CMS Pub. 100-04, ch. 5, § 20.1

Claims

(Rev. 11129, Issued: 11-22-21, Effective: 01-01-22, Implementation: 01-03-22)

Modifiers are used to identify therapy services whether or not financial limitations are in

effect. When limitations are in effect, the CWF tracks the financial limitation based on

the presence of therapy modifiers. Providers/suppliers must continue to report one of

these modifiers for any therapy code on the list of applicable therapy codes except as

noted in §20 of this chapter. Consult §20 for the list of codes to which modifiers must be

applied. These modifiers do not allow a provider to deliver services that they are not

qualified and recognized by Medicare to perform.

The claim must include one of the following modifiers to distinguish the discipline of the

plan of care under which the service is delivered:

• 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.

This is applicable to all claims from physicians, nonphysician practitioners (NPPs),

PTPPs, OTPPs, SLPPs, CORFs, OPTs, hospitals, SNFs, and any others billing for

physical therapy, speech-language pathology or occupational therapy services as noted on

the applicable code list in §20 of this chapter.

Modifiers GN, GO, and GP refer only to services provided under plans of care for

physical therapy, occupational therapy and speech-language pathology services. They

should never be used with codes that are not on the list of applicable therapy services. For

example, respiratory therapy services, or nutrition therapy services shall not be

represented by therapy codes which require GN, GO, and GP modifiers.

Contractors edit institutional claims to ensure the following:

• that a GN, GO or GP modifier is present for all lines reporting revenue codes

042X, 043X, or 044X.

• that no more than one GN, GO or GP modifier is reported on the same service

line.

• that revenue codes and modifiers are reported only in the following combinations:

o Revenue code 42x (physical therapy) lines may only contain modifier GP

o Revenue code 43x (occupational therapy) lines may only contain modifier GO

o Revenue code 44x (speech-language pathology) lines may only contain

modifier GN.

• that discipline-specific evaluation and re-evaluation HCPCS codes are always

reported with the modifier for the associated discipline (e.g. modifier GP with a

HCPCS code for a physical therapy evaluation).

Contractors return to the provider institutional claims that do not meet one or more of

these conditions.

CMS has established two modifiers, CQ and CO, for services furnished in whole or in

part by physical therapist assistants (PTAs) and occupational therapy assistants (OTAs).

The modifiers are defined as follows:

• CQ modifier: Outpatient physical therapy services furnished in whole or in part

by a physical therapist assistant

• CO modifier: Outpatient occupational therapy services furnished in whole or in

part by an occupational therapy assistant

Effective for claims with dates of service on and after January 1, 2020, the CQ and CO

modifiers are required to be used, when applicable, for services furnished in whole or in

part by PTAs and OTAs on the claim line of the service alongside the respective GP or

GO therapy modifier, to identify those PTA and OTA services furnished under a PT or

OT plan of care.

For those practitioners submitting professional claims who are paid under the PFS, the

CQ/CO modifiers apply only to services of physical and occupational therapists in private

practice (PTPPs and OTPPs); and not to the therapy services furnished by or incident to

the services of physicians or nonphysician practitioners (NPPs) ‒ including nurse

practitioners (NPs), physician assistants (PAs), and clinical nurse specialists (CNSs) ‒

because PTAs and OTAs do not meet the qualifications and standards of physical or

occupational therapists, as required by §§ 410.60 and 410.59, respectively. However, the

CQ and CO modifiers do apply to claims from physician or NPP groups when a PTPP or

OTPP has reassigned their benefits to the group and their NPI appears as the rendering

provider of the therapy service(s) on the claim.

For providers submitting institutional claims and paid at PFS rates for their outpatient PT

and OT services, the CQ and CO modifiers apply to the following providers: outpatient

hospitals, rehabilitation agencies, skilled nursing facilities, home health agencies and

CORFs. However, the CQ and CO modifiers are not applicable to claims from critical

access hospitals because they are paid on a reasonable cost basis, or from other providers

for which payment for PT and OT services is not made under the PFS rates.

The CQ modifier must be paired to the GP therapy modifier and the CO modifier with the

GO therapy modifier. Claims not so paired will be rejected/returned as unprocessable.

For dates of service, on and after January 1, 2022, claims billed with a CQ or CO

modifier to indicate the services were furnished in whole or in part by a PTA or OTA are

paid at an amount equal to 85 percent of the otherwise applicable Part B payment that’s

based on the MPFS. The 15 percent reduction is taken last, e.g., after the MPPR (and

other reductions where applicable) and right before sequestration. This reduction is

taken from the paid amount, i.e., the actual amount paid not the MPFS allowed amount.

Regulations for the payment of therapy claims and the policy for assigning the therapy

assistant modifiers (CO and CQ) for services provided in whole or in part by OTAs and

PTAs are found at §§ 410.59(a)(4) and 410.60(a)(4) for outpatient occupational and

physical therapy services, respectively and at § 410.105(d) for CORF OT and PT

services.