New Coding Requirement for Billing Habilitative and Rehabilitative Services in Some Private Insurance Plans
Federal regulations require individual and small group market health insurance plans to have separate visit limits for habilitative and rehabilitative services. On January 1, 2018, new modifiers (96 and 97) went into effect to allow insurance companies to distinguish between habilitation and rehabilitation when billing individual and small group plans. Some insurance companies may have been requiring use of the SZ modifier in order to make that distinction. Now there are two modifiers, which were designed to make it easier to track and enforce the separate visit limit requirement. The SZ modifier has been deleted.
Habilitative services help a person keep, learn, or improve skills and functioning for daily living. In contrast, rehabilitative services help a person keep, get back, or improve skills and functioning for daily living that have been lost or impaired because of being sick, hurt, or disabled.
Habilitative and rehabilitative services can involve the same services, provided in the same setting, to address the same functional deficits and achieve the same outcomes; the difference is whether they involve learning something new or relearning something that has been lost or impaired. Occupational therapy practitioners’ documentation should clearly convey whether the service is helping to learn or relearn a skill or function.
An occupational therapist teaching a child who had a stroke in utero the fine motor skills to groom and dress would be providing habilitative services, whereas a therapist helping a 10 year old who had a stroke re-learn how to groom and dress would be providing rehabilitative services. The same patient can receive both habilitative and rehabilitative services. Teaching baby care skills to a new mother with multiple sclerosis would be providing habilitative services; helping her recover from an injury incurred during a flare up and fall would be providing rehabilitative services.
All individual and small group plans, both on and off the Affordable Care Act’s marketplaces, must apply separate visit limits. Large employer plans, which cover most Americans, are not subject to the separate visit limit requirement. Occupational therapy practitioners should check with the insurance company for specific instructions on using the new modifiers.
For more information on coding requirements, visit http://www.aota.org/Advocacy-Policy/Federal-Reg-Affairs/Coding.aspx.