Following several CMS announcements 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. As a result, many providers have received denials on claims containing 97530 and 97140—even when using modifier 59 appropriately.
Background
In March 2020, CMS added the X sub-modifiers to the existing CMS policy document. In “Example 9” from that document, CMS lists 97140 (manual therapy) and 97530 (therapeutic activities) and explicitly states 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 should only 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.
Commercial Payer Denials and Appeals
Anthem, Aetna, and Humana, however, have decided 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 a 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.”
Alternate Codes
Alternatively, you can avoid the edit entirely by delivering interventions other than therapeutic activities (97530) when performing manual therapy (97150) 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), each 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, each 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, each 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.
Advocacy Efforts
The APTA has been working with Aetna, Anthem, and Humana for well over a year now to address their claim edit policies—and to push for reversal of the policies described in this article. Progress has been slow, but Aetna has indicated that it is monitoring appeal overturn rates to determine whether the policy should be rescinded. For this reason, it is essential that providers appeal these denials when the documentation does support the use of the edit. The APTA has indicated it will continue its efforts with commercial payers that adopt this type of restrictive front-end edit. The association will also continue working with CMS to request reconsideration of the edits that force therapists to “overuse” modifier 59.
There’s no question that the current modifier 59 situation is frustrating for PTs, but the best strategy to take at this point is the following:
- Always code correctly based on the intent of each code;
- Ensure your documentation supports the unbundling of edit pairs whenever you use modifier 59;
- Appeal all modifier 59-related denials; and
- Support the advocacy efforts already being undertaken by the APTA.
