One of the primary reasons medical providers depend on certified coders is that coders know how to maximize practice revenues. That’s because certified coders understand how and when to use modifiers—and there are a lot—to indicate anything from laterality (e.g., right [RT] and left [LT]), to separate and distinct procedures. With the latter, I’m of course referring to the very tricky—and very challenging—modifier 59. Physical therapists aren’t certified coders, and yet, when it comes to modifier 59, they essentially need to be. That’s because few modifiers cause as much confusion for PTs or wreak as much havoc on their payments than this mysterious modifier. In this post, I’ll demystify modifier 59 by detailing how and when physical therapists should use it. Here’s what PTs need to know:
1. Modifier 59 is predominantly intended for surgical procedures.
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.”
If you’re thinking that definition is not only dense, but also ill-fitting for rehab therapy providers, then you’re correct on both counts. Modifier 59 is intended mainly for surgical procedures, and that’s reflected in the CPT Manual’s definition. Don’t let that mislead you, though; modifier 59 absolutely affects physical therapy billing.
2. Modifier 59 is used in conjunction with edit pairs.
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 whether you’re providing linked services or wholly separate services. This, in turn, will determine whether modifier 59 is appropriate. As Brooke Andrus explains in this blog post, “when you append modifier 59 to one of the CPT codes in an edit pair, it signals to the payer that you provided both services in the pair separately and independently of one another—meaning that you also should receive separate payment for each procedure.”
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Example of Correctly Using Modifier 59 in PT
Let’s look at one of the more common physical therapy codes billed: 97140 (manual therapy techniques like mobilization/manipulation, manual lymphatic drainage, or manual traction, on one or more regions, and each for 15 minutes). For this code, NCCI indicates that 95851, 95852, 97018, and 97750 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 actually uses this example on their site for therapists regarding appropriate use of modifier 59.
CMS states that when billing 97140 and any of its paired codes 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 period.
Thus, if the care you provide meets that standard, you can add modifier 59
to 97530 to indicate you performed that service separately and thus should receive payment for it in addition to reimbursement for 97140. However, you can never bill 96523 or 97124 with 97140, because these codes represent mutually exclusive procedures.
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3. In 2021, CMS agreed to reimburse several former NCCI edit pairs without modifier 59.
At the behest of the APTA, CMS has agreed to pay providers for the following commonly paired services without the application of modifier 59. According to the APTA, this change is, “expected to reduce use of code modifiers that were creating confusion and sparking claim denials,” which is a big win for everyone involved. Thus, providers can perform the following services—and receive reimbursement—without affixing a modifier:
- 97110 with 97164
- 97112 with 97164
- 97113 with 97164
- 97116 with 97164
- 97140 with 97164
- 97150 with 97164
- 97530 with 97116
- 97530 with 97164
- 99281-99285 with 97161-97168
- 97161-97163 with 97140
- 97127 with 97164
- 97140 with 97530
- 97530 with 97113
4. WebPT can tell you when to add modifier 59.
Too often, PTs receive denied claims or insufficient payments because of improper modifier 59 use. That’s why we developed a feature (aptly named Built-In NCCI Edits) that will check your codes against the Medicare NCCI rules as you add services to be billed for each visit. Once you’ve turned on this feature, it will notify you of any NCCI edit pairs entered for the same date of service. If your documentation justifies billing both codes, you can acknowledge this, and WebPT immediately adds modifier 59 to the appropriate code. Pretty nifty, right?
Activating Built-In NCCI Edits within WebPT
To activate this feature, 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).
- Select “Display Insurance,” located on the left side of the WebPT Dashboard.
- Click “Edit” on the individual insurance for which you want to activate the feature.
- Once the insurance editing screen opens, check “Apply CCI edits”; then, select “Save.”
If you’re not yet a WebPT Member, you can see this functionality and an array of other awesome features in our free, live online demonstration. Request one here.
5. Modifier 59 isn’t your billing free card.
You should apply modifier 59 to denote when you have provided a typically bundled service wholly separate from its counterpart. That’s it. So, you shouldn’t use modifier 59 in an effort to guarantee more payment—nor should you purposefully skimp on your documentation or intentionally document vaguely or misleadingly. Additionally, do not routinely use modifier 59 in conjunction with re-evaluation codes, because doing so could throw up a red flag to your payers.
There you have it: the five things you, as a PT, need to know about modifier 59. If you scroll through the comments on this article, though, you’ll see that there’s plenty more that PTs want to know about this mystifying modifier. So, if you have lingering questions, stop scratchin’ your noggin and start typin’! Ask your question as a comment below, and I’ll get you an answer.