Q/A: Should I be Using Modifier 96 on PT Claims?

by  Wyn Staheli, Director of Content - innoviHealth
Apr 30th, 2018 - Reviewed/Updated Jan 30th

Question

As chiropractors we feel the new modifier 97 is more appropriate than 96 for our PT codes such as stim and traction. Yet Carefirst is asking for 96 only. Should we use this code on all the PT codes and for all the other insurance companies?

Answer

We also agree that modifier 97 would be the correct modifier for most physical therapy services provided in a chiropractic setting. Do not begin using modifier 96 for any payer UNLESS it truly is to help a person DEVELOP skills or functions they didn't have before. If not, then the documentation would not meet the requirements of that modifier and we have concerns about future claim reviews with the possibility of fraud allegations.

Before you bill CareFirst with modifier 96, get an official statement from them that they want you to use modifier 96 for both habilitative and rehabilitative services. 

After reviewing CareFirst policies, it would appear that using modifier 96 would be inappropriate in your setting.

CareFirst policy 8.01.011 Habilitative Services was updated last year with the following definition: "Habilitative services means services and devices, including occupational therapy, physical therapy, and speech therapy, that help a child keep, learn, or improve skills and functioning for daily living." Interestingly, policy 8.01.001 Physical Therapy does not include this change or mention using modifier 97 with rehabilitative services, just modifier 96 for habilitative services.

CLICK HERE to read a more comprehensive article on these two modifiers.