Eli's Rehab Report

Published on Wed Oct 24, 2007 PDF

Question: I've been getting a lot of denials on claims I bill with modifier 59 (Distinct procedural service), and my therapists' documentation is usually very thorough in explaining separate and distinct procedures. So I'm wondering if I'm putting the modifier on the wrong code. Are there any official instructions from CMS on this?


Ohio subscriber

Answer: Chapter 23 of the Medicare Claims Processing Manual, Section 20.9.1.1.B (page 58) instructs you to put the modifier 59 on the "secondary, additional, or lesser" procedure. But to put this into a therapist's perspective, let's review the two kinds of Correct Coding Initiative (CCI) edits--mutually exclusive and column 1/column 2--and how you would use modifier 59 in each case.

Mutually exclusive edits: These are codes you cannot bill together because you would not normally perform them together. One example is mechanical traction (97012) and manual therapy (97140). CMS considers manual therapy mutually exclusive of mechanical traction--and not the other way around. If you provide both of these interventions on the same day to a Medicare patient receiving outpatient therapy, you must append modifier 59 to 97140 to have both interventions reimbursed. If you place modifier 59 on 97012 instead, you will not be reimbursed for 97140.

Column 1/column 2 edits: This is a code pair in which CMS considers one of the codes a component of a more comprehensive code on the claim. An example is therapeutic activities (97530) and self-care/home management (97535).

Self-care/home management is considered a component of the more comprehensive code, therapeutic activities. So if you provide both of these interventions on the same day to a Medicare patient receiving outpatient therapy, you must append modifier 59 to 97535 to have both interventions reimbursed. If you place modifier 59 on 97530 instead of 97535, you will not be reimbursed for 97535.

Resource: CMS posts the CCI edits on its Web site for free at www.cms.hhs.gov/NationalCorrectCodInitEd/.

Reader Questions were answered by Rick Gawenda, PT, director of physical medicine & rehabilitation at Detroit Receiving Hospital, and owner of Gawenda Seminars.