Inpatient Facility Coding & Compliance Alert

Question: Do you know if Medicare requires modifiers to be in a specific order? For example, on a 97002 we are adding GP and 25 and KX. We filed the modifiers in that order and Medicare denied for “benefit max”.

California Subscriber

Answer: There are several issues here. Modifier GP refers specifically to a physical therapist and is used for services provided by a physical therapist under a physical therapy plan of care. See also the functional limitation G-codes. For re-evaluation services, PTs can report 97002 (Physical therapy re-evaluation). However, PTs can’t report modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) since it is meant specifically for physicians and is used only on E/M codes.

Warning: PTs and OTs should be careful not to use 97002 or 97004 every time the therapist treats the patient following the initial evaluation. Although OTs will informally re-evaluate patients as part of each treatment, they should use the re-evaluation code sparingly.

You must have exceeded the cap without submitting the required documentation to seek advance clearance for reimbursement. When a physical, speech-language or occupational therapy service exceeds the caps, providers and suppliers must indicate that the service is medically necessary by adding the KX modifier (Requirements specified in the medical policy have been met) to each therapy service that uses a GN modifier (Services delivered under an outpatient speech language pathology plan of care), GO modifier (Services delivered under an outpatient occupational therapy plan of care) or GP modifier (Services delivered under an outpatient physical therapy plan of care). As usual, the ability to use the KX modifier for therapy cap exceptions, in theory, expires at the end of a given calendar year unless Congress acts to continue the cap.

Bottom line: Check whether you have exceeded your therapy caps. If so, you need to furnish documentation to support medical necessity for further therapy while seeking prior approval. And, you must not add modifier 25.