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.
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Frequently Asked Questions
How do I determine correct CPT codes for physical therapy services?
Determining the correct CPT codes for physical therapy services involves reviewing the specific treatment provided, consulting the latest CPT coding guidelines, and ensuring alignment with payer requirements to maximize reimbursement and reduce billing errors.
What are the regulations for electronic claims submission in physical therapy billing?
The regulations for electronic claims submission in physical therapy billing include compliance with HIPAA standards, ensuring secure transmission of patient data, and adherence to specific payer requirements for format and coding.
What are the benefits of outsourcing pt billing services?
The benefits of outsourcing PT billing services include increased efficiency, reduced billing errors, and improved cash flow. By leveraging specialized expertise, clinics can focus on patient care while maximizing revenue collection and ensuring timely insurance reimbursements.
Can physical therapy billing services increase revenue?
Physical therapy billing services can significantly increase revenue by optimizing billing processes, reducing errors, and enhancing collection rates. This specialized support ensures clinics maximize their insurance reimbursements, leading to improved financial outcomes.
How do physical therapy billing services handle denied claims?
Physical therapy billing services handle denied claims by promptly reviewing the reasons for denial, correcting any errors, and resubmitting claims to ensure proper reimbursement. This process minimizes revenue loss and enhances the clinic's financial health.
Can pt billing be done electronically?
Physical therapy billing can indeed be done electronically. This method streamlines the billing process, reduces errors, and enhances efficiency in managing insurance claims and collections.
How can pt billing errors be avoided?
Avoiding PT billing errors requires implementing thorough training for staff, utilizing specialized billing software, and conducting regular audits to identify discrepancies. Consistent communication with insurance providers also helps ensure accurate claim submissions and timely collections.
What are the most common pt billing errors?
The most common PT billing errors include incorrect patient information, coding mistakes, and failure to verify insurance eligibility. These errors can lead to claim denials and delayed payments, impacting a clinic's revenue cycle.
How does pt billing differ from other medical billing?
Physical therapy billing differs from other medical billing primarily in its focus on specific treatment codes and reimbursement practices tailored to rehabilitation services, emphasizing patient progress and therapy outcomes, which can lead to unique challenges in claims processing and collections.
What are the benefits of outsourcing physical therapy billing services?
The benefits of outsourcing physical therapy billing services include increased efficiency, reduced billing errors, and improved cash flow. This allows clinics to focus on patient care while experts handle insurance claims and collections, ultimately enhancing profitability.
Can physical therapy billing services reduce practice expenses?
Physical therapy billing services can indeed reduce practice expenses. By streamlining billing processes and minimizing errors, these services enhance efficiency, leading to lower operational costs and improved revenue management for physical therapy clinics.
What software is used for pt billing management?
The software used for PT billing management typically includes specialized platforms designed for healthcare providers, such as AdvancedMD, Kareo, or WebPT, which streamline billing processes, enhance claim submissions, and improve revenue cycle efficiency.
What is the process for verifying patient insurance benefits?
The process for verifying patient insurance benefits involves collecting patient information, contacting the insurance provider, and confirming coverage details, including eligibility, co-pays, and deductibles, to ensure accurate billing and maximize revenue for the clinic.
What is the turnaround time for physical therapy billing services?
The turnaround time for physical therapy billing services typically ranges from 24 to 48 hours for claim submissions, ensuring prompt processing and quicker reimbursements. This efficiency helps clinics maintain a steady cash flow and optimize revenue.
Do physical therapy billing services offer electronic claims submission?
Physical therapy billing services do offer electronic claims submission. This feature streamlines the billing process, reduces errors, and accelerates reimbursement, helping clinics improve their financial outcomes efficiently.
Are physical therapy billing services compliant with HIPAA?
Physical therapy billing services are compliant with HIPAA regulations. They ensure the protection of patient information and maintain confidentiality throughout the billing process, safeguarding sensitive data in accordance with federal standards.
How do I handle denied physical therapy claims?
Handling denied physical therapy claims involves reviewing the denial reason, gathering necessary documentation, and promptly resubmitting the claim with corrections. Additionally, maintaining clear communication with the insurance provider can help resolve issues efficiently.
What certifications do physical therapy billing services require?
The certifications required for physical therapy billing services typically include credentials such as Certified Professional Coder (CPC), Certified Billing and Coding Specialist (CBCS), and specific training in medical billing and coding relevant to physical therapy practices.
How do physical therapy billing services process claims?
Physical therapy billing services process claims by meticulously gathering patient information, verifying insurance coverage, submitting claims electronically, and following up on denials or underpayments to ensure timely and accurate reimbursement for services rendered.
Do physical therapy billing services provide detailed reports?
Physical therapy billing services provide detailed reports that offer insights into billing performance, collections, and revenue trends. These reports help clinics identify areas for improvement and optimize their financial outcomes.
What is the importance of accurate diagnosis coding in physical therapy billing?
The importance of accurate diagnosis coding in physical therapy billing lies in its role in ensuring appropriate reimbursement and minimizing claim denials. Precise coding directly impacts revenue, as it reflects the services provided and supports the necessity for treatment.
How do I bill for physical therapy services provided in a hospital setting?
Billing for physical therapy services in a hospital setting involves using the appropriate CPT codes, ensuring compliance with hospital billing regulations, and submitting claims to the correct insurance payers. Accurate documentation and adherence to payer guidelines are essential for successful reimbursement.
How do I submit a physical therapy claim to insurance?
Submitting a physical therapy claim to insurance involves gathering patient information, completing the necessary claim forms, and including detailed documentation of services rendered. Once prepared, send the claim to the appropriate insurance provider for processing.
What are the common codes used in physical therapy billing?
Common codes used in physical therapy billing include CPT codes like 97110 for therapeutic exercises, 97112 for neuromuscular re-education, and 97530 for therapeutic activities, which help accurately describe services provided and ensure proper reimbursement.
What are the consequences of pt billing mistakes?
The consequences of physical therapy billing mistakes can significantly impact a clinic's revenue and reputation. These errors may lead to delayed payments, increased claim denials, and ultimately, financial losses for the practice.
What is the process of pt billing in a medical facility?
The process of PT billing in a medical facility involves verifying patient insurance, documenting services rendered, submitting claims to insurance providers, and following up on payments. This ensures accurate reimbursement and minimizes billing errors.
What is the role of a physical therapy billing specialist?
The role of a physical therapy billing specialist involves managing the billing process, ensuring accurate coding of services, submitting insurance claims, and following up on payments to maximize revenue and minimize billing errors for physical therapy clinics.
What is the role of a pt billing specialist?
The role of a PT billing specialist involves managing the billing processes for physical therapy clinics, ensuring accurate insurance claims submissions, optimizing collections, and minimizing billing errors to enhance the clinic's revenue cycle efficiency.
What challenges arise in physical therapy billing?
The challenges that arise in physical therapy billing include complex insurance regulations, frequent claim denials, insufficient documentation, and the need for accurate coding, all of which can hinder revenue flow and increase administrative burdens for clinics.
How can practices improve their pt billing processes?
Practices can improve their PT billing processes by implementing streamlined workflows, utilizing specialized billing software, training staff on best practices, and regularly conducting audits to identify and rectify errors.
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