It may sound a little weird, but I kind of feel bad for the dinosaurs. They were just sitting around—hunting, fighting, escaping Jurassic-themed parks, and generally minding their own business—when an enormous asteroid careened out of the sky, slammed into the Earth, and ended everything they knew in one big blaze of fire. It’s a little tragic, right? They were regular ol’ creatures expecting to live another regular ol’ day, but they were smacked in the face with some meteoric consequences. 

It was another regular ol’ day when CMS first toyed with the idea of implementing PTA and OTA payment cuts—and now that those cuts are final, some therapists are feeling like they’re in the same position as the dinosaurs: facing an unstoppable meteoric force of budgetary consequences that will trigger an industry-wide extinction event. 

Fortunately, the PTA and OTA cuts are looking like they might be fairly manageable—and they almost certainly won’t make rehab therapy go extinct. In fact, making up for the revenue lost to these cuts might be as easy as strategically organizing and packing your clinic’s schedule. In any case, there’s no reason to panic. Even though rehab therapists must start using the PTA/OTA modifiers in 2020, the associated reimbursement reduction won’t take effect until 2022. So, you still have the better part of two years to figure out how to minimize the impact of these cuts—which is good news, since some commercial payers have decided to follow CMS’s lead and require the PTA and OTA modifiers themselves. Here’s how to get started. 

Understand how the modifiers work. 

Before you can even think about trying to negate the effects of the PTA and OTA payment cuts, you have to understand when they apply—because they don’t necessarily take effect every single time an assistant contributes to a patient’s outpatient treatment. So, let’s cover the facts included in the 2020 final rule:

  • The new outpatient payment modifiers are CQ for PTAs and CO for OTAs and COTAs. 
  • Starting in 2020, whenever an assistant provides an outpatient service “in whole or in part” to a Medicare patient, therapists must include the correct assistant payment modifier on each applicable claim service line. 
  • An assistant has provided a service “in part” when he or she has, separately and individually of a therapist, provided more than 10% of a service. 
  • Starting in 2022, CMS will pay 15% less for services tagged with CQ or CO. 

If you’d like to walk through some real-life examples of when to apply these modifiers, check out this post

One of the biggest takeaways here is that an assistant can treat alongside a therapist without negatively affecting payments—so, you don’t have to worry about rescheduling the PTAs and OTAs who assist with complex treatments. 

Divide work by scope of practice.

It is absolutely critical that you divvy up the work in your clinic by scope of practice. What I mean by that is PTs and OTs should provide services that specifically require their skill set (e.g., evaluations or joint mobilizations) while PTAs and OTAs provide the rest (e.g., therapeutic exercise or functional training). This, in theory, should free up your therapists to take on more patients—thus improving the clinic’s overall productivity and increasing your bottom line. 

This advice comes straight from Heidi Jannenga, who personally took this approach in her own clinics: “Logistically speaking, we should be leveraging assistants to improve efficiency and increase patient volume,” Jannenga said. “Rehab therapists must get out of the mindset that PTs and OTs need to stay with their patients throughout the entirety of the appointment, because that frankly is not always the case.”

Over at 6 Hands Physical Therapy and Wellness, Business and Compliance Operations Manager Melissa Swinehart takes the same approach to improving clinic efficiency. “Techs prep rooms and equipment/supplies,” said Swinehart. “PTAs perform treatments, while PTs perform evals and some treatments.”  

Technicians and Aides 

The idea of divvying up work by scope of practice doesn’t only apply to therapists and therapist assistants; if your assistants are overwhelmed by work that could be completed by someone who doesn’t require provider credentials—like a technician or aide—then it’s probably time to shift those responsibilities down the line. Offloading tasks like hot and cold pack preparation, equipment sanitation, or patient intake can free up your PTAs to help provide even more services. 

Give assistants autonomy—and keep them busy. 

You’d never want to see a therapist wandering around the clinic half the day, trying to figure out what to do, right? It may be nice to have someone around who can jump in to help with treatments when necessary, but it’s much more efficient—and cost-effective—to assign individual tasks and responsibilities to individual people. Essentially, what I’m saying is that therapists have fixed schedules that clearly outline what they need to do that day—so, why should that be any different for PTAs and OTAs?

Jannenga made separate schedules for the assistants in her practice: “The assistants never hung around, waiting to pick up a therapist’s slack; they followed their own patient treatment schedule and worked with purpose each day,” she said. 

Unchain your assistants from your side give them some autonomy. They are perfectly capable of interacting with patients one-on-one; they don’t need to be glued to a therapist’s hip at all times. This will, again, boost the clinic’s overall productivity and ability to take on more patients—especially non-Medicare patients. 

And there’s no need to be nervous about patients feeling unhappy with this change—as long as you get their buy-in on the ground floor. In Jannenga’s clinic, she made sure patients were introduced to the entire team during their first appointment, thereby establishing that care would come from a dedicated group of people. “Our patients were very satisfied with their care, they achieved stellar outcomes, we could leverage therapists more efficiently, and we were able to use our assistants to their greatest potential,” she said.

Don’t overburden your staff. 

Now, I realize that a good chunk of this advice suggests increasing your clinic’s efficiency and overall productivity levels. I want to make it perfectly clear that mitigating these cuts doesn’t boil down to telling therapists and assistants to work more—or drastically increasing their productivity requirements. When people overburden themselves and work too much—regardless of their field—the quality of their work plummets, and they’re sent careening toward burnout. That is never the answer. 

Instead, I’m suggesting that you delegate effectively and reshuffle job duties in a way that allows staff to do more without any significant increase to their workload. 

Split codes on your claims. 

This last suggestion has less to do with strategic scheduling, and more to do with strategic billing. In the 2020 final rule, CMS specified that therapists could split up units of a billable service onto two different claim lines, and affix the assistant modifier only to the units it applies to. So, for example, if an OT provided 15 minutes of 97110 (therapeutic exercise), and then a COTA separately provided another 15 minutes of 97110, you could give each unit its own claim line. One unit would require the CO modifier—and would receive the 15% payment reduction—and one would not. 


These payment reductions are definitely not ideal for any rehab therapy clinic’s bottom line—but they’re probably not the death knell that you think they are. This is not rehab therapy’s extinction event, and you shouldn’t have to lay off your assistants in droves to stay afloat. I have full confidence that PTAs and OTAs will still be kicking in the next trillion years—or something like that.