96 and 97 Modifiers
The 97 modifier update is currently in Limited Release to a select group of Members and will be gradually rolled out over the following weeks.
Habilitative and rehabilitative service informational modifiers are used in therapy to distinguish services reported to insurance companies. You will need to decide which modifier needs to be used for your services.
- 96 Modifier: Habilitative services help a person maintain or develop skills or functions that they may be losing or did not have before the onset of the injury or illness.
- 97 Modifier: Rehabilitative services help a person restore function that was impaired or lost and is aimed at improving, adapting, or restoring functions.
Turn on the Modifier Company Setting
In order to apply to a case, the modifier setting must be turned on in the Company Fee Schedule.
- Select Company Fee Schedule from the Clinic Name drop-down.
- Under the Modifiers section, click the Active checkbox next to 96/97 Habilitative Services or Rehabilitative Services.
- Click the Save at the bottom of the page. This will make the 96/97 modifier option available for selection on patient cases. You'll need to manually select the modifier from the patient's case as outlined below.
Adding the Modifier to the Patient Case
Once turned on in the Company Fee Schedule, select the appropriate modifier.
- While on the patient’s chart, click Patient Info.
- On the Patient Info screen, add a new case or edit an existing case.
- The Apply Hab/Rehab Modifiers defaults to None. Select from the options: None, Habilitative (96), or Rehabilitative (97).
Note: If you had the Habilitative/96 Modifier setting selected before the 97 Modifier option was added, your existing patient cases will show the Habilitative radio button selected.
- Click Ok to close the Case window.
- Click Save Patient to save changes. The modifier will then be applied to the CPT codes used in SOAP notes for that case.
What are Habilitative Services and Rehabilitative services?
According to the APTA, “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 that the service is helping to learn something new.
- 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.
- 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 but would need separate cases in their chart to apply the appropriate service modifier.
- 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.
Why did the SZ Modifier change to the 96/97 Modifier?
The Affordable Care Act requires 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 the 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.
In the CPT codebook, the SZ modifier has been deleted. However, since not all insurances have made the switch, WebPT will maintain both modifiers for the time being.