Orthopedic Coding Alert

Modifier requirement returns

Medicare carriers and many private insurers will now require orthopedic practices to append the appropriate modifier - -GN (Services delivered under an outpatient speech language pathology plan of care), -GO (Services delivered under an outpatient occupational therapy plan of care), or -GP (Services delivered under an outpatient physical therapy plan of care) - to codes representing outpatient rehabilitation services.
 
Some orthopedic practices may already be familiar with this mandate, which has fluctuated from being effective in 1999 to being unnecessary in 2002. According to the Nov. 2, 1998, Federal Register, all outpatient therapy services furnished under a therapy plan of care on or after Jan. 1, 1999, must include the appropriate -GN,
-GO or -GP modifier appended for analytic purposes.
 
Essentially, the modifier allows the payer to easily track whether the patient has met or exceeded his or her therapy cap. 
 
Some carriers relaxed this requirement after the therapy cap moratorium took effect on Jan. 1, 2000. Earlier this year, however, with the new $1,590 therapy cap (which took effect on Sept. 1, 2003) looming, most payers reinstated the modifier requirement.
 
For instance, HGSAdministrators, a Part B carrier in Pennsylvania, released a memorandum on July 25, 2003, that stated, "Effective for dates of service on and after July 1, 2003, modifiers -GN, -GO and -GP must be used for outpatient rehabilitation services." Most other Medicare carriers released similar memoranda.
 
HGSA indicated that this rule applied to physicians, nurse practitioners, physician assistants, physical therapists, occupational therapists and speech-language pathologists, and warned that claims without the appropriate modifiers would be returned unpaid.
 
Therefore, if your orthopedist, nurse, physician assistant or therapist works on gait training (97116, Therapeutic procedure, one or more areas, each 15 minutes; gait training) with a patient as part of a physical therapy plan of care, your practice should report 97116-GP.