Ep 1: The Occupational Therapy Assistant Modifier

This summer, Elevator your impact at the Amplify Therapy Summit hosted by Amplify OT. It's happening July 30 through August 2, 2025. It is 100% virtual and free to attend select sessions with live panels and pre-recorded content focused on OT policy, reimbursement and workforce issues. If you want extended access and up to 15 CEU hours, upgrade to the Explorer Pass starting at just $99. You can shape policy, feel inspired and achieve new heights with the Amplify Therapy Summit. Register now at AmplifytherapySummit.com or using the link in the show notes. I'll see you there. Hi, I'm Clarice Grote and welcome to the Amplify OT podcast. I'm an occupational therapist by trade and a policy-longed-by choice. This podcast is here to help you survive and thrive in the U.S. healthcare system through a better understanding of policy, advocacy and value-based care. So let's dive in. Welcome everyone to the Amplify OT podcast. I'm Clarice Grote and I am an occupational therapist and the founder of Amplify OT. I am so glad to have you here with me and to have an opportunity to share with you my passions which are occupational therapy, policy and advocacy. I started Amplify OT in October of 2020 and it's a company that I run where I provide free articles for primarily occupational therapy practitioners and students all about Medicare policy, reimbursement, federal legislation, quality measures, pretty much the things that I think practitioners and students need to know and things frankly that I wish that I knew when I was a new grad as well as a clinician and things that I ended up having to look up for myself and figure out and I just want to make that process easier for everyone else because I know not everyone loves reading policy and legislation like I do and so we need people who are excellent practitioners who do patient care and we also need people on the other side who worry about how exactly we are going to get paid, right? So that's a little bit about Amplify OT for a little bit of background on me for those of you who haven't met me. Like I said, I'm an occupational therapist, I went to Columbia University in New York so I lived in New York for two years and I loved it. Before going to Columbia, I got my bachelor's from the University of Iowa so GoHox so I have my bachelor's in music performance and health studies and I'm from Kansas City, Missouri. So after I graduated from Columbia, I returned home to Kansas City to start my career, I started off in home health. I worked there for nine months working with older adults as well as home hospice and palliative care so I was a contractor so I worked for quite a few different agencies and then after home health, I went to work at North Kansas City Hospital which is a acute care hospital, has about 400 beds and I really liked it. I worked there as acute care therapist primarily but also covered on outpatient as well as doing lymphedema therapy. I'm not lymphedema certified but I just did primarily lower legs so bandaging and some wound care and I really enjoyed it. So it's definitely been a challenge with the pandemic and that's kind of what spurred me to start amplify OT and kind of start branching into the policy and advocacy world as a career. So when I was in school, it was during the 2016 presidential election and so obviously healthcare was a hot topic during that election year and I thought to myself as a student, you know why would I sit around and just wait to see what happens with healthcare legislation and have it potentially negatively impact the career that I've spent all this time and money to become and do nothing. So I ended up searching out opportunities for how to get involved and I discovered that the American Occupational Therapy Association or AOTA has fieldwork opportunities and I applied and was fortunately accepted to do a fieldwork opportunity with the AOTA and their federal affairs team. So after I finished my physical disabilities fieldwork, I moved to DC for three months and worked for AOTA and the federal affairs team. I worked on therapy cap legislation as well as the Medicare Home Health Flexibility Act and a variety of other projects and it just really lit a flame in me of how much I really like policy and how I'd really like to make it my career. So that's a little bit to explain how I wound up here talking to you. So for my first episode since this is such a hot button issue, I wanted to make sure to talk about the Occupational Therapy Assistant Modifier Payment Reduction and this is being implemented January 1st of 2022. So I wanted to make sure I got this episode out before the new year so that you all would be prepared. I've got articles up on my website about it but I know it's a little bit easier sometimes to kind of talk it through. So the Occupational Therapy Assistant Modifier or the OTA Payment Modifier is all referred to it is something that was created as part of the 2018 Balance Budget Act so that passed in February of 2018 and if you're familiar it is actually the legislation that permanently repealed the Medicare Therapy Cap. So it was a big win to repeal the therapy cap but then we had the big loss to follow of the OTA Payment Modifier. Now I'll go ahead and say that AOTA and APTA were completely blindsided by this piece of legislation. I can attest to that because I was part of a lot of those meetings that led up to the passage of this legislation because remember I was at AOTA in the Fallen Winter of 2017 so just before this bill passed and the staff who put the bill together did not tell us that the OTA and PTA Modifier would be in there so that was a big surprise and a big bummer. But this is the world we live in and this is what it is now basically the OTA Payment Modifier Reduction was put into that bill as a way to pay for the permanent repeal of the therapy cap. So when Congress proposes legislation a lot of time they have pay for us so ways to pay for the modifications that they're making and this was one of the ones that they decided to put in. So since 2018 AOTA and APTA have been engaging in a lot of advocacy