Using Modifiers 96 and 97

by  Wyn Staheli, Director of Research
August 16th, 2018

The Affordable Care Act (ACA) requires coverage of certain essential health benefits (EHBs), two of which are rehabilitative and habilitative services and devices. Since the ACA did not define these terms or specify coverage requirements, it is left up to individual states to create benchmark plans to determine coverage requirements. As of January 1, 2018, there are two informational modifiers which should be used when reporting these two different types of services. Since physical therapy services may be either habilitative or rehabilitative, the appropriate modifier needs to be used when reporting these services.

What's the Difference?

Requirements may vary from payer to payer. Let's examine some key concepts excerpted from one payer's policy (emphasis added):

Rehabilitative

  • The therapy is aimed at improving, adapting or restoring functions which have been impaired or permanently lost as a result of illness, injury, loss of a body part, or congenital abnormality; and
  • There is an expectation that the therapy will result in a practical improvement in the level of functioning within a reasonable and predictable period of time

Habilitative

  • The therapy is intended to maintain or develop skills needed to perform ADLs or IADLs which, as a result of illness (including developmental delay), injury, loss of a body part, or congenital abnormality, either:
    1. have not (but normally would have) developed; or
    2. are at risk of being lost; and
  • There is the expectation that the therapy will assist development of normal function or maintain a normal level of function;
  • An individual would either not be expected to develop the function or would be expected to permanently lose the function (not merely experience fluctuation in the function) without the habilitative service.

- Amerigroup Guideline #CG-REHAB-04

The above policy includes more descriptive requirements than the simplified description at the beginning of this article. As you can see, it is necessary to verify payer policies to ensure coverage requirements for medical necessity are met. Don't forget to also make sure that your documentation clearly identifies the type of service as well as payer requirements to ensure compliance in the case of an audit.

References:

Using Modifiers 96 and 97. (2018, August 16). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/using-modifiers-96-and-97-33955.html

© InnoviHealth Systems Inc

Article Tags  (click on a tag to see related articles)


Publish this Article on your Website, Blog or Newsletter

This article is available for publishing on websites, blogs, and newsletters. The article must be published in its entirety - all links must be active. If you would like to publish this article, please contact us and let us know where you will be publishing it. The easiest way to get the text of the article is to highlight and copy. Or use your browser's "View Source" option to capture the HTML formatted code.

If you would like a specific article written on a medical coding and billing topic, please Contact Us.


contact

innoviHealth Systems, Inc.
62 East 300 North
Spanish Fork, UT 84660
Phone: 801-770-4203 (9-5 Mountain)
Email:
free demo
request yours today
pricing
for any budget
sign IN
welcome back!

Thank you for choosing Find-A-Code, please Sign In to remove ads.