Accurate billing in physical therapy is crucial for receiving proper reimbursements, and one key tool for ensuring claims are correctly processed is CPT Modifier 59. It is also known as the distinct procedural service modifier, is used to indicate that two or more procedures are separate and should be billed independently. However, improper use can result in claim denials or audits. In this blog, we’ll clarify when and how to apply Modifier 59, with examples specific to physical therapy services, so that your clinic can avoid billing errors and maximize reimbursement.
What Is CPT Modifier 59?
CPT Modifier 59 is used to denote that a procedure or service was distinct from other services provided on the same day. In physical therapy, this modifier is particularly useful when performing and billing for multiple therapies or treatments that would otherwise be bundled together.
For example, if you’re performing both manual therapy (CPT 97140) and therapeutic exercises (CPT 97110) in the same session, Modifier 59 indicates that these procedures were separate and should not be bundled by the payer. By using Modifier 59 correctly, you ensure that each service is reimbursed properly, even if the CPT codes are typically bundled together.
When to Use CPT Modifier 59 in Physical Therapy
Knowing when to apply Modifier 59 is essential to avoid denied claims or audits. It should only be used in cases where services are:
- Distinct and separate from one another.
- Performed at different anatomic sites.
- Provided at different times during the treatment session.
Here are some common scenarios where Modifier 59 may be required in physical therapy:
1. Manual Therapy and Therapeutic Exercise
If you perform manual therapy (CPT 97140) on a patient’s neck and then provide therapeutic exercises (CPT 97110) for the lower back, Modifier 59 should be used to indicate that these are separate services, as they involve different anatomic sites.
2. Neuromuscular Re-Education and GAIT Training
When performing neuromuscular re-education (CPT 97112) and gait training (CPT 97116) in the same session, Modifier 59 can be applied to show that these are distinct procedures aimed at different therapeutic goals.
3. Splinting and Therapeutic Exercises
If you provide splinting (CPT 29125) followed by therapeutic exercises in the same visit, Modifier 59 will indicate that these are separate services.
In each case, it’s important to clearly document the distinct services in the patient’s medical record to justify the use of Modifier 59 and avoid denials from payers.
How to Properly Apply CPT Modifier 59
While Modifier 59 is useful, it is often overused or applied incorrectly, leading to denials or audits. Here are a few key steps to ensure you’re using Modifier 59 appropriately:
1. Ensure Documentation Justifies Separate Services
Proper documentation is critical. Always document why the services are distinct, whether by anatomical site or therapeutic purpose. For example, if manual therapy is performed on the upper body and therapeutic exercises target the lower body, your notes should reflect the separation of these areas.
2. Apply Modifier 59 Only When Necessary
Modifier 59 should only be used when there is no more specific modifier available. For example, if a more appropriate modifier exists (such as anatomic modifiers like RT for right side or LT for left side), it should be used instead of Modifier 59.
3. Avoid Modifier 59 for Routine Services
Do not use Modifier 59 for routine physical therapy services that are commonly performed together unless there is a clear distinction in the service provided. Improper use of Modifier 59 can lead to audits or claim rejections.
Common Errors to Avoid with CPT Modifier 59
1. Overusing Modifier 59
Over-application of Modifier 59 is a common billing mistake. It should only be used when there is a clear distinction between services. Overuse can result in payer audits or claim denials.
2. Failing to documents separate services
Insufficient documentation is another frequent issue. Always ensure that your documentation clearly shows why services were performed separately and how they were distinct in the therapy session.
3. Building Issues
Sometimes, services that would normally be bundled together can be billed separately when they are performed for different reasons or in different parts of the body. However, improper bundling without the correct use of Modifier 59 may lead to payment rejections.
Why Accurate Use of CPT Modifier 59 Matters
Properly applying Modifier 59 ensures that your physical therapy clinic receives appropriate reimbursement for distinct services provided to patients. When used correctly, Modifier 59 prevents bundling of services that should be billed separately, thereby protecting your clinic from revenue loss.
At Physical Therapy Billing, we understand how crucial it is to get billing right the first time. Our expert billing team can assist with applying the right modifiers and ensure compliance with payer regulations. By partnering with us, your clinic can maximize reimbursement while avoiding the common pitfalls associated with improper use of CPT codes and modifiers.
Conclusion
CPT Modifier 59 plays an important role in physical therapy billing by distinguishing separate procedures and ensuring proper reimbursement. By understanding when and how to apply Modifier 59, and by maintaining detailed documentation, physical therapy clinics can avoid costly denials and audits while maximizing revenue. At Physical Therapy Billing, we help clinics navigate the complexities of medical billing with expert guidance and support. Contact us today to learn more about how we can assist your practice in optimizing billing processes.