January 22nd, 2019
Effective January 1, 2018, CPT modifiers 96 "habilitative services" and 97 "rehabilitative services" will be in effect. There have been questions on whether modifier 96 will be preferred over HCPCS modifier SZ, which describes the same types of habilitative (but not rehabilitative) services, but payers have not yet indicated which modifier they would like billed. As 2018 approaches, be sure to check with payers ahead of time on their preferred modifier usage to avoid potentially denied claims.
What is the difference between habilitative and rehabilitative? Simply put, rehabilitative services help patients restore functions or skills that had been lost, while habilitative services develop skills and functions that had not been previously acquired.
Speculation on the reason for the new modifiers suggests that they will help payers track the number of rehabilitative and habilitative visits, both considered essential health benefits under the ACA, for coverage purposes. This reason also suggests that many payers may prefer using modifier 96 rather than modifier SZ, but it is always necessary to check with the individual payer.