CQ and CO Modifiers Revisited: What's Changed with the 2022 Proposed Rule (With Examples)

The new year is just around the corner, which means it’s out with the old, and in with the new. Well, okay—we still have a ways to go before we kick off 2022, but we already know it’s brimming with changes, and (as we see it) it’s never too early to prepare for a shake-up. This is especially true for changes that are regulatory in nature—like the PTA and OTA payment modifiers, CQ and CO. Even though CMS first introduced these modifiers back in 2018 and asked rehab therapists to begin using them by 2020, the actual payment differential itself isn’t set to take effect until January 1, 2022. CMS took advantage of this delay to propose one last set of changes to the CQ and CO application rules. Come check ‘em out!

Note: The examples in this blog post are taken directly from the 2022 proposed rule—which means they are not yet finalized and are subject to change.  

CQ and CO Modifier Application Basics

Let’s start with the basics. CMS is asking PTs and OTs to apply the assistant modifiers—CQ for PTAs and CO for OTAs—on a de minimis standard. That basically means that when an assistant provides a service in whole or in part (i.e., they provide more than 10% of a service), the corresponding claim line must contain an assistant payment modifier. That payment modifier will signal to CMS that the specific line item (not the whole claim) should be paid at 88% of its full value. 

Math-Lite Calculation Method

Luckily, CMS provided a calculator-lite method to determine whether or not you need to apply the modifiers to a specific line item. Simply follow these three steps: 

1. Count up the total number of minutes a service was provided. 
2. Divide by 10 and round to the nearest whole number. 
3. Add one minute to the total. 

If the PTA or OTA provided care independently of a therapist for longer than that calculated total, apply the CQ or CO modifier. That’s it!

Math-Heavy Calculation Method

If, however, math is your bread and butter and you’re itching to pull out a calculator, you can also follow this slightly more complex (but still perfectly legitimate) method:

1. Count up the total number of minutes a PTA or OTA independently provided a service. 
2. Count up the total number of minutes the service was provided in total. 
3. Divide the number of minutes that a PTA or OTA independently furnished a service by the total number of minutes the service was furnished as a whole. 
4. Multiply that number by 100. 

If your final total is greater than 10%, then apply the CQ or CO modifier, as applicable.  

Rules to Remember

Of course, the induction of new payment modifiers wouldn’t be complete without a few extra rules to follow—so here are some big ones to remember: 

New Midpoint Rule

In the 2022 proposed rule, CMS proposed adding one final new CQ and CO application rule to address the concerns of some therapy advocates. Specifically, it states that if a PT or OT “provides enough minutes of the service on their own to bill for the last unit of a timed service, (more minutes than the midpoint or 8 minutes of a 15-minute timed code),” disregard any time furnished by the therapy assistant, and do not apply an assistant modifier. 

So, what the heck could this new midpoint rule mean for 2022? Let’s dive into some examples to find out. And as a reminder, the following examples were taken directly from the 2022 proposed rule, which means they may be subject to change upon the release of the 2022 final rule. 

{{inline-form}}

Example #1 

A PT and a PTA work together to provide therapeutic exercise (CPT code 97110) to a patient. The PT works with the patient for five minutes, and the PTA independently works with the patient for 10 minutes. In total, the patient receives 15 minutes of therapeutic exercise. 

Billing Analysis

Per the 8-minute rule, you can only bill one unit of 97110 in this scenario. Because the therapist provided fewer than eight minutes of this service, the midpoint rule does not apply—and the de minimis standard kicks in. Under the de minimis standard, the CQ modifier applies if the PTA provided more than three minutes of this service. 

Solution: Bill one unit of 97110 with the CQ modifier. 

Example #2

A PT and a PTA work together to treat a patient. The PTA independently oversees the patient’s therapeutic exercise (CPT code 97110) for five minutes before the PT takes over and leads the final six minutes of treatment. In total, the patient receives 11 minutes of therapeutic exercise. 

