Modifier 59 in Physical Therapy Billing: A Comprehensive Guide

Modifier 59 in Physical Therapy Billing

Modifier 59 is an extremely useful modifier, but it should be used only when necessary. Incorrect use of the modifier can result in claim denial by Medicare and commercial payers.

NCCI has identified certain services that therapists commonly perform together as ‘edit pairs.’ These pair with other CPT codes to create modifier 59-eligible code sets.

Navigating Edit Pairs: Identifying Modifier 59-Eligible Services

Modifiers are tricky, and if used incorrectly, they can be a big red flag for payers. This is especially true for modifier 59, which is frequently misused by physical therapists. Misusing this modifier can lead to bundled claims and claim denials. To avoid these issues, it is important to understand the definition of modifier 59 and when it should be used.

In a nutshell, modifier 59 in physical therapy billing is a way to indicate that two procedures that would normally be billed together on the same date of service are actually separate and distinct services. This is accomplished by using the code pair edits established by NCCI. These edits identify sets of procedures that should never be billed together, and they are designed to prevent duplicate payments.

Strategic Usage: Proper Application of Modifier 59

To use this modifier correctly, a therapist must know the appropriate pairs of CPT codes and which ones are eligible to be billed separately. This is also known as recognizing edit pairs. For example, if a Level 3 established patient visit (CPT code 99213) is billed with psychological testing (CPT code 96101), the therapist must apply modifier 59 to the testing code to bill it independently from the E/M visit.

Another situation where this modifier is frequently used is for re-evaluation and treatment services. However, it is important to remember that re-evaluation is a part of the treatment process and cannot be billed separately. To ensure that you are billing for both services correctly, you must document that the re-evaluation was necessary and that it led to a change in the plan of care.

Beyond Pairing: Distinguishing Anatomical Sites and Encounters

This modifier may be used to distinguish procedures performed on different anatomical sites or during different patient encounters. However, it should be used only when no other modifier more appropriately describes the relationship between the two procedures. It should never be used to bypass NCCI or payer edits or to guarantee more payment.

Modifiers in Action: Effective Utilization of Modifier 59

Modifier 59 in physical therapy billing is a powerful tool in the physical therapy world. But, if it is misused, it can raise red flags for payers and trigger denials.

Payers look at a combination of CPT, NCCI, and proprietary edits when determining what services they will cover. This includes Medicare as well as commercial insurances. So, therapists should only use modifier 59 when the documentation supports characterizing those services as separate and distinct.

One of the most common mistakes made by PTs is using modifier 59 improperly. This is often due to confusion about how and when the modifier should be used.

A key concept to remember is that the 59 modifier is only used when two procedures are performed in the same treatment session. If the procedures are done in different sessions, they do not need a modifier. For instance, if a patient has a gait training session followed by a manual therapy session, both treatments can be billed. But, if they are done in the same session, then you must add modifier 59 to the 97140 code on the claim form.

In addition, if two codes are part of an edit pair, then the 59 modifier must be appended to only one of the procedures. The NCCI has identified procedures that therapists commonly perform together and labeled them as an edit pair. For example, 97140 Manual therapy techniques, one or more regions (each for 15 minutes) links to 97530 Therapeutic activities, direct one-on-one patient contact by the provider, each 15 minutes.

These code pairs are not meant to be billed separately. They are part of an edit pair and should only be billed if the documentation clearly supports that they were performed in distinctly separate and distinct time blocks. This is also true of re-evaluation and discharge/discharge codes, as these are part of an edit pair as well. However, some therapists routinely append a 59 to re-evaluation and discharge codes just because they know it will guarantee more payment. However, this is a big mistake that can easily trigger a payer audit. For any pt billing assitance, contact our company.

Documentation Shield: Supporting Modifier 59 Usage

Modifier 59 should be used only when your clinical decision-making indicates that the services provided are distinct and separate and must be billed independently. It should also be used when no other modifier better describes the relationship between the two codes. The list of CPT code pairs that constitute an NCCI edit is regularly updated, and you should be familiar with these prior to billing. You should also be aware of which codes can never be billed together and which ones may be billed together if the correct modifier is used. A useful resource for this is the latest fact sheet on Modifier 59.

Using the correct modifier is critical to avoiding claim denials from payers. This is especially true with the Centers for Medicare and Medicaid Services (CMS) and commercial insurance companies. Many of these payers closely monitor the use of modifiers and will trigger audits when they see a high percentage of claims being submitted with certain modifiers. Modifier 59 is one of the most commonly used modifiers in physical therapy, and it can be a red flag for CMS and commercial payers when not used properly.

The most common use of this modifier is to indicate that a diagnostic procedure was the basis for performing a linked therapeutic procedure. For example, if a patient was brought into the clinic with a new diagnosis, it would be appropriate to complete a re-evaluation to ensure that the treatment plan was appropriate. The re-evaluation would need to be performed before the therapist could begin treating the patient. The re-evaluation should be billed with a diagnostic code, and the linked treatment should be billed with a treatment code. Modifier 59 can be added to the re-evaluation code to indicate that the re-evaluation and the linked treatment were performed separately from each other.

To support the use of this modifier, you will need detailed documentation in the patient’s medical record to demonstrate that the two procedures were truly separate and distinct from each other. This includes documentation that clearly demonstrates that the 15-minute timed services were provided in distinctly different increments and that they were not overlapping. The documentation should also be clear in demonstrating that no other modifier was able to adequately describe the relationship between the two services.

Summarizing Modifier 59 in Physical Therapy Billing

If you use modifier 59 inappropriately, it can raise red flags with the US Centers for Medicare and Medicaid Services and even trigger an audit. Thankfully, there are ways to avoid misusing this modifier in a physical therapy setting.

First, you must recognize the instances when it’s appropriate. The key is knowing which codes form an NCCI ‘pair edit.’ (For more on this topic, check out our blog post on NCCI Modifier Pairs.) Once you know which pairs to look out for, you can understand when the 59 modifier is warranted.

When a pair of NCCI codes includes procedures that you can’t bill for together, the 59 modifier may be used to indicate separate and distinct services. However, there must be documentation supporting the characterization of those services as separate and distinct. This means different times, separate patient encounters, and/or different body parts. The 59 modifier is not intended to break NCCI PTP bundling edits unless it’s the only option.

In addition, if another modifier is available, it should be utilized before appending the 59 modifier to the claim. The 59 modifier should only be applied if no more descriptive modifier better explains the circumstances and documentation.

Likewise, you should never use the 59 modifier with re-evaluation codes. Instead, use a more descriptive re-evaluation modifier such as GO, GP, or CQ. This will help you distinguish re-evaluation services from the other treatment provided on the same day. For more tips for your PT clinic, click here.

Finally, if you’re using the 59 modifier to unbundle NCCI edits for a surgical procedure, it’s important to remember that this is only applicable if the surgeon knew that the initial procedure would lead to another, more extensive operation before performing the original one. For example, if the surgeon did a biopsy and found cancer, then the doctor will need to do an additional surgery to remove the tumor. In this case, a 58 modifier will be appropriate for the second surgery.

The 59 modifier is an excellent tool for separating and identifying unique physical therapy services, but only if it’s used properly. When you apply it improperly, it can cause a red flag to be raised by the US Centers for Medicare and Medicaid Services or even by a private payer. By understanding when and how to use the 59 modifier, you can ensure that your billing and documentation align with CMS guidelines.