to make sure that this modifier has as little of an impact as possible but the main reason why we're seeing this and why it's really not realistic for us to completely eliminate the OTA modifier is because this is standardizing the way that Medicare reimbursees other assistance in other areas. So a physician is paid at 100% and nurse practitioners and physician assistants are reimbursed at 85% of what a physician is. So changing this now to impact occupational therapy and physical therapy and assistant will now be reimbursed at 85% of what an occupational therapist or physical therapist would be reimbursed under Medicare. An important distinction to this information is that this only applies to Medicare Part B. So this is going to be your Medicare outpatient program. So your private practice, your hospital outpatient programs unless you're a critical access hospital if you're a critical access hospital then you're exempt from this modifier or at least from the payment reduction. But it applies to your private practice, your hospital outpatient, your skilled nursing facility, Part B. So any of your Part B patients, not your Part A, your home health Part B or even your hospital observation stays. So all of those fall under this Part B. Now you may remember in 2020 that this modifier was actually implemented but it didn't have a payment reduction attached to it. So if you notice at the beginning of 2020 that all of a sudden your documentation might have, it was probably because that time CMS required that we implement the use of the modifier but it didn't carry along yet the payment reduction. So now we are to 2022. So on January 1st of 2022 the OTA payment modifier payment reduction is now mandatory to be implemented. So it's been what, four years since that original law passed. So I will tell you what I always say which is important to get involved early because if you're not involved early by time you're finding out about it, by time it's impacting your practice it is most likely too late to really do anything about it. So let's talk about how exactly the OTA modifier will impact billing. Now I at least have a little bit of difficulty explaining the math of it all just because I struggle personally with math but I have examples written out on my articles so definitely go check out, check that out especially if you're more of a visual learner. But for Medicare Part B Medicare reimburse is only 80% of what you bill. So under Medicare Part B patients have a 20% copay and Medicare Reim v. 80%. Now this 15% payment reduction is only being applied to the 80% that Medicare is paying for. But 20% remains untouched. So if you do the math out the way it works out is that really overall it's about a 12% reduction from your total overall cost versus a 15% reduction. So still not great to losing 12% but at least it's better than losing the whole 15. So that's how Medicare has decided to calculate the 15% payment reduction. Now obviously the next question is when do I have to use the payment modifier? So the payment modifier has to be utilized when therapy services have been provided in whole or in part by an occupational therapy assistant or a physical therapy assistant. So what does the whole or in part mean? And that question is a bit more tricky. But generally it means that the OTA or the PTA has provided at least 10% of that build unit. So again that's by build unit and not by the entire treatment. So if you provided a 30 minute treatment it's not like if they provide 3 minutes of it then you have to apply the modifier to the entire treatment. treatment session. That's originally what Medicare proposed and thanks to advocacy by everyone who left comments and AOTA and APTA that is no longer the case because that would have been a bit ridiculous. Listen up, if you love the Amplify OT podcast then the Amplify OT learning platform is the perfect next step. It takes everything you enjoy here, you know, clear practical insights on billing and Medicare and turns it into a full on-demand training library made specifically for OT practitioners and students. With flexible pricing plans, office hours and an interactive learning community it's built to fit your schedule, your budget and your practice. So no matter what setting you're in, the Amplify OT learning platform helps you cut through the confusion and feel confident in your documentation, reimbursement and your role. It's super easy to join just visit learn.amplifyot.com to view more information and our pricing plans. Again that's learn.amplifyot.com we also have link in the show notes. And if you're an educator this platform is also available to you and your students as a dynamic virtual textbook. We're an affordable program with faculty support tools, a code alignment and real world examples that prepare your students for field work and clinical practice. So now is the time to join over a dozen universities who are dedicated to preparing their students for the realities of healthcare. Learn more at the link in our show notes or at Amplifyot.com/program. We can get your students started as soon as next week. So no matter where you are in your clinical career the Amplify OT learning platform is here to support you. If you're ready to level up your occupational therapy practice, Medbridge is the partner that you need. With hundreds of evidence-based courses plus resources on documentation, policy and even patient education, Medbridge supports you at every stage of your OT journey. What sets Medbridge apart for me is that it doesn't just focus on clinical skills. It also offers training on reimbursement, compliance and advocacy topics that we talk about all the time here on the show. And here's the best part. As an Amplify OT listener you get $101 off an individual Medbridge plan when you use the promo code AmplifyOT at checkout. And students you can use AmplifyOT student for up to $75 off your subscription. Suggest head to Medbridge.com or check the links in the show notes to get started. When you sign up through these links you're not just investing in your own growth, you're also supporting Amplify OT's mission to keep our