Today's blog post comes from Geoff Elledge, WebPT Billing Specialist. Thanks, Geoff! 

One of the primary reasons medical providers depend on certified coders is for their ability to maximize practice revenues. To do so, certified coders must understand how and when to use modifiers—and there are a lot—from the common sides of treatment, like right (RT) and left (LT), to the more challenging modifier 59. 

The CPT Manual defines modifier 59 as the following:

“Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures [and/or] services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used."

Got that? Yeah, we know. It’s a bit dense and doesn’t seem the most relatable. But that’s because modifier 59 is intended mainly for surgical procedures, so the definition leans a great deal that way.

So how does modifier 59 come into play in the therapy setting? If you’re providing two wholly separate and distinct services during the same treatment period, it might be modifier 59 time! The National Correct Coding Initiative (NCCI) has identified procedures that therapists commonly perform together and labeled these “edit pairs.” Thus, if you bill a CPT code that is linked to one of these pairs, you’ll receive payment for only one of the codes. It’s therefore your responsibility as the therapist to determine if you’re providing linked services or wholly separate services. This will determine whether modifier 59 is appropriate.

For example, let’s look at one of the more common codes billed: 97140 (manual therapy techniques like mobilization/manipulation, manual lymphatic drainage, manual traction, on one or more regions, each for 15 minutes). For this code, NCCI states 95851, 95852, 97002, 97004, 97018, 97124, 97530, 97750, and 99186 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 actuallyuses this example on their site for therapists regarding appropriate use of modifier 59.

CMS states that when billing a 97140 and 97530 (therapeutic activities; direct, one-on-one patient contact by the provider; use of dynamic activities to improve functional performance; each for 15 minutes) for the same session or date, modifier 59 is only appropriate if the therapist performs the two procedures in distinctly different 15 minute intervals. This means that you cannot report the two codes together if you performed them during the same 15 minute time interval.

Thus, if your care meets that standard, you can add a modifier 59 to 97530 to indicate it was a separate service and should be payable in addition to the 97140. The same holds true for billing 97140 with 95851, 95852, 97002, 97004, 97018, 97124, 97530, or 97750. However, you can never bill 99186 with a 97140—you cannot add any modifier to change this because these codes are mutually exclusive procedures, according to CMS.

With WebPT, you have options to identify these potential CCI denials. You can turn on a feature for individual insurances that will check your codes against the Medicare CCI rules as you add services to be billed for each visit. Once you have turned this feature on, it will notify you of any CCI edit pair entered on the same visit. If your records justify billing both codes, you can acknowledge this, which immediately adds modifier 59 to the appropriate code. If you are interested in activating this feature within WebPT, please follow the steps below. Note that you’ll need to complete these steps for each insurance plan. We recommend applying this to commercial and government plans only, i.e. no workman’s compensation, legal/lien, and auto liability policies.

1. Select Display Insurance, located on the left side of the WebPT application.
2. Click Edit on the individual insurance for which you want to activate the feature.
3. Once the insurance editing screen opens, check Apply CCI edits and select Save.

Below is a table with all of the common CCI edit pairs related to different therapy types. Look for the primary CPT you are billing in Column 1. If you are billing any of the codes in Column 2, they will be considered mutually exclusive or linked. If the code in Column 2 has a “y” next to it, you can add a modifier 59; if “n,” then you should not bill the code in combination with the code in Column 1.

Note that this is the CCI edit list from Medicare. Most government payers, like Medicare, Tricare, and Medicaid, use this same list. However, private payers often create their own edit pairs; therefore, there is no guarantee they will pay even with an applied modifier 59.