Earlier this month, we covered some major changes to the NCCI edit rules set forth by the Centers for Medicare and Medicaid Services (CMS). Per those changes, as of January 1, 2020, PTs, OTs, and ATCs were no longer receiving payment on the following CPT codes when billed with CPT® code 97530 (therapeutic activities) and/or 97150 (group therapy):
It feels like the term “breaking news” has lost some of its gravity these days thanks in large part to the era of the 24-hour news cycle. However, today we’re bringing you information that’s hot off the press—and absolutely crucial to every single outpatient physical therapist and occupational therapist who bills for therapeutic activities, group therapy, and manual therapy.
Here are answers to every question you’ve ever had about Medicare Part B for outpatient rehabilitation services.
Billing for physical therapy services is tricky, time-consuming, and nerve-racking. After all, there are so many rules you have to follow, and it seems like those rules are constantly changing. That makes mistakes tough to avoid.
Today’s blog post comes from Geoff Elledge, WebPT Billing Specialist. Thanks, Geoff!
One of the primary reasons medical providers depend on certified coders is for their ability to maximize practice revenues. To do so, certified coders must understand how and when to use modifiers—and there are a lot—from the common sides of treatment, like right (RT) and left (LT), to the more challenging modifier 59.
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.”
Got that? Yeah, we know. It’s a bit dense and doesn’t seem the most relatable. But that’s because modifier 59 is intended mainly for surgical procedures, so the definition leans a great deal that way.
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 if you’re providing linked services or wholly separate services. This will determine whether modifier 59 is appropriate.
It’s a mad, mad, mad, mad Medicare world, and unfortunately, just about every regulation requires a modifier. If you apply the wrong modifier—or forget one entirely—then your clinic suffers decreased payments or flat-out denials. Even worse, if you amass enough modifier mistakes, you make your practice vulnerable to an audit.