CurrentHumanaPolicy CP2018009

Modifiers CO and CQ (OTA/PTA outpatient services billing and payment)

Humana's claims payment policy for use and reimbursement of CMS modifiers CO (OTA services) and CQ (PTA services) for outpatient occupational and physical therapy services for Medicare Advantage and Commercial products.

Policy Summary

PayerHumana

PolicyModifiers CO and CQ (OTA/PTA outpatient services billing and payment)

Policy CodePolicy CP2018009

Change TypeBilling requirement and reimbursement adjustment

Effective Date2020-01-01 (billing); 2022-01-01 (reimbursement)

Next Review Date

Key ActionSubmit modifier CO for OTA involvement and modifier CQ for PTA involvement on outpatient OT/PT claims for dates of service January 1, 2020 and later.

SourceLink

POLICY UPDATE CHANGES

Humana requires submission of modifier CO or CQ for outpatient OT/PT services provided January 1, 2020 or later.

Effective January 1, 2022, Humana allows a charge for an outpatient OTA or PTA service at 85% of the contracted rate or base maximum amount payable.

85%allowed payment rate for OTA/PTA outpatient services (effective 2022-01-01)

2020-01-01CO/CQ submission required from

CP2018009Policy identifier

Applicability and Coverage Criteria

Outpatient OT/PT assistant services

Applicability and billing requirements for outpatient OT/PT assistant-provided services:

ALL of the following

For outpatient occupational or physical therapy services provided on or after January 1, 2020, providers must submit modifier CO for occupational therapy assistant (OTA) involvement or modifier CQ for physical therapist assistant (PTA) involvement on professional or institutional claims (except institutional type of bill 85x).
Claims payments remain subject to other plan requirements including medical necessity, reasonableness, and applicable referral or authorization requirements.
Effective for dates of service beginning January 1, 2022, Humana allows payment for outpatient OTA or PTA services reported with modifier CO or CQ at 85% of the contracted rate or the base maximum amount payable under the member's plan.

Applicable Modifiers and Payment Details

Policy Summary

PayerHumana

PolicyModifiers CO and CQ (OTA/PTA outpatient services billing and payment)

Policy CodePolicy CP2018009

Change TypeBilling requirement and reimbursement adjustment

Effective Date2020-01-01 (billing); 2022-01-01 (reimbursement)

Next Review Date

Key ActionSubmit modifier CO for OTA involvement and modifier CQ for PTA involvement on outpatient OT/PT claims for dates of service January 1, 2020 and later.

SourceLink

On This Page

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Billing and Submission Requirements

Billing Rule

Modifier submission required for assistant-provided outpatient OT/PT services

Submit modifier CO for outpatient occupational therapy services provided in whole or in part by an occupational therapy assistant (OTA) and modifier CQ for outpatient physical therapy services provided in whole or in part by a physical therapist assistant (PTA) on applicable outpatient OT/PT claims for dates of service January 1, 2020 onward.

Effective for dates of service on or after 2020-01-01, submit modifier CO for OTA-provided outpatient occupational therapy services.
Effective for dates of service on or after 2020-01-01, submit modifier CQ for PTA-provided outpatient physical therapy services.
Requirement applies to outpatient professional and institutional claims (except institutional type of bill 85x).

Billing Rule

Reimbursement adjustment for assistant-provided services

Effective January 1, 2022, Humana will reimburse outpatient OT/PT services reported with modifier CO or CQ at 85% of the contracted rate or base maximum amount payable under the member's plan.

Applies when modifier CO or CQ is appropriately submitted for the service.
Reimbursement allowed at 85% of the contracted rate or the plan's base maximum amount, whichever is applicable.
Effective for dates of service on or after 2022-01-01.

Terms and Modifier Definitions

Base maximum amount payable under the member's plan

DefinitionThe maximum amount of reimbursement for a covered expense, determined by the member's plan; may be the maximum allowable fee, the appropriate Medicare fee schedule rate, or an amount derived from another payment model

Actual reimbursementActual plan reimbursement may be less than this base maximum amount because of applicable adjustments

Determined byMember's plan terms and applicable payment model

Modifier CQ

Modifier CQ — definitionOutpatient physical therapy services furnished in whole or in part by a physical therapist assistant

Use caseSubmitted on outpatient physical therapy claims when a PTA furnished the service in whole or in part

Applicability noteApplies to Medicare Advantage and commercial claims per Humana policy when PTA involvement occurred

Modifier CO

Modifier CO — definitionOutpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant

Use caseSubmitted on outpatient occupational therapy claims when an OTA furnished the service in whole or in part

Applicability noteApplies to Medicare Advantage and commercial claims per Humana policy when OTA involvement occurred

Occupational therapy assistant (OTA)

Definition (Medicare Advantage)An individual who qualifies as an occupational therapy assistant for Original Medicare

Definition (Commercial)An individual who qualifies as an occupational therapy assistant as defined in Humana's Physical Therapy and Occupational Therapy Medical Coverage Policy

Policy applicabilityHumana requires submission of modifier CO for outpatient OTA involvement on services provided January 1, 2020 and later; reimbursement adjustment to 85% applies effective January 1, 2022 when CO is appropriate

Physical therapist assistant (PTA)

Definition (Medicare Advantage)An individual who qualifies as a physical therapist assistant for Original Medicare

Definition (Commercial)An individual who qualifies as a physical therapist assistant as defined in Humana's Physical Therapy and Occupational Therapy Medical Coverage Policy

Policy applicabilityHumana requires submission of modifier CQ for outpatient PTA involvement on services provided January 1, 2020 and later; reimbursement adjustment to 85% applies effective January 1, 2022 when CQ is appropriate

CO	Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant.
CQ	Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant.