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:

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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.”

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, 97164, 97168, 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 actually uses this example on their site for therapists regarding appropriate use of modifier 59.

CMS states that when billing 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 period.

Thus, if your care 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. The same holds true for billing 97140 with 95851, 95852, 97164, 97168, 97018, 97530, or 97750. However, you can never bill 99186 or 97124 with 97140, because these codes represent mutually exclusive procedures.

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3. There’s an edit pair chart.

Below is a table with all of the common CCI edit pairs related to different therapy types (current as of March 2016), courtesy of PT compliance expert Rick Gawenda, owner of Gawenda Seminars & Consulting. Here’s how to use the chart:

  1. Look for the primary CPT code you are billing in Column 1.
  2. Check Column 2. If you are billing any of the codes listed, they will be considered mutually exclusive or linked.
    1. If the code in Column 2 has a “y” next to it, you can add modifier 59.
    2. If there’s an “n” in Column 2, then you cannot apply modifier 59, and 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 for both codes in an edit pair, even with an applied modifier 59.

Download your CCI Edit Chart.

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Correct Coding Initiative (CCI) Edits

Edited to incorporate new PT and OT evaluation codes January 2017
All other edits current as of March 2016

CPT Code Description Timed? Column 2
y = use 59 modifier
n = do not bill the code in combination with code in column 1
90911 Biofeedback for Incontinence N 90901n; 97032y; 97110y; 97112y; 97530y; 97535y; 97550y
G0451 Developmental testing N 96125y
G0237 Therapeutic procedures to increase strength or endurance of respiratory muscles Y 97161y; 97162y; 97163y; 97164y; 97165y; 97166y; 97167y; 97168y; 97750y; 97530y; 97150y; 97112y; 97110y
G0238 Therapeutic procedures to improve respiratory function, other than described by G0237 Y 97161y; 97162y; 97163y; 97164y; 97165y; 97166y; 97167y; 97168y; 97750y; 97530y; 97150y; 97112y; 97110y
G0239 Therapeutic procedures to improve respiratory function or increase strength or endurance of respiratory muscles, two or more individuals N 97161y; 97162y; 97163y; 97164y; 97165y; 97166y; 97167y; 97168y; 97750y; 97530y; 97150y; 97112y; 97110y
92507 Speech Treatment N 97110y; 97112y; 97150y; 97530y; 97532y; 97533y
92508 Speech Group N 92507y; 97110y; 97112y; 97150y; 97530y; 97532y; 97533y
92521 Evaluation of Speech Fluency N 96101y; 96102y; 96103y; 96105y; 96118y; 96119y; 96120y; 96125y; G0268n
92522 Evaluation of Speech Production N 96101y; 96102y; 96103y; 96105y; 96118y; 96119y; 96120y; 96125y; G0268n
92523 Evaluation of Speech Production with Evaluation of Language Comprehension and Expression N 92522n; 96101y; 96102y; 96103y; 96105y; 96118y; 96119y; 96120y; 96125y; G0268n
92524 Behavioral and Qualitative Analysis of Voice Resonance N 96101y; 96102y; 96103y; 96105y; 96118y; 96119y; 96120y; 96125y; G0268n
92526 Treatment of Swallowing Dysfunction N 92511y; 92520y; 97032n; 97110y; 97112y; 97150y; 97530y; 97532y; G0283n
92597 Evaluation of Voice Prosthetic N 97755n
92607 Evaluation of Speech Generating Device Y 92506y; 92507y; 92508y; 92597n; 92609y; 97755n
92608 Eval of Speech Device (additional half-hour) Y 97755n
92609 Training and Fitting for Device N 92506y; 92507y; 92508y; 97755n
