Rehab therapy billing: It’s a total numbers game. Between CPT codes and billing modifiers, knowing which digits belong on a claim is no simple task. After all, rules seem to change with the seasons, and they often vary from payer to payer. Here on the WebPT Blog, we receive a lot of comments and queries in response to these ever-changing rules, and one of the hottest points of confusion these days is the difference between modifier 59 and modifier 25. When applied to CPT codes, both modifiers indicate that two services—billed on the same date of service but not typically billed together—were separate and distinct from one another. But, while these modifiers may be similar, they are not the same—and it’s crucial to know when and how to use each. To that end, here’s the 411 on 59 and 25:

The 2018 Rehab Therapy Salary Guide - Regular BannerThe 2018 Rehab Therapy Salary Guide - Small Banner

What is Modifier 59?

According to the CPT manual, modifier 59 indicates a “distinct procedural service.” Specifically, a provider can use the 59 modifier to indicate that he or she performed a service that was distinct and independent from all other services performed during the same session. Even more specifically, a provider would use this modifier to justify billing a pair of codes that ordinarily would not be billed together. As we explain here, these “edit pairs” (as they’re called by the National Correct Coding Initiative [NCCI]) are sets of procedures that therapists commonly perform together. (You can get the full list of edit pairs, as well as guidance on which ones are modifier 59-eligible, here.)

If your claim contains codes that form an edit pair—and you don’t include the appropriate modifier—the payer will only reimburse you for one of the procedures, “because the payer will assume that one of the services was essentially ‘built into’ the other.”

When Should You Use Modifier 59?

If you’re a rehab therapist, you should use modifier 59 when:

  1. You bill for two services that form an NCCI edit pair, and you provided those services independently from one another.
  2. The insurance payer recognizes NCCI edits.
  3. Your documentation supports that you performed those services separately and distinctly of one another.

If you’re still unsure of whether you should use the 59 modifier, check out this blog post.

Download your modifier 59 decision chart.

Enter your email address below, and we’ll send you a super-simple flow chart to help you decide whether it’s appropriate to use modifier 59 in any given billing situation.

Please enable JavaScript to submit form.

What is Modifier 25?

As this article from HCPro states, the CPT-4 Manual defines a modifier 25-eligible service as a "significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service." Use of this modifier implies that on the day a service was performed, the patient’s condition required a separate and independent E/M service above and beyond the other procedure.

When Should You Use Modifier 25?

Simply put, providers should only ever use modifier 25 in conjunction with an E/M code—specifically, those within the range of 99201-99499. Because it’s highly unusual for rehab therapists to submit E/M codes, they generally should not use modifier 25. But, should you ever need to use modifier 25, you must ensure your documentation supports it completely.


So, there you have it: your quick guide to modifiers 59 and 25. Still have burning questions about either one of these modifiers? Drop them in the comment section below!

  • Should PTs, OTs, and SLPs use the New X Modifiers? Image

    articleNov 7, 2018 | 4 min. read

    Should PTs, OTs, and SLPs use the New X Modifiers?

    When it comes to Medicare, a lot can change in four years—whether it be the rise and fall of functional limitation reporting or answers to questions like, “Do outpatient rehab therapists have to report MIPS?” (You can get that answer here , by the way.) So, when CMS introduced the X modifiers back in 2015 and told PTs, OTs, and SLPs they wouldn't have to use them, anyone familiar with Medicare rules knew that advice was subject …

  • Common Questions from Our Medicare Open Forum Webinar Image

    articleOct 25, 2018 | 43 min. read

    Common Questions from Our Medicare Open Forum Webinar

    Earlier this week, WebPT President Dr. Heidi Jannenga, PT, DPT, ATC, teamed up with Rick Gawenda, PT—President and CEO of Gawenda Seminars & Consulting—to host a Medicare Open Forum . As expected, we received more questions than our Medicare experts could answer during the live session, so we've provided the answers to the most frequently asked ones below. Don't see the answer you're looking for? Post your question in the comment section at the end of this …

