Modifiers CQ/CO

Reimbursement Policy:

Modifiers CQ/CO for Physical Therapy Assistant/Occupational Therapy Assistants Services

Effective Date:

June 27, 2022

Purpose:

Provide guidelines for the reimbursement of eligible services appropriately appended with Modifiers CQ or CO for professional providers.

Scope:

All products are included, except

• Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
• COB
• SHBP/SEHBP (Non Par providers only)

All Insured and Administrative Services Only (ASO) accounts are included.

Definitions:

• Modifier CQ: Outpatient physical therapy services provided in whole or in part by a physical therapist assistant.
• Modifier CO: Outpatient occupational therapy services provide in whole or in part by an occupational therapy assistant.
• De minimis Standard: Refers to services provided “in whole or in part” by a physical or occupational therapy assistant. (In Part means exceeds more than 10% of the total service time.)

Policy:

Consistent with the approach taken by CMS in their guidelines, Horizon BCBSNJ shall consider for reimbursement services rendered by PTAs/OTAs appended with Modifiers CQ/CO at 85% of the applicable Horizon BCBSNJ fee schedule amount as provided below:

Services rendered by PTAs/OTAs, must be appended with Modifier CQ or CO when:

• Services are provided in whole by PTA/OTA.
• Services provided in-part by the PTA/OTA are 8 or more minutes of a 15-minute service and the Physical Therapist (PT)/Occupational Therapist (OT) provided less than 8 minutes (de minimis standard exceeded).
• Services are provided by both the PTA/OTA and PT/OT with each providing less than 8 minutes of service, append modifiers CQ/CO if the minutes provided by the PTA/OTA exceed de minimis standard.

Modifiers CQ/CO would not apply when:

• Services are provided in whole by PT/OT.
• PT/OT and PTA/OTA provided services to a patient at the same time, and the patient requires both providers for a highly skilled procedure or both are needed for safety reasons.
• Outpatient physical and occupational therapy are provided by, or incident to, the services of physicians or non-physician practitioners.
• There is one (1) final 15-minute unit left to bill on a treatment day and the PT/OT provides 8 or more minutes of that final unit.

In cases where there are two (2) units left to bill, and the PT/OT and the PTA/OTA each provide between 9 and 14 minutes of a 15-minute service and the total time of therapy provided by the PT/OT and PTA/OTA is at least 23 minutes, but no more than 28 minutes:

• Bill one (1) unit without Modifier CQ/CO
• Bill one (1) unit with Modifier CQ/CO

Procedure:

Eligible physical and occupational therapy services appended with Modifier CQ/CO shall be considered for reimbursement at 85% of the applicable Horizon BCBSNJ fee schedule

In instances where the provider is participating, there shall be no member liability.

In instances where the provider is non-participating, the member’s liability shall be up to the provider’s charge.

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, and medical necessity
• Mandated or legislative required criteria will always supersede.

Policy154_v1.0_01282022