| Our office provides the patients with hydrotherapy (9022) and we bill 97022 with modifier GP. We mostly bill this to our Medicare and Medicare HMO patients. Our new billing department is claiming that the doctor can not bill modifier GP unless he is PT certified. Is this accurate? |
No, that is not accurate. There is no reference for that. The GP Modifier may be submitted by a podiatrist if the service provided is part of an outpatient physical therapy plan of care.
The HCPCS code set can be found here: https://www.cms.gov/medicare/coding-billing/healthcare-common-procedure-system
On line 120 of that document you can see the actual descriptor for the GP Modifier is “Services delivered under an outpatient physical therapy plan of care.” That does not say use of the Modifier requires a PT certification. It says the service has to be part of a physical therapy plan of care. That is reinforced in the CMS Manual System, Pub 100-04, Medicare Claims Processing, Transmittal 4440, which is found here: https://www.cms.gov/regulations-and-guidance/guidance/transmittals/2019downloads/r4440cp.pdf
This document from a Medicare Contractor states the GP Modifier may be used for a “Service delivered personally by a physical therapist or under an outpatient physical therapy plan of care.” https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00144500 If a provider other than a physical therapist delivers the service under an outpatient physical therapy plan of care, then the GP Modifier may be used.
Another document from a different Medicare Contractor states, “Therapy services provided by physicians, nonphysician practitioners, physical and occupational therapists, and speech language pathologists in private practice must be submitted with the appropriate modifier (HCPCS modifier GP, GN or GO) when the services are performed under a therapy plan of care.” https://www.palmettogba.com/palmetto/jmb.nsf/DIDC/8EELK67582~Specialties~Therapy
The Plan of Care must outline the physical therapy regimen that is intended to provide rehabilitative services that lead to "recovery or improvement in function and, when possible, restoration to a previous level of health and well-being." The Plan of Care must include diagnoses being addressed, long-term treatment goals, type of therapy, amount, duration, and frequency of therapy services, and the medical necessity of therapy services. This Plan of Care must be established before therapy services begin. You did not share in what capacity the hydrotherapy services are being provided. If it is part of a Plan of Care for a physical therapy regimen as defined above, then the GP Modifier may be used. Some podiatrists have inappropriately used this coding for whirlpool services that are routinely provided when the patient presents for at-risk foot care every two to three months. This is not an example of care that is part of an outpatient physical therapy plan of care. Perhaps that is what your billing department is referring to, but they just did not explain it properly.
Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC, CPMA
Certified Professional Coder
Certified Professional Medical Auditor
Lehrman Consulting, LLC