BC Advantage - 2018 Issue 9
Using Modifiers 96 and 97
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Article Overview
This article covers the use of informational modifiers associated with habilitative and rehabilitative services in the context of ACA essential health benefits. It is aimed at coders, billers, therapists, and compliance staff who need a clear high-level understanding of how payer policies may differ and why documentation should align with coverage requirements. The discussion includes general definitions, payer-policy considerations, and audit-related documentation concerns without serving as a substitute for the full policy guidance.
Why This Topic Matters
Coverage rules for habilitative and rehabilitative services can vary by payer, so understanding the general framework helps support accurate reporting, medical necessity review, and documentation compliance.
What You Will Learn
- The general distinction between habilitative and rehabilitative services
- Why payer policies should be reviewed before reporting these services
- How documentation supports compliance and audit readiness
- How ACA essential health benefits relate to these service categories
Who Should Read This
- Medical coders
- Billers
- Therapists
- Revenue cycle staff
- Compliance staff
Modifiers Discussed
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