Provider Alert! Therapy Modifiers

Therapy modifiers

A modifier must be used to indicate when treatment services have been rendered by a licensed therapist/ physician or a therapy assistant under supervision of a licensed therapist.

The following modifiers are not required for evaluation or re-evaluation codes because those services may not be rendered by therapy assistants.

• UB – Services delivered by a licensed therapy assistant under supervision of a licensed therapist.
• U5 – Services delivered by a licensed therapist or physician.

Claims for co-treatment services must be submitted with modifier U3:

• U3 – Therapy Co-Treatment Modifier

Use of approved modifiers

HCPCS modifiers established for dates of service on or after January 1, 2015 will be processed by Texas Children’s Health Plan in the following manner:

• XE – Separate encounter – Texas Children’s Health Plan will process payment for this modifier upon original submission
• XP – Separate practitioner – Texas Children’s Health Plan will process payment for this modifier upon original submission
• XS – Separate structure – Texas Children’s Health Plan will process payment for this modifier upon original submission
• XU – Unusual non-overlapping service – Texas Children’s Health Plan will deny this modifier upon original submission and request medical records to support the use of the modifier

All claims are subject to retrospective review by Texas Children’s Health Plan Compliance Department and payment may be amended after this retrospective medical records review if the requested medical records do not support the use of the modifier.

These above modifiers do not replace the approved modifier 59 for separate and distinct service. However, claims submitted with modifier 59 should be filed as a paper claim with supporting medical records attached. Claims will deny unless medical records are attached. Modifier 59 usage should be limited to only those situations where one of the modifiers above does not apply. Providers should always use the most descriptive modifier available.

For more information on Texas Children’s Health Plan processing of these modifiers, please contact Provider Relations at 832-828-1008 or 1-800-731-8527.