Using Modifiers 96 and 97

by  Wyn Staheli, Director of Content - innoviHealth
Aug 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?

• Habilitative (modifier 96): services that help a person DEVELOP skills or functions they didn't have before.
• Rehabilitative (modifier 97) services that help a person RESTORE functions which have become either impaired or lost.

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

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.