Following several announcements from CMS that providers were overusing modifiers 25 and 59 as a means to bypass edit pairs without supplying proper documentation to support those bypasses, multiple commercial payers—including Anthem, Aetna, and Humana—adopted front-end claim edit policies for claims containing these modifiers. And while Aetna and Humana have resolved the issues surrounding modifier 59 denials for 97530 and 97140, Anthem hasn’t yet updated its policies. So, where are providers going wrong in their coding with Anthem patients, and how can you avoid modifier 59 denials for 97530 and 97140 in your own practice? Here’s what you need to know.
What’s the background on modifier 59 denials for 97530 and 97140?
In March 2020, CMS added the X sub-modifiers to a now-rescinded CMS policy document. In that document, CMS listed 97140 (manual therapy) and 97530 (therapeutic activities) and explicitly stated that:
“Modifier 59 may be reported if the two procedures are performed in distinctly different 15-minute time blocks. For example, one service may be performed during the initial 15 minutes of therapy and the other service performed during the second 15 minutes of therapy.
Alternatively, the therapy time blocks may be split. For example, manual therapy might be performed for 10 minutes, followed by 15 minutes of therapeutic activities, followed by another 5 minutes of manual therapy. CPT code 97530 should not be reported and modifier 59 should not be used if the two procedures are performed during the same time block.”
In other words, modifier 59 was only to be applied “when two timed procedures are performed in different blocks of time on the same day.” No X sub-modifier is indicated as the 59 modifier is appropriate.
However, CMS has since updated its modifier 59 and X-modifier policies to allow modifiers 59, XE, XS, XP, or XU to be used with Column 1 or Column 2 codes—although modifier 59 should not be used with evaluation/management (E/M) services, and shouldn’t be used when there is a more descriptive modifier available. CMS also clarifies that providers shouldn’t use modifiers 59, XE, XS, XP, or XU, and other NCCI PTP-associated modifiers should not be used to bypass a National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) edit “unless the proper criteria for use of the modifiers are met,” also noting that “medical documentation must support the use of the modifier.”
How should I handle commercial payer denials and appeals?
As a result of CMS’s policy reversal, Aetna and Humana changed course on similar policies they had implemented around coding edits and modifier 59 denials for 97530 and 97140. However, Anthem continues to deny providers' use of the second column code (97530) as mutually exclusive, thus forcing providers to appeal the coverage decision and show their documentation.
If you receive this type of denial, then your billing team should absolutely appeal the decision. You’ll need to demonstrate that you are using modifier 59 appropriately and thus, deserve to receive payment for both services. This means your documentation must include:
- Interventions that apply to each CPT code, grouped appropriately (i.e., all manual therapy inventions should be separate from any therapeutic activities).
- The one-on-one time in minutes for both manual therapy and therapeutic activities, as well as the total one-on-one treatment time in minutes.
- The body part involved in each intervention, as in many cases, your name for an exercise (e.g., dead bug or pendulum swings) is not helpful to a reviewer (because different practices may use different names for the same exercise).
- This statement (or a similar version of this statement): “The manual therapy interventions were performed at a separate and distinct time from the therapeutic activities interventions.”
What alternate CPT codes can I use?
Alternatively, you can avoid the edit entirely by delivering interventions other than therapeutic activities (97530) when performing manual therapy (97140) during the same patient visit. These interventions might include therapeutic exercise (97110) and/or neuromuscular reeducation (97112). However, you cannot simply perform a therapeutic activity and bill it as a therapeutic exercise. That would be fraudulent, and reviewers are specifically looking for this maneuver. Instead, you must bill for the intervention intent reflected in each code definition. Let’s examine that intent further.
97530: Therapeutic Activities
Definition: Direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), every 15 minutes.
Key words here are “dynamic activities” and “functional performance.” Think of “dynamic” as “big” body movements or multi-segment movements. Think of “functional” as meaning “real-life” movements—like lifting, carrying, squatting, bending, jumping, and lunging.
97112: Neuromuscular Re-education
Definition: Neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture and proprioception for sitting and standing activities. Therapeutic procedure, one or more areas, every 15 minutes.
This code emphasizes specific feedback to the patient about the quality and/or specificity of instruction in movement, mechanics, posture, and balance, as well as facilitation/inhibition techniques and training in proprioception and desensitization.
97110: Therapeutic Exercises
Definition: Therapeutic exercises to develop strength, endurance, range of motion, and flexibility. Therapeutic procedure, one or more areas, every 15 minutes.
Granted, this is a vague definition, which makes it tempting to use this code for all movement interventions. And that’s exactly why it tends to be overused. Instead, only code for therapeutic exercise if the movement doesn’t meet the criteria for either therapeutic activity or neuromuscular reeducation. Active and passive range of motion, manual stretching, and most manual resistance exercises would correctly fall under this code.
Are there any policy changes coming from Anthem?
The advocacy efforts of the APTA were crucial in getting CMS to change the policies restricting certain code pairings that, when adopted by private payers, created a glut of modifier 59 denials for 97530 and 97140. And just as they did when they initially adopted CMS’s more burdensome NCCI edit changes, Humana and Aetna soon followed suit and reversed their claim edit policies as well. However, Anthem remains a holdout—which means that it is essential that providers appeal denials from that payer when the documentation does support the use of the edit—and continue to support any efforts from the APTA to push Anthem to change their policy as well.
There’s no question that the current modifier 59 situation is frustrating for PTs, but the best strategy to take at this point is this:
- Always code correctly based on the intent of each code, and
- Ensure that your documentation supports the unbundling of edit pairs whenever you use modifier 59.