The Basic Principles of Using Modifier 59

For therapists, coding can be complicated. And it gets even more complicated when modifiers enter the picture.

Modifiers are tricky things. Used wisely, they can help maximize your revenue. But used erroneously, they can wreak havoc in the form of claim denials and penalties. And if there’s one modifier that causes this the most, it’s modifier 59.

Modifier 59 has boggled many a physical therapist, and it’s not hard to see why. Essentially, it allows PTs to charge for two separate services that have been paired by the National Correct Coding Initiative (NCCI) as one. But there are many other factors that affect its use and may cause errors instead. To clear the confusion and make the most out of this modifier, here is what you need to know.

What Is Modifier 59?

The NCCI identified certain procedures that therapists often perform together in the same treatment period as “edit pairs”. Should you charge for any two CPT codes that make up an edit pair, the payer will automatically pay for only one of those services. This is unless those services were provided wholly separate from each other and modifier 59 is applied to one of the codes.

Modifier 59 then basically signifies separate payment for code pairs that are considered to have just one payment. For example: code 97140, which indicates manual therapy techniques on one or more regions (each for 15 minutes) links to several other codes to form edit pairs. To be able to charge for 97140 as well as its partner code in an edit pair separately, the services need to have been performed in different time periods (different 15-minute periods in this case), and have modifier 59 attached to the linking code.

Modifier 59 was intended primarily for surgical procedures, but does affect physical therapy billing and is widely recognized. Medicare is not the only third-party payer that recognizes and requires this modifier. Many other payers also do, with some having a few differences in edit pairs.

When and How Should Modifier 59 be Used?

There are certain conditions necessary for this modifier to be effective. First of course, is that you use it with an existing edit pair. Some codes represent mutually exclusive procedures and can therefore never be billed with another code. For a guide on how and where to look up edit pairs, visit www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/. Take note however, that some private payers have their own set of edit pairs. For cases like this it’s best to consult the payer directly.

Next, you need to be able to prove the necessity of the modifier. That means you need sufficient documentation to show that the two services of the edit pair were indeed provided completely separate of each other and therefore require separate payment. Using the modifier without sufficient proof for its necessity will most likely lead to an audit, and you may face denials and penalties.

When Should Modifier 59 NOT be Used?

Modifier 59 should never be used as a means of guaranteeing payment of services. It should only denote separate payment of proven separately-given services that are otherwise considered as one in terms of payment. You should also avoid using modifier 59 routinely with re-evaluation codes, as this can arouse suspicion from your payers.

If you still need help regarding modifier 59 or other billing issues, talk to the specialists at Park Medical Billing. We’ll make sure you get the solutions you need to make billing easier, error-free and more effective for your practice. Get in touch with us by calling 1-201-585-7306 today.

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