Modifiers 96 & 97

Modifiers 96 & 97 are intended to be reported with services that are identified as being either habilitative or rehabilitative in nature, such as physical medicine and rehabilitation codes, allowing the payer the ability to differentiate habilitative from rehabilitative services. This differentiation is required by the Patient Protection and Affordable Care Act (Obamacare).

Modifier 96 – Habilitative Services

When a service or procedure that may either be habilitative in nature or rehabilitative in nature is provided for habilitative purposes, the physician or other qualified healthcare professional may add modifier 96 to the service or procedure code to indicate that the service or procedure provided was habilitative. Such services help an individual learn skills and functioning for daily living that the individual has not yet developed, and then keep or improve those learned skills. Habilitative services also help an individual keep, learn, or improve skills and functioning for daily living.

Habilitative services help a person DEVELOP skills or functions they didn’t have before.

• The therapy is intended to maintain or develop skills needed to perform ADLs or IADLs which, as a result of illness (including developmental delay), injury, loss of a body part, or congenital abnormality, either:

1. have not (but normally would have) developed; or
2. are at risk of being lost; and

• There is the expectation that the therapy will assist development of normal function or maintain a normal level of function;

• An individual would either not be expected to develop the function or would be expected to permanently lose the function (not merely experience fluctuation in the function) without the habilitative service.

Modifier 97 – Rehabilitative Services

When a service or procedure that may be either habilitative or rehabilitative in nature is provided for rehabilitative purposes, the physician or other qualified healthcare professional may add modifier 97 to the service or procedure code to indicate that the service or procedure provided was rehabilitative. Rehabilitative services help an individual keep, get back, or improve skills and functioning for daily living that have been lost or impaired because the individual was sick, hurt, or disabled.

Rehabilitative services help a person RESTORE functions which have become either impaired or lost.

• The therapy is aimed at improving, adapting or restoring functions which have been impaired or permanently lost as a result of illness, injury, loss of a body part, or congenital abnormality; and

• There is an expectation that the therapy will result in a practical improvement in the level of functioning within a reasonable and predictable period of time