Providers with Aetna Commercial and Medicare Advantage contracts should be aware of an upcoming payment policy change impacting outpatient therapy services. In the September 2023 issue of
Aetna’s OfficeLink Updates is a 90-day notice of upcoming payment reductions for certain outpatient physical and occupational therapy (PT/OT) services furnished by therapy assistants. Specifically, the policy states:
Effective December 1, 2023, we will pay eligible services billed by occupational therapy assistants (OTAs) and physical therapist assistant (PTAs) at 85% of allowed.
- CO: Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant
- CQ: Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant
Impacted’ providers are encouraged to review this policy change and contact their Aetna representative if there are any questions.
Background
Section 53107 of the Bipartisan Budget Act (BBA of 2018) added a new section 1834(v) of the Social Security Act which requires CMS, through the use of new modifiers, to make a reduced payment for OT and PT services furnished in whole or in part by OT assistants (OTAs) and PT assistants (PTAs) at 85 percent of the otherwise applicable Part B payment for the service effective January 1, 2022. CMS implemented these amendments through the annual physician fee schedule (PFS) rulemaking process.
Other commercial and Medicare advantage payers often adopt certain portions of Medicare Part B payment policies for similar covered services.
More detailed information about the Medicare outpatient therapy assistant payment reduction policy, including coding and billing examples on the use of the CO and CQ modifiers, that Aetna will use to apply the payment reduction effective December 1, 2023, can be found on
CMS’ website.