Billing Analysis

Per the 8-minute rule, this scenario only allows for one unit of 97110. Because the therapist provided fewer than eight minutes of therapeutic exercise, the midpoint rule does not apply. The de minimis standard then applies to this scenario, meaning the CQ modifier applies if the PTA provided more than two minutes of this service. 

Solution: Bill one unit of 97110 with the CQ modifier.  

Example #3

A PT and PTA work together to provide therapeutic exercise (CPT code 97110). The PTA independently works with the patient for 22 minutes, and the PT works with the patient for 23 minutes. In total, the patient receives 45 minutes of therapeutic exercise. 

Billing Analysis

Alright; here’s where it gets a little complicated. Under the 8-minute rule, you can bill three units of 97110.  Since the PTA independently provided 15 full minutes of treatment, one of those three units is affixed with the CQ modifier. Similarly, since the PT provided 15 full minutes of treatment, one of those three units is not affixed with the CQ modifier. 

At this point, we have one unit left to bill and we’re left with seven minutes of PTA treatment time and eight minutes of PT treatment time. This is where you’d apply the midpoint rule. Since the PT could theoretically bill this final unit using their time alone (i.e., they provided eight or more minutes of the service), the CQ modifier does not apply. 

Solution: Bill one unit of 97110 with the CQ modifier and two without. 

Example #4

A PT and a PTA work together to treat a patient. The PT first provides 12 minutes of therapeutic exercise (CPT code 97110), and afterward the PTA independently provides 14 more minutes. Then, the PT provides 20 minutes of manual therapy (CPT code 97140). In total, the patient receives 46 minutes of timed treatment. 

Billing Analysis

Per the 8-minute rule, you can bill three units here. First, you can bill one unit of 97140—and since 15 minutes of this service were provided solely by the PT, it wouldn’t require a CQ modifier. Two units of 97110 remain here—which you can split up to properly apply the CQ modifier. One unit would receive the CQ modifier, and one would not.

Specifically, this applies because CMS proposed a two-unit rule that says when “there are two remaining 15-minute units of the same service for which the PTA/OTA and the PT/OT each provided between 9 and 14 minutes with a total time of at least 23 minutes and no more than 28 minutes. In this scenario, we propose that one unit of the service would be billed with the CQ/CO modifier and the other unit of the service would be billed without the assistant modifier.”

Solution: Bill one unit of 97140 without the CQ modifier, one unit of 97110 with the CQ modifier, and one unit of 97110 without the CQ modifier. 

Example #5

An OT and an OTA work together to treat a patient. The OTA independently provides 11 minutes of self care and home management training (CPT code 97535) and the OT provides 11 minutes of therapeutic activities (CPT code 97530). In total, the patient receives 22 minutes of treatment. 

Billing Analysis

Under the 8-minute rule, this scenario allows for one billable unit. Since both services were provided for an equal number of minutes, you can choose what to bill: either 97530 without the CO modifier or 97535 with the CO modifier. 

Solution: Either bill one unit of 97530 without the CO modifier, or one unit of 97535 with the CO modifier. 

Example #6

An OT and an OTA work together to provide group therapy (CPT code 97150). The OTA first provides 20 minutes of treatment (totally independent of the OT) followed by the OT independently providing 20 more minutes of the service. In total, the patient receives 40 minutes of group therapy. 

Billing Analysis

Since group therapy in an untimed service, these 40 minutes of treatment allow for only one billable unit. Under the de minimis standard, the CO modifier applies if the OTA provided five or more minutes of the service. 

Solution: Bill one unit of 97150 with the CO modifier.

The CQ and CO modifiers may feel complex and overwhelming, but like with all new regulations, PTs and OTs will adapt and persevere—and get in the groove relatively quickly. Got any pressing questions about the assistant payment modifiers? Feel free to drop ‘em below and our team will do its best to help you out!