92610 Evaluation of Swallowing N 92511y
92611 Radiopaque Swallow Study N 92511y; 92610y
92612 Flexible Fiberoptic Endoscopic Swallow Evaluation N 92511n; 92520n; 92610y; 92611y; 92614n
92614 Flexible Fiberoptic Endoscopic Evaluation, laryngeal sensory testing by cine or video recording N 31575n; 76120n; 76125n; 92511n; 92520n; 92610y; 92611y; C9742n
92616 Flexible Fiberoptic Endoscopic Evaluation of swallowing and laryngeal sensory testing by cine or video recording N 31575n; 76120n; 76125n; 92511n; 92520n; 92610y; 92611y; C9742n
95831 Muscle testing, extremity (excluding hand) or trunk N 95851n; 97140y
95832 Muscle testing, hand N 95852n; 97140y
95833 Muscle testing, total eval body, excluding hands N 95831n; 95832n; 95851n; 97140y
95834 Muscle testing, total eval body, including hands N 95831n; 95832n; 95833n; 95851n; 95852n; 97140y
95992 Canalith Re-positioning N 97110y; 97112y; 97140y; 97530y
96105 Assessment of Aphasia Y 96110y; 96125y; G0451y
96110 Developmental testing, limited N 96125y
96111 Developmental testing, extended N 96125y; 97161y; 97162y; 97163y; 97164y; 97165y; 97166y; 97167y; 97168y; G0451n; G0459n
96125 Standardized Cognitive Performance Testing Y 96127n
29581 Multi-Layer Compression System, Below Knee N 29540y; 29550y; 29580y; 97140y; 97535y
29582 Multi-Layer Compression System, Entire Leg N 29540y; 29550y; 29581y; 97140y; 97535y
29583 Multi-Layer Compression System, Upper Arm & Forearm N 29105y; 29125y; 29126y; 97140y; 97535y
29584 Multi-Layer Compression System, Entire Arm N 29125y; 29126y; 29130y; 29131y; 97140y; 97535y
97012 Mechanical Traction N 97164y; 97168y; 97018y; 97140y
G0281 Electrical Stimulation, Stage 3-4 Wounds N 97164y; 97168y; 97032y; G0283y
G0283 Electrical Stimulation, Other Than Wound Care N 97164y; 97168y; 97032y
97016 Vasopneumatic device N 97164y; 97168y; 97018y; 97026y
97018 Paraffin Bath N 97164y; 97168y; 97022y
97022 Whirlpool N 97164y; 97168y
97024 Diathermy N 97164y; 97168y; 97018y; 97026y
97026 Infrared N 97164y; 97168y; 97018y; 97022y
97028 Ultraviolet N 97164y; 97168y; 97018y; 97022y; 97026y
97032 Electrical Stimulation Y 64550y; 97164y; 97168y
97033 Electrical Current Y 97164y; 97168y
97034 Contrast Bath Y 97164y; 97168y
97035 Ultrasound Y 97164y; 97168y
97036 Hubbard Tank Y 97164y; 97168y
97039 Physical Therapy Treatment Y 97164y; 97168y
97110 Therapeutic Exercises Y 97164y; 97168y
97112 Neuromuscular Re-education Y 97164y; 97168y; 97022y; 97036y
97113 Aquatic Therapy/Exercises Y 97164y; 97168y; 97022y; 97036n; 97110y
97116 Gait Training Y 97164y; 97168y
97124 Massage Y 97164y; 97168y
97139 Physical Medicine Procedure Y 97164y; 97168y
97140 Manual Therapy Y 95851y; 95852y; 97164y; 97168y; 97018y; 97124n; 97530y; 97750y
97150 Group Therapeutic Procedures N 97164y; 97168y; 97110y; 97112y; 97113y; 97116y; 97124y; 97140y; 97530y; 97532y; 97533y; 97535y; 97537y; 97542y; 97760y; 97761y
97161 Physical therapy evaluation: low complexity N 95831n; 95832n; 95833n; 95834n; 95851n; 96105y; 96125y; 97750n; 97755n; 97762n; 99201y; 99202y; 99203y; 99204y; 99205y; 99211y; 99212y; 99213y; 99214y; 99215y; 97164n; 97165n; 97166n; 97167n; 97168n
97162 Physical therapy evaluation: moderate complexity N 95831n; 95832n; 95833n; 95834n; 95851n; 96105y; 96125y; 97750n; 97755n; 97762n; 99201y; 99202y; 99203y; 99204y; 99205y; 99211y; 99212y; 99213y; 99214y; 99215y; 97161n; 97164n; 97165n; 97166n; 97167n; 97168n
97163 Physical therapy evaluation: high complexity N 95831n; 95832n; 95833n; 95834n; 95851n; 96105y; 96125y; 97750n; 97755n; 97762n; 99201y; 99202y; 99203y; 99204y; 99205y; 99211y; 99212y; 99213y; 99214y; 99215y; 97161n; 97162n; 97164n; 97165n; 97166n; 97167n; 97168n
