July 3, 2024 | Net Health

9 min read

What Is a GP Modifier?

Within the billing process, physical therapy modifiers are important to ensure accurate billing. GP modifiers themselves are simple to use, but knowing when and why to use them can be more complex.

Integrating Electronic Health Records (EHR) with billing tools can streamline the insurance billing process, reduce errors, and ensure proper reimbursement for services provided.

A GP modifier is a billing code used in healthcare to indicate that a service or services were provided under an outpatient physical therapy plan of care. Used in conjunction with CPT® (Current Procedural Terminology) codes, the modifier “GP” shows that the therapy services were specifically provided by a physical therapist. This helps ensure accurate billing and reimbursement for physical therapy services under Medicare and other insurance company plans.

So, why are these modifiers necessary? When certain CPT® codes already represent services typically provided by licensed rehab therapists, isn’t the use of these codes within rehab therapy operation a bit redundant?

We’ll explore how GP modifiers are used, the “why” behind this particular modifiers use and what could happen if these modifiers are not appropriately applied.

How are GP Modifiers Used?

In practice, when a physical therapist bills for their services, they append physical therapy modifiers, like the GP modifier, to relevant CPT® codes on the claim form. This modifier specifically differentiates physical therapy services from other types of therapy services like occupational therapy (which uses the GO modifier) and speech-language pathology (which uses the GN modifier).

How does it work? If a physical therapist provides, say, therapeutic exercise, they might use the CPT code 97110. As therapeutic exercise would likely fall within the patient’s physical therapy plan of care, the modifier would be added to the code, so it reads “97110-GP.” It’s that simple.

Specific settings where the use of GP modifiers is useful include:

  • Private Practices. When services are provided in a private practice setting, physical therapists should use these modifiers to denote outpatient physical therapy services.
  • Hospital Outpatient Departments. When a physical therapy service is performed in the outpatient department of a hospital, GP modifiers are used to specify that these services are part of an outpatient physical therapy plan.
  • Skilled Nursing Facilities (SNFs). In a SNF, when physical therapy services are provided to patients not in a covered Part A stay (i.e. they are not receiving inpatient SNF care), use GP modifiers.
  • Home Health Agencies. Use only when outpatient services are provided by a home health agency but do not fall under a home health plan of care.
  • Comprehensive Outpatient Rehab Facilities (CORFs)
  • Community Health Centers (CHCs) and Federally Qualified Health Centers (FQHCs)

It’s important to note that while Medicare requires GP modifiers for outpatient physical therapy services, commercial plans may have different requirements. It’s essential to verify the specific guidelines of each insurance company you work with.

For Medicare billing, however, understanding and correctly applying the GP modifier within various care settings is crucial for compliance and proper reimbursement within healthcare billing guidelines. Additionally, a certified occupational therapy assistant may also be involved in providing therapy services under the supervision of an occupational therapist, ensuring comprehensive care.

What Is the Purpose of GP Modifiers in Physical Therapy?

By indicating which services are part of an outpatient therapy plan of care, GP modifiers help address several key issues related to medical billing processes. Additionally, services provided by a physical therapist assistant should also be accurately identified and billed under the correct categories, ensuring the use of the CQ modifier when a therapy assistant like a PTA provides a service.

Differentiation of Physical Therapy Services

GP modifiers differentiate physical therapy services from other types of therapy services, such as those provided by an occupational therapist (OC) or a speech-language pathologist (SLP). This ensures that each type of rehab therapy is accurately identified and billed under the correct categories.

Reimbursement Accuracy

By using GP modifiers, physical therapists can ensure their services are reimbursed correctly by Medicare and other insurance providers which also require these modifiers. It helps payers recognize that the services provided fall under the physical therapy benefit category, which may have specific coverage and payment rules. Additionally, the KX modifier is used to justify continued therapy treatment after surpassing Medicare’s therapy threshold, ensuring services are justified with appropriate documentation.

Insurance Billing Process Compliance

The GP modifier helps physical therapists comply with Medicare and other insurance billing requirements. The proper use of the modifier reduces the risk of claims denials or delays due to incorrect coding or lack of clarity about the nature of the services provided. The GA modifier indicates an Advance Beneficiary Notice of Noncoverage (ABN) is on file for services considered not medically necessary, allowing providers to bill secondary insurance or the patient directly.

Tracking and Reporting

The modifier aids in tracking and reporting the use of PT services. This is important for both providers and payers who strive to monitor therapy use, ensure medical necessity, and manage costs.

Annual Therapy Threshold Management

Although the hard therapy cap has been effectively repealed, modifiers like GP are still used to monitor therapy services, especially when approaching any soft caps or Medicare’s therapy threshold. GP modifiers help indicate that services are part of a physical therapy plan of care, which is relevant for determining whether services exceed annual limits and require additional documentation or justification.

