Part B Insider (Multispecialty) Coding Alert

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

 

Answer: There are several issues here. Modifier GP refers specifically to a physical therapist and is used for 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 healthcare professional on the same day of the procedure or other service) since it is meant specifically for physicians.

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 (Specific required documentation on file) to each therapy service that uses a GN modifier (Service delivered personally by a speech-language pathologist or under an outpatient speech-language pathology plan of care), GO modifier (...an occupational therapist or under an outpatient occupational therapy plan of care) or GP modifier (...a physical therapist or under an outpatient physical therapy plan of care). As usual, the ability to use the KX modifier for therapy cap exceptions expires at the end of the year without an act of Congress.

So, you need to 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.