Commercial health insurance giant Humana has announced that it's falling in line with rules from the Centers for Medicare and Medicaid Services designed to establish an 85% payment differential for therapy services delivered "in whole or in part" by a PTA or occupational therapy assistant. Consistent with CMS, Humana is requiring use of code modifiers in 2020, with no changes to payment until 2022.

The new system, which establishes a code modifier ("CQ" for PTAs and "CO" for OTAs) began on January 1 for Medicare Part B payments. The new approach was triggered by federal law that mandated the creation of a way to denote the volume of physical therapy and occupational therapy services delivered by PTAs or OTAs, and then create a payment differential for those services. In its announcement, Humana states that its policy will mirror the CMS rule, "as applicable in the Federal Register and relevant CMS guidance." Like CMS, Humana also is requiring the modifier on all applicable claims submitted for services delivered beginning January 1, 2020.

While the modifier system won't affect payment immediately, both CMS and Humana have stated that they intend to reimburse at 85% of the physician fee schedule for services delivered "in whole or part" by a PTA or OTA beginning in 2022.

Recognizing that CMS was legally bound to establish a differential system, APTA fought initial drafts of the rule that were needlessly burdensome and seemed to ignore the realities of PT and PTA practice. The final rule included several modifications either suggested or supported by APTA, and the association continues to advocate for changes to the system.

APTA will meet with Humana representatives to address the adoption of the modifiers and the payment differential and will work to limit the adoption of this policy by other payers.

APTA offers a quick guide to using the PTA modifier and provides more resources on the differential at the APTA fee schedule webpage.