On January 1, 2018, the Centers for Medicare and Medicaid Services (CMS) released MLN Matters Number: MM10176. In this notice, CMS identified certain services subject to the therapy cap. The revision became effective on January 1, 2018. Due to this revision, some providers have begun to receive claim rejections because they are not using the appropriate modifier. The article states the following:
"Services furnished under the Outpatient Therapy (OPT) services benefit – including Speech Language Pathology (SLP), Occupational Therapy (OT), and Physical Therapy (PT) – are subject to the financial limitations, known as therapy caps, originally required under Section 4541 of the Balanced Budget Act (1997)."
We have received confirmation that this edit is also in effect for chiropractors. Even though therapy services are statutorily non-covered in Medicare, the "claim hard-code editing" does not have any exclusions for certain specialties, this means chiropractors will need to report the appropriate therapy modifier (GP) with HCPCS code G0283 (or any code in the list in the article) in order to receive the appropriate denial for secondary insurance purposes. If both modifiers GP and GY are reported, the service would continue to deny as a noncovered service and a statutory exclusion (which occurred prior to the implementation of the aforementioned CMS instruction).
It is recommended that any claim filed with the affected codes, contain the modifier GPGY if performed by a chiropractic physician or their staff, under delegation of duties. Since this edit is from CMS and not a local carrier, this will affect all chiropractic care in the United States, unless modifications are made in the future.
The therapy codes affected by this edit are as follows:
97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034,
97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97139, 97140,
97150, 97530, 97533, 97535, 97537, 97542, 97750, 97755, 97760, 97761,
97762*, 97799, G0281, G0283
*Note: code 97762 was deleted this year and replaced by 97763.