resources accessible and advocacy focused. So that leads us to this next question of what exactly does per unit mean. So for the per unit we're going to be using Medicare's 15 minute rule. So not the 8 minute rule but the 15 minute rule. So back to that 30 minute example. So under 30 minutes you would have two 15 minute units. So if the occupational therapist provide, so here's an easy scenario. If the occupational therapist provided the first 15 minutes of treatment and the OTA provided the second 15 minutes of treatment you would only apply the OTA modifier to the second 15 minute code. So you would receive 100% reimbursement for the first code, build by the OT and then you would receive 88% of the second code, build by the OTA. Now here's an example where things get a little bit trickier and where the 8 minute rule actually comes into play. So if we look again at that 30 minutes of service time provided and let's say that the occupational therapist provides the first 25 minutes of therapy and the OTA provides the last five minutes of therapy. Let's say the OTA had to go start the next patient or go answer a phone call so the OTA took over. Now when you're looking at that last unit of therapy the occupational therapist meets the Medicare billing requirements for that 15 minute time service without the minutes that were provided by the occupational therapy assistant because they provided more than the 15 minute midpoint which would be 8 minutes which is also known as the 8 minute rule. So in this case that final unit can be built without the modifier because the occupational therapist met the billing requirements without those minutes provided by the OTA. Now there's another scenario in which something like this also applies but it gets a little bit confusing due to all the different numbers and so I have that example listed in my article so go and look at it there so that way you can keep the numbers in the ratios straight when you're reading it through. Now this last scenario that will go through is one that I don't think happens overly frequently but it is a scenario that's worth going through and it's one of PT and a PTA provide a treatment together or when an OTA and an OTA provide a treatment together. The time that I see this most often probably would happen is if an occupational therapist is doing an evaluation and working with a patient and they need a second set of hands and so the OTA is providing that second pair of hands. Now when the occupational therapist is the person providing the treatment and even though the OTA is present you do not have to utilize that billing modifier the OTA modifier because CMS considers those services provided by the occupational therapist. So in those scenarios where you are co-treating with an OTA and you're the OTA or with a PTA and you're the PTA you do not need to use the modifiers if you are the primary treating clinician and the OTA or PTA is just serving as a second pair of hands. Like I said there's a lot of complex math that kind of goes into these determinations of when you do and do not bill the modifier so it's really worth reviewing and going through so that at least you understand and you know that you're complying with the code and even for someone like myself who reads policy regularly because I do struggle with some of this math it is a very complex regulation and so it's really worth having something in front of you that you're able to read through. Now if you haven't heard of the 15 minute rule and you're really only familiar with the 8-minute rule under Medicare you have to really follow the more 15-minute rule. Now 8 minutes is the diminimus standard in order for you to bill a unit but you can't do with Medicare what you might do under private insurance where if you provided 16 minutes of therapy you might be able to provide two units under 8 minutes of peace and private insurance under Medicare if you provide 16 minutes of therapy that is only one unit because they follow more of the 15-minute rule so each unit is in 15-minute intervals. So like I said there are a lot of different ways in which this math breaks down and it gets fairly complicated to explain in a podcast format so I highly encourage you again to go look at the article and I'll link it in the show notes for you because it's a lot easier to read it on paper because if you're like me you have to read it about five times before you start to understand it because otherwise the codes and the numbers just get a little bit too confusing when it's all set over air. So if I had to sum up everything of what I just said the occupational therapy assistant modifier has to be implemented when the OTA provides at least 10% of that build unit and again it's a 15% reduction of the 80% that Medicare pays. Now if you're wondering what code is the OTA payment modifier the C O is for OTA and the C Q is for PTA or the physical therapy assistant. So I know that was a lot so now that that has kind of set in let's talk about what's next so what is AOTA doing and what can you do about this modifier. So earlier in the fall AOTA announced that they have introduced legislation in the House of Representatives so this is on the federal level because federal Congress dictates what Medicare does so they introduced legislation in the House of Representatives to mitigate the effects and delay the implementation of the OTA payment modifier payment reduction. Now this was a joint effort by AOTA and APTA and the bill is called the Smart Act. Now this is not the only Smart Act in Congress because there's nothing Congress loves more than a fantastic acronym but this Smart Act stands for stabilizing Medicare access to rehabilitation and therapy services. So again that's the stabilizing Medicare access to rehabilitation and therapy services. So from here on out we'll just refer to it as the Smart Act because that name is a mouthful. So the Smart Act this is actually a bigger piece of legislation that it kind of sounds like on the surface. So there's three main components to this legislation and again it's only introduced in the House we still have yet to introduce it in