1751-P)
- CMS – Billing Examples Using CQ/CO Modifiers for Services Provided by PTAs & OTAs
- AOTA – OTA Modifier Examples
- Amplify OT – Applying the OTA and PTA Modifier (CO/CQ) for Outpatient Therapy
- Amplify OT – How To Bill Occupational Therapy Under Medicare Part B