Administrative Efficiency

Using the GP modifier streamlines the claims processing system by providing clear and consistent coding. This reduces administrative burdens for both providers and payers, leading to more efficient processing of claims and fewer disputes or audits.

What Can Happen if a GP Modifier Is Not Used?

Payers like Medicare and private insurance companies cannot simply assume that CPT codes for rehab-based services were provided by a licensed physical therapist. Many of the same codes could be used by various types of healthcare professionals, all of whom are held to different standards and are reimbursed in different ways.

So, when a physical therapist does not use this modifier for outpatient PT services, the following issues can arise. Missing or improper modifiers can lead to claim denials, reimbursement inaccuracies, and revenue generation issues.

Claim Rejections

Insurance companies, including Medicare, may deny claims because they lack the necessary information, like physical therapy modifiers, to identify the service as part of a therapeutic plan of care. This can delay reimbursement and require resubmission, which costs both time and money. In fact, fighting a single denial costs providers an estimated average of $43.84 per claim.

Incorrect Reimbursements

Without GP modifiers, the service may be incorrectly categorized, leading to incorrect reimbursement amounts. The physical therapist may receive less payment than they are entitled to for the services provided.

Increased Administrative Burden

Denied or underpaid claims often must be corrected and resubmitted, increasing administrative workload. This additional burden may lead to delays in payment and more time spent on administrative tasks rather than patient engagement and care.

Compliance Issues

Consistently failing to use the correct physical therapy modifiers can lead to compliance issues with Medicare and other insurance providers. This could result in audits, penalties, or more stringent scrutiny of future claims. Ensuring compliance with the National Correct Coding Initiative is crucial to reduce documentation errors and increase reimbursement for therapy services.

Patient Confusion

If claims are denied or incorrect payments are made, it can lead to confusion and frustration for a PT patient. They could receive unexpected bills or have to provide additional information to their insurance providers.

Financial Impact on the Practice

All of these issues can snowball into a situation that impacts the financial health of the practice. Consistent issues with claim submissions can lead to cash-flow problems, affecting the overall operation of the clinic.

When Would Use Be Inappropriate?

While physical therapists are generally required to use this particular modifier for services provided under an outpatient physical therapy plan of care, specific scenarios exist when the use of this modifier is not appropriate within the medical billing process. The Centers for Medicare & Medicaid Services (CMS) require therapy modifiers on ‘Always Therapy’ codes to ensure accurate reimbursement for rehab services.

Non-Outpatient Physical Therapy Services

If services performed by the PT or physical therapy assistant are not considered part of the therapy plan of care, their corresponding CPT® billing codes do not need to include this modifier. For instance, if a therapy provider communicates general health advice or other non-therapy-related services, their procedure codes do not need the CPT® modifier.

Inpatient Settings

When rehabilitative services are provided in an inpatient setting, such as during a hospital or a covered inpatient skilled nursing facility (SNF) stay, this therapy modifier is not required. Inpatient services are billed differently and do not require outpatient therapy modifiersm such as GO modifier, GX modifier or GP.

Services Billed under Different Plans

If a physical therapist’s services are provided under a different type of plan of care—say from an occupational therapy or speech-language pathology plan of care—GP is not the appropriate modifier to use. Instead, use GO for occupational therapy and GN for speech-language pathology.

Certain Bundled Payments

In cases where services are bundled under a single payment system, such as can be the case under some Medicare bundled payment programs, individual modifiers like GP may not be necessary. The billing requirements for specific Medicare programs can vary, so it’s essential to follow each program’s specific guidelines.

Use of Non-Medicare Payers

Some private insurance payers may have different requirements when it comes to modifiers. It’s important to check all billing guidelines and keep up with changes made by each payer to determine which modifiers, including GP modifiers, are needed to prevent billing errors. Certain codes are ‘Always Therapy’ services requiring a therapy modifier to indicate they are provided under physical medicine services.

Proper Modifier Use Is an Ongoing Learning Process

Staying informed about the correct use of GP and other modifiers is essential for ensuring smooth billing processes and accurate reimbursements in rehab therapy. Manual therapy often requires specific CPT codes and modifiers, and in some cases, patients are asked to sign an ABN if the therapist believes the manual therapy may not be medically necessary.

Properly using this modifier clarifies the nature of the services provided, reduces the risk of claim denials, and ensures compliance with payer requirements. To maintain the financial health of your practice and provide uninterrupted care to patients, it’s crucial to stay updated on these and other billing guidelines.

To make strides in this respect, consider regularly reviewing payer policies and attending relevant coding workshops or webinars. Leveraging resources from professional organizations like the American Physical Therapy Association (APTA) can also provide valuable insights and updates.

By committing to ongoing education, appropriate documentation and meticulous billing practices, therapy teams can navigate the complexities of medical billing with confidence, ensuring their services are recognized and reimbursed correctly. This proactive approach ultimately supports both the sustainability of the practice and the quality of patient care.

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