Physical therapists often grapple with the complexity of their billing process, especially when it comes to the usage of the 59 modifier. This essential tool in the billing toolkit has left many therapists perplexed, leading to improper usage and subsequent claim denials. This comprehensive guide aims to demystify the modifier 59, explaining its proper application in physical therapy and providing practical examples for better understanding.
What is the 59 Modifier?
The 59 modifier is primarily designed for surgical procedures but holds significant relevance in the realm of physical therapy. Essentially, it identifies procedures or services that are not usually reported together but are appropriate under certain circumstances. CMS refers to this as a "separate" or "distinct procedural service."
However, the modifier 59 should only be used when there isn't a more descriptive modifier available. If another established modifier better explains the circumstances, it should be used instead of the 59 modifier.
When to use the 59 Modifier in Physical Therapy
In the context of physical therapy, the 59 modifier comes into play when two completely separate and distinct services are provided in the same treatment period. The National Correct Coding Initiative (NCCI) has identified certain procedures that therapists commonly perform together, dubbed "edit pairs."
If a therapist bills a Current Procedural Terminology (CPT) code linked to one of these pairs, they are generally reimbursed for only one of the codes. In such scenarios, the modifier 59 can be employed to indicate that both services were provided independently, warranting separate payment.
NCCI Edit Pairs
NCCI edit pairs, also known as National Correct Coding Initiative edit pairs, are a set of coding rules developed by the Centers for Medicare and Medicaid Services (CMS). The intent of NCCI edit pairs is to prevent improper payments and ensure accurate coding and billing practices.
In physical therapy the most common NCCI edit pair involves CPT code 97140. For this code, NCCI indicates that 97530, 95851, 95852, 97018, and 97750 are all linked services when billed in combination with 97140. So, if you bill any of these codes with 97140, you’ll receive payment for only 97140. Medicare actually uses this example on their site for therapists regarding appropriate use of modifier 59.
Examples of Using the 59 Modifier in Physical Therapy
Consider a therapist providing 15 minutes of manual therapy (CPT code 97140) and 15 minutes of therapeutic activities (CPT code 97530) on the same date of service. By appending the modifier 59 to code 97530, the therapist indicates that both services were provided separately, thus qualifying for separate reimbursement for each procedure.
CPT Code | Modifiers | Units |
97140 Manual Therapy | GP | 1 |
97530 Therapeutic Activities | GP, 59 | 1 |
Another instance could be when a patient requires a re-evaluation during the same visit due to lack of progress. The 59 modifier can be used to bill for both the re-evaluation and the therapeutic exercise.
Precautions When Using the 59 Modifier
Despite its utility, the 59 modifier should not be used indiscriminately. It is not a tool to guarantee increased payment and should not be appended without sufficient proof of necessity. Using the 59 modifier without adequate justification can lead to audits and penalties. Moreover, routine use of the 59 modifier with re-evaluation codes can raise red flags with payers.
Dealing with Commercial Payer Denials and Appeals
Commercial payers, following the lead of CMS, have adopted front-end claim edit policies for claims containing modifiers 59. These policies have led to a slew of denials, especially for 97530 and 97140. When faced with such denials, therapists should appeal the decision and provide evidence supporting the correct usage of the 59 modifier.
Alternatives CPT Codes 97530 and 97140
To avoid NCCI edit pairs altogether, therapists can provide interventions other than therapeutic activities (97530) when performing manual therapy (97140) during the same patient visit. These interventions could include therapeutic exercise (97110) and/or neuromuscular reeducation (97112). However, therapists must ensure that the intervention delivered aligns with the intent reflected in each code definition.
PatientStudio can automatically add modifier 59
PatientStudio EMR can help physical therapists ensure proper usage of the 59 modifier by automatically checking NCCI edits against the assigned charges. This feature can prevent denials and potential penalties, as well as save time by eliminating the need for manual checks.
Conclusion
The 59 modifier, although complex, is a crucial component of physical therapy billing. By understanding its intent and proper usage, therapists can maximize their revenue while maintaining compliance with billing regulations. Remember, the key is to make judicious use of the 59 modifier, ensuring that it reflects the actual services provided and that your documentation supports its usage.
Finally, keep abreast of policy changes from CMS and commercial payers. Stay informed, stay compliant, and ensure that you receive the payment you deserve for the services you provide.