  • FAQ: Physical Therapy Billing Live Q&A Image

    articleAug 30, 2019 | 51 min. read

    FAQ: Physical Therapy Billing Live Q&A

    Earlier this week, Heidi Jannenga, PT, DPT, ATC—WebPT’s Co-Founder and Chief Clinical Officer—and John Wallace, WebPT’s Chief Business Development Officer of Revenue Cycle Management, paired up to answer rehab therapists’ most burning billing questions during a live Q&A-style webinar . And, boy, did we get a lot of great ones. So many, in fact, that we couldn’t possibly get to them all live, so we created this massive post-webinar post (our biggest yet) with the most commonly …

  • Double Duty: How to Bill for PT and OT on the Same Day Image

    articleNov 12, 2018 | 6 min. read

    Double Duty: How to Bill for PT and OT on the Same Day

    In many cases, physical therapy and occupational therapy go together like peanut butter and jelly. PTs and OTs often share similar goals and interventions, treat the same types of patients in the same settings, and get confused by the billing rules that apply to our respective specialties. This confusion leads to quite a few questions, including this head-scratcher: how does one bill for OT and PT provided to a single patient on the same day? While the …

  • How to Bill Medicare Patients for Non-Covered Services Image

    articleDec 28, 2018 | 5 min. read

    How to Bill Medicare Patients for Non-Covered Services

    If you’re a rehab therapist who works with Medicare beneficiaries, chances are you’ll find yourself performing a service that isn’t covered by their insurance. When that happens, you could find yourself in a billing predicament—if you don’t take the proper steps, that is. What are those proper steps? Read on to find out. Which services does Medicare not cover? To start, it’s important to identify which services Medicare won’t cover. Typically, Medicare denies coverage for one of …

  • Denial Management FAQ Image

    articleMay 26, 2017 | 22 min. read

    Denial Management FAQ

    During our denial management webinar , we discussed the difference between rejections and denials, explained how to handle both, and provided a five-step plan for stopping them in their tracks. The webinar concluded with an exhaustive Q&A, and we’ve amassed the most common questions here. Insurance Issues Claim Quandaries Compliance Qualms Documentation Dilemmas Front-Office Frustrations Insurance Issues We’ve had issues with auto insurances denying 97112 (neuromuscular re-education) for non-neuro diagnoses, even in cases when the patient’s medical …

  • The Complete PT Billing FAQ Image

    articleMay 24, 2016 | 25 min. read

    The Complete PT Billing FAQ

    Over the years, WebPT has a hosted a slew of billing webinars and published dozens of billing-related blog posts. And in that time, we’ve received our fair share of tricky questions. Now, in an effort to satisfy your curiosity, we’ve compiled all of our most common brain-busters into one epic FAQ. Don’t see your question? Ask it in the comments below. (And be sure to check out this separate PT billing FAQ we recently put together.) Questions …

  • FAQ: Unwrapping MIPS and the Final Rule: How to Prepare for 2019 Image

    articleDec 14, 2018 | 38 min. read

    FAQ: Unwrapping MIPS and the Final Rule: How to Prepare for 2019

    Earlier this week, Heidi Jannenga, PT, DPT, ATC, WebPT President and Co-Founder, and Dianne Jewell, PT, DPT, PhD, FAPTA, WebPT Director of Clinical Practice, Outcomes, and Education, hosted an hour-long webinar that unwrapped the many layers of MIPS and the 2019 physician fee schedule. Unsurprisingly, tearing through the layers of CMS’s latest gift revealed a crush of questions—many of which our experts didn’t have time to fully address. So, we compiled the most frequently asked ones for …

  • ICD-10 Open Forum Image

    webinarOct 5, 2015

    ICD-10 Open Forum

    On October 1, the US officially said RIP to ICD-9 and brought ICD-10 to life. For some of you, the transition might’ve been all sugar and spice—a real treat. But for many others, the switch to the new code set might’ve left you feeling overwhelmed, tricked, or even a bit scared. At the very least, you might be haunted by some lingering questions. That’s where we can help. We’ve brewed a cauldron filled to the brim with …

Achieve greatness in practice with the ultimate EMR for PTs, OTs, and SLPs.