Accurate use of modifiers plays a direct role in coding and reimbursement. If you are a physical therapist or related qualified professional, you must have provided habilitative (modifier 96) and rehabilitative services (modifier 97).
The confusion between the two modifiers is a common problem that many medical billers face. This is because both modifiers can be attached to the same therapy CPT codes. However, each represents a different meaning.
Modifier 97 informs the payer that the patient is attempting to regain a previously acquired skill. Still confused? Relax and read this blog to explore more about this modifier.
Modifier 97 – Description
The 97 modifier is officially defined as:
“Rehabilitative services: Services provided to restore skills or function lost or impaired due to illness, injury, or disability.”
Modifier 97 is used to bill only for rehabilitative therapy, where the therapist’s focus is on restoring the function the patient once had but lost due to illness, injury, surgery, or another medical event. It applies to speech-language pathology, occupational therapy, and physical therapy services where the clinical objective is to restore lost function.
Rehabilitative therapy includes all therapies that assist patients in regaining a function, movement, or skill lost due to illness or injury. You can think of a patient who needs to relearn how to walk after a lower extremity fracture.
Appropriate Use Cases for Modifier 97
Although modifier 97 can be used in a variety of clinical settings, the most typical ones are listed below.
Speech & Language Pathology
Consider a 50-year-old patient who has developed neurologic impairments like communication and swallowing problems after a severe stroke.
A speech-language pathologist provides therapy to improve speech production, language skills, cognitive-communication abilities, and swallowing function. The treatment aims to restore functional communication and swallowing abilities impaired by the medical condition.
Since the service meets the applicable payer requirements for rehabilitative treatment, modifier 97 may be appended to the relevant CPT code.
Occupational Therapy
In another case, suppose a factory worker suffers a serious hand injury that affects grip strength and fine-motor control. Following medical treatment, an occupational therapist works with the patient to restore the ability to perform work-related and everyday activities.
He uses various techniques like hand-strengthening exercises, fine-motor training, functional task practice, and adaptive techniques. The objective of the therapy is functional rehabilitation rather than simply evaluating the patient’s condition. Here, the claim for services must be submitted with the modifier 97.
Rehabilitation After Total Knee Replacement
Again, imagine a patient who is recovering from a total knee replacement surgery. He needs to attend outpatient physical therapy to regain the range of motion and strength he had before surgery.
The therapist provides him with physical therapy focusing on balance and coordination exercises, strengthening activities, walking and transfer training, and activities of daily living training.
Why is modifier 97 applicable here? Because the treatment is intended to restore functional abilities affected by a physical condition.
Accurate Usage Guidelines for Modifier 97
Follow these rules to bill the 97 modifier and prevent reimbursement delays and denials.
Modifier 97 vs 96
What distinguishes modifier 97 from modifier 96 is the first thing to understand before learning to bill 97 correctly. Modifier 96 is usually applied in pediatric or developmental contexts when the goal is to help a patient learn a new function or ability.
On the other hand, 97 is used to enhance or reinstate previously acquired but diminished abilities. To avoid confusion in future billing, there is a clear distinction between the two modifiers.
Documentation
Documentation for modifier 97 is more about the prior level of function, or PLOF. It helps the payer to see what the patient was capable of doing before and what therapy is doing to help him recover.
Hence, without a clearly documented PLOF, a rehabilitative claim can look unsupported to any reviewer.
You can add the following information to support the use of the 97 modifier.
- Specify the patient’s previous level of function.
- The date and reason for functional decline.
- Function or skill being restored.
- Patient’s prior function level.
- Measurable goals.
- Impairment base level.
Payer’s Policies
Modifiers 97 and 96 are not always required for outpatient therapy claims under Medicare Part B. Since Medicare and private payer systems operate under separate standards, this is one of the areas where providers make mistakes.
This does not imply that you can completely disregard Medicare patients’ modifier requirements. You should verify requirements with your Medicare Administrative Contractor (MAC) and review the most recent guidelines from the Centers for Medicare and Medicaid Services.
GP, GN, or GO Modifier
Remember that modifier 97 cannot be reported alone and must be paired with the most appropriate outpatient therapy modifier: GP (physical therapy), GN (speech therapy), and GO (occupational therapy).
Final Thoughts
Finally, keep in mind that modifier 97 is typically used for adults to help them regain the prior functional abilities and skills they may have lost as a result of an injury or illness.
Additionally, it is crucial to understand the modifier’s proper documentation. We assure you that paying attention to these two factors is the modifier’s cheat code for avoiding payment issues.
And if modifier usage is still something that you struggle with, you can use NeuraBill’s expert medical billing and coding services. With professional assistance, you will be able to file cleaner claims on time.