the Senate but I know that that's being worked on as we speak. So the three main components of this legislation is one it wants to delay the implementation of the OTA payment modifier so delay its payment reduction effects past January 1st of 2022 to allow practitioners and clinics to have more time to learn how to implement the modifier because it is a little bit confusing and to adjust all of their billing records to prevent errors. And so it wants to delay the implementation of the payment reduction. Secondly it wants to mitigate the effects of the OTA modifier by introducing a exemption for rural and underserved areas because rural and underserved areas they already have increased difficulty getting access to services and having this kind of payment reduction because as we know rural clinics already operate on a pretty fine margin of income. So having this kind of payment reduction could potentially put those business and put those clinics out of business and therefore reduce patient access. And when you're talking to Congress talking about patient access is always going to be your number one hook. So that's the second one is to mitigate the effect of the OTA modifier. And the third piece is something that it's really exciting is that it would eliminate the need for direct supervision of an OTA or a PTA under Medicare Part B. So this is a little bit different from the payment modifier, but it is related. So under Medicare Part B, this is your outpatient therapy. It is the only part of Medicare that requires direct supervision for assistance. So under all other types of Medicare, all other types of insurance, only general supervision is required, which means that a OTA or PTA just has to be available either by phone or in person. They just have to be in the building or available by phone. But under direct supervision, an occupational therapist or physical therapist has to be in the clinic to supervise that OTA or PTA. It cannot just be available by phone or available kind of wandering around the building. They have to be within sight in the clinic to provide supervision. So that's obviously extremely burdensome and has really prevented a lot of assistance from being able to work in outpatient settings because of that requirement. So if this legislation would be passed, it is not only huge, not only for the payment reduction, but also for that piece of the direct supervision. And I think that piece of the legislation is really exciting. And also, you know, talking to Congress about reducing unnecessary burdens on clinicians and on patients is also another great talking point. So all in all, the Smart Act is great. The one downside of the Smart Act and the thing that they're going to have trouble with is that it will come with a cost because anytime you are implementing something new or delaying something that would be a payment cut is going to have a cost. And like I said, the last time that we had something that was pretty expensive, we wound up with the OTA payment modest fire. So anytime we take on legislation that has an expense, we always have to be aware that there may potentially be a fallout in some other area. But since this is just a delay, hopefully the cost wouldn't be so high as if we tried to delay it really far out or if we try to eliminate it altogether. So what you can do to help this bill pass is contact your representatives and ask them to support this legislation by co-signing it. This legislation was introduced by Bobby Rush, a Democrat from Illinois and Jason Smith, a Republican from Missouri. So it is a bipartisan bill which is very exciting. But you can take action at aota.org/takeaction. So again, that's aota.org/takeaction. So that's a free resource for anyone to use. It's a letter that you are able to go in and edit. So I encourage you to edit. Tell your story. Talk about how this, how the payment reduction would impact your clinic. Talk about how it would impact your patients. Talk about the direct supervision requirement and how that would impact your patients as well as your clinic. All those sorts of things talk about your story because that's what's really compelling. You know, they're going to hear aota story. They're going to hear the policy side. But what they want to know is what you the constituent has to say about this policy issue. So I will leave that link also in the show notes along with my article which also has a link to the take action page. So I think that's all I have to tell you about the OTA payment modifier. I know it sounds really confusing but you just need to really know that it's there because most of your clinics are going to have a billing department that helps take care of it. If you are a private practice owner then you definitely need to know this in and out. And there's lots of really great resources out there to learn more about it. So let me know if you have any questions and thank you so much for tuning in to my first episode of the Amplify OTA podcast. If you made it this far I want to just take a moment to say thank you so much for listening to the Amplify OTA podcast and I hope you're feeling a little more inspired and prepared to amplify your value and the value of occupational therapy. If you found yourself at any point thinking gosh, I guess policy isn't that dull and boring and you're definitely going to love how we talk about policy and advocacy in the Amplify OTA learning platform. There's a link in the show notes where you can sign up today so you can take an immediate next step towards emerging as a competent clinician. And of course don't forget to follow the Amplify OTA podcast so that way you never miss an episode. And you know while you're there why don't you go ahead and leave us a five star review because that's the best way to help others find the podcast too. And of course thank you so much to Jessica Rikio for editing this podcast and for all of you for giving me a reason to record it. You're now officially part of the OTA amplifier community and you are now prepared to go out there and advocate for OTA because remember if we don't advocate for occupational therapy then who will?