97164 Re-evaluation of physical therapy established plan of care N 95831n; 95832n; 95833n; 95834n; 95851n; 96105y; 96125y; 97750n; 97755n; 97762n; 99201y; 99202y; 99203y; 99204y; 99205y; 99211y; 99212y; 99213y; 99214y; 99215y; 97165n; 97168n
97165 Occupational therapy evaluation: low complexity N 95831n; 95832n; 95833n; 95834n; 95851n; 96105y; 96125y; 97750n; 97755n; 97762n; 99201y; 99202y; 99203y; 99204y; 99205y; 99211y; 99212y; 99213y; 99214y; 99215y; 97164n; 97168n
97166 Occupational therapy evaluation: moderate complexity N 95831n; 95832n; 95833n; 95834n; 95851n; 96105y; 96125y; 97750n; 97755n; 97762n; 99201y; 99202y; 99203y; 99204y; 99205y; 99211y; 99212y; 99213y; 99214y; 99215y; 97164n; 97165n; 97168n
97167 Occupational therapy evaluation: high complexity N 95831n; 95832n; 95833n; 95834n; 95851n; 96105y; 96125y; 97750n; 97755n; 97762n; 99201y; 99202y; 99203y; 99204y; 99205y; 99211y; 99212y; 99213y; 99214y; 99215y; 97164n; 97165n; 97166n; 97168n
97168 Re-evaluation of occupational therapy established plan of care N 95831n; 95832n; 95833n; 95834n; 95851n; 96105y; 96125y; 97750n; 97755n; 97762n; 99201y; 99202y; 99203y; 99204y; 99205y; 99211y; 99212y; 99213y; 99214y; 99215y; 97164n
97530 Therapeutic Activities Y 95831n; 95832n; 95833n; 95834n; 95851n; 95852n; 97164y; 97168y; 97113y; 97116y; 97532y; 97533y; 97535y; 97537y; 97542y; 97750y
97532 Cognitive Skills Development Y 97164y; 97168y
97533 Sensory Integration Y 97164y; 97168y
97535 Self Care Management Training Y 97164y; 97168y
97537 Community/work Reintegration Y 97164y; 97168y
97542 Wheelchair Management Training Y 97164y; 97168y
97545 Work Hardening Y 97164y; 97168y; 97140n
97597 Wound Care Selective, first 20 sq centimeters N 29105y; 29125y; 29130y; 29260y; 29345y; 29405y; 29425y; 29445y; 29515y; 29540y; 29550y; 29580y; 29581y; 29582y; 29584y; 97164y; 97022y; 97602n; 97605y; 97606y; 97610y
97598 Wound Care Selective, each additional 20 sq centimeters N 29580y; 29581y; 29582y; 97164y; 97022y; 97602n; 97605y; 97606y; 97610y
97602 Wound Care Non-Selective N 29580y; 29581y; 97164y
97605 Negative pressure wound therapy utilizing DME (surface area less than or equal to 50 square centimeters) N 97164y
97606 Negative pressure wound therapy utilizing DME (surface area greater than 50 square centimeters) N 97164y
97608 Negative pressure wound therapy utilizing disposable, non-durable medical equipment (surface area greater than 50 square centimeters) N 97164y
97610 Low Frequency, Non-Contact, Non-Thermal Ultrasound N 97035y; 97602n
97750 Physical Performance Test Y 95831n; 95832n; 95833n; 95834n; 95851n; 95852n; 97150n
97755 Assistive Technology Assessment Y 97035y; 97110y; 97112y; 97140y; 97530y; 97532y; 97533y; 97535y; 97537y; 97542y; 97545y; 97750n; 97760y; 97761y; 97762n
97760 Orthotic Management and Training Y 29105y; 29125y; 29126y; 29130y; 29131y; 29200y; 29240y; 29260y; 29280y; 29505y; 29515y; 29520y; 29530y; 29540y; 29550y; 29580y; 29581y; 29582y; 29583y; 29584y; 97164y; 97168y; 97016y; 97110y; 97112y; 97116y; 97124y; 97140y; 97662y
97761 Prosthetic Training Y 97164y; 97168y; 97016y; 97110y; 97112y; 97116y; 97124y; 97140y; 97760y; 97762y

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 CCI Edits) that will check your codes against the Medicare CCI rules as you add services to be billed for each visit. Once you’ve turned on this feature, it will notify you of any CCI 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 CCI 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).

  1. Select “Display Insurance,” located on the left side of the WebPT Dashboard.
  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”; 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.

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