Common Modifiers for ST/OT/PT Claims

In this week’s article we wanted to highlight and discuss the proper usage of some of the more common Modifiers on pediatric ST/OT/PT claims. A Modifier is a two-character code that is added on claims after the CPT Code. The purpose of the Modifier is to communicate one of three things to the insurance company: 1. Pricing, 2. Payment, and/or 3. Location.

1.     Pricing Modifications would include Modifier “HM” which indicates a pricing adjustment for services performed by a Therapist Assistant.

2.     Payment Modifications would include Modifier “59” which indicates that two separate services are being rendered on the same day.

3.     Location Modifications would include Modifier “GT” which indicates that services are being done “via interactive audio and video telecommunications systems.”

When adding Modifiers to your claims, be sure to add them in the order listed above. For example, an Occupational Teletherapy service performed by an assistant on the same day as a Speech Therapy service would use HM first, then 59, then finally GT. It would look like this on the claim form: 97530 HM 59 GT.

That said, let take a quick look at the most commonly used Modifiers below:

·      HM to denote “Therapist Assistant” and should be used whenever services are rendered by a Therapist Assistant.

·      GN to denote “Speech Therapy Services Provided” and is used for some commercial insurance companies to process claims correctly.

·      GO to denote “Occupational Therapy Services Provided” and is used for some commercial insurance companies to process claims correctly.

·      GP to denote “Physical Therapy Services Provided” and is used for some commercial insurance companies to process claims correctly.

·      59 to denote a “Distinct Procedural Service” which basically means any two services or procedures done on the same day should each have this Modifier. The first example would be an Evaluation (92523) and Treatment (92507) being done on the same day requires “59” to be added to both claim lines. A second example would be Speech and Occupational Therapy being performed on the same day requires a “59” Modifier.

·      GT to denote Teletherapy when done “via interactive audio and video telecommunications systems.”

·      95 to denote Teletherapy when done “synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system.”

·      TL to denote when “Early intervention/individualized family service plan (IFSP)” are provided. This is for claims sent to Primary insurances such as Sunshine Health Plan or Simply Health when Part C/Early Steps is the payer of last resort.

It’s important to note that not all of these Modifiers are used on claims for all payers. For instance, FL Medicaid claims don’t require the use of modifier “59” when two separate therapy treatments are performed on the same day. You will need to do some work to find out that United Healthcare requires the “GN” Modifier to process and pay a Speech Therapy claim. But hopefully we’re providing a good list to help you in your research.

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