Q/A: Should I be Using Modifier 96 on PT Claims?

April 30th, 2018 - Wyn Staheli, Director of Research
Categories:   Chiropractic   Modifiers   Compliance  
0 Votes - Sign in to vote or comment.

Question

As chiropractors we feel the new modifier 97 is more appropriate than 96 for our PT codes such as stim and traction. Yet Carefirst is asking for 96 only. Should we use this code on all the PT codes and for all the other insurance companies?

Answer

We also agree that modifier 97 would be the correct modifier for most physical therapy services provided in a chiropractic setting. Do not begin using modifier 96 for any payer UNLESS it truly is to help a person DEVELOP skills or functions they didn't have before. If not, then the documentation would not meet the requirements of that modifier and we have concerns about future claim reviews with the possibility of fraud allegations.

Before you bill CareFirst with modifier 96get an official statement from them that they want you to use modifier 96 for both habilitative and rehabilitative services. 

After reviewing CareFirst policies, it would appear that using modifier 96 would be inappropriate in your setting.

CareFirst policy 8.01.011 Habilitative Services was updated last year with the following definition: "Habilitative services means services and devices, including occupational therapy, physical therapy, and speech therapy, that help a child keep, learn, or improve skills and functioning for daily living." Interestingly, policy 8.01.001 Physical Therapy does not include this change or mention using modifier 97 with rehabilitative services, just modifier 96 for habilitative services.

CLICK HERE to read a more comprehensive article on these two modifiers.

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

2023 ICD-10-CM Code Changes
October 6th, 2022 - Christine Woolstenhulme, CPC, CMRS, QCC, QMCS
In 2022 there were 159 new codes; the 2023 ICD-10-CM code update includes 1,176 new, 28 revised, and 287 deleted codes, a substantial change from last year. The 2023 ICD-10-CM codes are to be used for discharges from October 1, 2022 through September 30, 2023, and for patient encounters from ...
Emergency Department - APC Reimbursement Method
September 15th, 2022 - Christine Woolstenhulme, CPC, CMRS, QCC, QMCS
CMS pays emergency department visits through a payment method using Ambulatory Payment Classifications (APCs). Most payers also use the APC reimbursement system; however, there may be some differences in payer policies (always review your specific payer policy). APCs are the primary type of payment made under the OPPS, comprising groupings ...
Why Medical Coding and Billing Software Desperately Needs AI
September 7th, 2022 - Find-A-Code
It has been said that the healthcare industry is notoriously slow in terms of technology adoption. One need only look at how convoluted medical coding and billing are to know that it needs a technology injection. Specifically, medical coding and billing software desperately needs artificial intelligence (AI).
CMS says Less Paperwork for DME Suppliers after Jan 2023!
August 18th, 2022 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
Attention providers, suppliers, billers, and vendors who bill Durable Medical Equipment (DME) to Medicare!  Currently, a supplier receives a signed Certificate of Medical Necessity (CMN) from the treating physician or creates and signs a DME Information Form (DIFs); these are required to be sent with the claim. However, this is about ...
Things to Consider Before Upgrading Medical Billing Software
August 11th, 2022 - Find-A-Code
Your practice has utilized the same medical billing software for years. The medical billing staff says it is time for a change. You don't necessarily disagree, but you also don't know where to begin your search for new software. There are so many vendors offering so many products that making sense of it all can be challenging.
Calendar Year 2023 Medicare Advantage and Part C & D Payment Policies
August 9th, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Each year CMS publishes an Advance Notice of the upcoming years Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies and asks for comments related to it. Each of the comments are carefully reviewed and responded to and often are impactful to changes seen between the Advance Notice and final publication referred to as the Rate Announcement. With health equity as a primary focus for 2023, CMS announced some policy changes that may impact your organization.
How CMS Determines Which Telehealth Services are Risk Adjustable
August 9th, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Medicare Advantage Organizations (MAOs) have gone back and forth on whether or not to use data collected from telehealth, virtual Care, and telephone (audio-only) encounters with Medicare beneficiaries for risk adjustment reporting, but the following published documents from CMS cleared that up once and for all by providing an answer to a question specifically related to this question.



Home About Contact Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2022 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association